american journal of medical and physical education vol.7, issue 1; january-febuary 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 1 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe the impact of minor changes in instruction on student learning daniel (robert) nesbit mechanical engineering technician, craigavon, northern ireland, united kingdom abstract childhood obesity is a growing concern, with the percentage of children and adolescents who are obese increasing from 7% to 18% in the united states between 1980 and 2010. physical activity is a key component in the promotion and maintenance of a healthy lifestyle, and can help to reduce childhood obesity. physical education is an ideal setting for promoting physical activity, but it is important to ensure that physical education programs are designed in a holistic way that meets the needs of all students. keywords: childhood obesity, physical activity, physical education, holistic approach, obesity prevention strategies 1. introduction it is well known from popular media that obesity rates in children and adolescents have been a concern for many years. according to the center for disease control the percentage of children aged 6–11 years in the united states who were obese increased from 7% in 1980 to nearly 18% in 2010. similarly, the percentage of adolescents aged 12–19 years who were obese increased from 5% to 18% over the same period (center of disease control and prevention, 2013). the iom (2013) has stated that less than half of the youth meet the required 60 minutes of physical activity per day and this lack of energy expenditure results in sedentary behaviors which is strongly linked to childhood obesity. physical activity is viewed as a key component in the promotion and maintaining of a physically healthy lifestyle (mckenzie et al. 1996). participation in physical activity serves as a way to strength bone mass; reduce cholesterol and blood pressure which aids in the reduction of childhood obesity (riddoch, 1998). with the recent concerns of the weight status of children there has been several claims of how and why physical education should join in the fight against obesity (sallis & mckenzie, 1991). the physical education setting is a perfect avenue for not only teaching motor competence and skill but its acts as an opportunity to promote physical activity during the school day (siedentop, 1994). physical education should include teaching to the student in a holistic way, but it can be questioned whether or not this is being done. professionals in the field understand the benefits of physical activity and how physical education can be a portal for expanding a child’s knowledge and likelihood of participation in physical activity (sallis & mckenzie, 1991). however, it must be taken into consideration whether or not the children being educated really understand the importance (spencer-cavaliere & rintoul, 2012). for some students a major component to the aversion of physical education is the fear of being left out, and they are being alienated because of this (carlson, 1995). the students who are overweight and considered obese are being ostracized and alienated due to their inability to perform at the level other students can (southall, okely, & steele, 2004). we have seen this situation numerous times in movies, narratives in research, and for some of us, first hand in the physical education settings. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 1; january-febuary 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 2 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe teachers must take caution to show interest in each individual student, and to not maintain their focus on only highly skilled students. as a teacher, one should we be motivated to help each kid no matter their ability level or appearance. when certified physical educators were asked if the schools were doing enough to combat obesity, 80% of them felt as though the schools were not (greenleaf and weiller, 2005). physical educators must become part of a solution that begins by creating a nurturing environment that protects a child’s self-esteem. current research should drive professionals in the field to examine their methodology to determine to what extent physical activity is being positively promoted or, conversely, the role that educators and other experts are playing as catalysts in the growth of obesity. what does the research tell us a study conducted by meaney, hart, and griffin (2011) examined overweight participants’ attitudes toward physical activity and how they perceived their physical education classes. the bactive program uses mastery motivational climate (mmc) to foster a sense of success and accomplishment. the purpose was to create positive self-efficacy in these individuals. throughout this study the finding showed that overweight student’s perceptions were impacted by factors within the instruction environment (meaney, hart, and griffin, 2011). participants in the bactive program enjoyed it. they were among peers of the same weight and situation so they felt more at ease. one participant responded that she felt like she belonged and another participant said that kids weren’t mean to me here like they are in my physical education class (meaney, hart, and griffin, 2011). these students built a strong social support with their peers and they were able to feel less anxiety about participating in physical activities. students were asked how their physical education class could be changed in order to promote involvement. almost all of the students commented on how the class was programmed, by stating that they only play one type of activity and that activity usually last for a week which resulted in boredom. students advocated for more variety in activities. classroom management appeared to be a common theme as well. students emphasized that the majority of their time in physical education class was spent on management and sitting in their designated areas, which only left about 5 minutes of actual activity time (meaney, hart, and griffin, 2011). along with bad management, disciplinary problems affected the whole class and their opportunity to engage in activities. if one student was to act up then all the students would suffer. these inappropriate teaching behaviors promote student’s inactivity. a research study conducted by trout and graber (2009) revealed students ranged from enjoyment to hatred when it came to how they categorized their physical education experience. this study used interviews tied to the learned helplessness framework to see exactly how overweight students perceived physical education. several main contributors to negative perceptions were highlighted, with one significantly contributing factor identifies as the desire to become invisible. a majority of these students did not poses the motivation to achieve in the physical education classes due to their low self-efficacy and the fact that they were continuously spotlighted because of their inability to perform. in certain activities such as fitness testing, several students were made fun of because their inability to do well on the running test made it easy to see them fail because they were the first ones out or the last ones to finish. the public humiliation for most students whether they are overweight or unable to successful complete a task is too much to handle. the culmination of these factors resulted in students being “competent bystanders.” a competent bystander is a student in a physical education class that is familiar with the structure of the task at hand and is able to avoid participation. students will move to the back of the line when they know they will not be noticed so that they do not have to perform in front of others (tousignant & siedentop, 1983). in the instance where a student has to perform on a fitness test, a handful of participants in this study stated they tried to miss that day of school by acting sick or employing some other tactic. one student reported that on a mile run day, if he walked at any time mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 1; january-febuary 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 3 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe during the run, the teacher would punish his classmates by making them run more. subsequently, his classmates alienated him for his failure and blamed him for their extra running (trout & graber, 2009). while research studies give insight into the world through the eyes of overweight students, an important question is, “how can physical education teachers use this research to improve learning experienced for overweight students?” some research suggests that teachers may not be fully aware of how to teach fitness and therefore are unable to modify tasks to suit overweight students (trout and graber, 2009). other studies suggest that if students are allowed to sit out and not participate then they are more likely to find physical activity less important and will not engage in physical activity outside of school (meaney, hart, and griffin, 2011). what can physical educators do through examining research on the perceptions of overweight children in physical education, one major theme stands out; inappropriate teaching practices are present in physical education classrooms. the national association for sport and physical education (naspe) provides educators with guidelines for appropriate instructional practices at all levels k-12. neglecting these practices can breed a negative environment for overweight or obese children. in order to create a more positive experience for all students’ teachers can look at the guidelines as a compass. when creating lessons a teacher needs to take into consideration all of their students. this seems like common sense but it is not always done. should overweight students be expected to perform at the same level as normal weight students? the answer is no. this element needs to be addressed. teachers may fail to adapt their lessons to tailor to the needs of overweight children due to two factors. first is the notion that if overweight students work as hard as normal weight students then they will benefit more and get more exercise. what is not taken into consideration is their current level of fitness. an overweight child may suffer from breathing problems and other medical concerns that could make being asked to run a mile non-stop an impossible task at their current physical level. the second factor is the teacher’s lack of content knowledge when it comes to fitness. a teacher should be able to modify a student’s task that suits the needs of the student. for example instead of having students simply go out and run a mile the teacher could consider doing interval training. that way all the students are running at their own pace, preferably within their target heart zone. by doing this type of exercise a student can judge their ability and students are required to walk to let their heart rate lower. this makes it harder for students who might be struggling to be noticed (trout and graber, 2009). instructional strategies such as allowing children to choosing teams can have a negative effect on a child’s willingness to engage in physical activity. a study by cardinal, yan, & cardinal (2013) asked young adults about their physical activity levels and how their previous experience affected their current status. results indicated that the underlying factor for decline in physical activity as an adult was being picked last for a team. the responses also showed that out of the choses of not being given the opportunity to play and being cut from a particular team had less impact then being chosen last. these types of strategies employed by teachers can impact a student’s more than one would assume. curriculum plays a major role in how students experience physical education. due to the competitive nature of traditional physical education classes many overweight children are turned off. freedom of choice might be an effective avenue for creating enjoyment in physical education. research shows that providing noncompetitive opportunities for students who do not wish to participate leads to a reduction of stress and more enjoyment towards physical education (carlson, 1995). this more automatous environment also contributes to student’s sense of control. lack of control for an overweight student can stem from their skill level or their perceived motor competence. if an overweight student is in a position where they feel as though they aren’t successful compared to others they will most likely be alienated by others or themselves for fear of failure (carlson, 1995). a teacher can help elevate some of these experiences by creating developmentally and physically appropriate tasks. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 1; january-febuary 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 4 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe allowing students to self-pace through activities and setting up small goals within each task you are facilitating small success which will aid in enjoyment and act as a motivation to continue. the teaching of fundamental motor skills is another link to promoting physical activity for a life-time. williams et al. (2008) showed evidence that children who had higher levels of motor skill performance spent more time in moderate-to-vigorous physical activity compared to the low skilled counterparts. to strengthen the argument that physical education teachers should focus on the acquirement of fundamental motor skills is a systematic review conducted lubans et al. (2010). contrary to belief children do not naturally acquire these skills and must be taught how to perform them accurately. based on the results from the systematic review 21 research articles were found that assessed the effects fundamental motor skills had on health. not only was fundamental motor skills inversely related to weight status it was strongly associated with a child’s physical actively levels. those children and adolescents who established more fundamental motor skill competence had higher levels of engagement in physical activities. students must also be taught to value physical activity. a study by lee (1997) showed students were more likely to engage and continue to work towards a task they found useful or interesting. if students do not see the value in being physically active then they will more likely to be less motivated to engage in it. in the study by trout and graber (2009) most overweight participants perceived many aspects of physical education to be of little or no value overall. it is the teacher’s responsibility to present the positive influences that can come from being physically active and the benefits you gain. if students see that a teacher does not value the concepts of health and fitness being taught, then the students may have a difficult time fully grasping the impact being healthy can have on life. the importance of exercise and being outside moving can act as a huge incentive for children, and the concepts taught in lessons should be relatable to the students in some way. this can do done by introducing the effects that exercise has on movements performed in their everyday lives, or by intertwining how exercise can relate to activities they enjoy doing outside of school. equity is a key variable in overweight student’s involvement in a physical education classroom. as a teacher, it is important to put aside personal bias and reach for the greater good of their students. no matter who the student is, they should receive the same treatment as students viewed to be more proficient. while the outcomes may be different, it is important that each student is held to a high personal standard, appropriate for their personal fitness and skill level. the classroom environment should be created to provide encouragement and support. students should be taught to see a person for who they are, and not simply judged for their abilities. some ways that this type of teaching can occur is to apply the simple principle of getting to know the students. one strategy to gain individual information from students on their personal fitness or skill level is to conduct a survey at the beginning of a new unit. by getting to know the students, educators can modify lessons to involve some elements that each child can be good at. this will foster a sense of accomplishment among all students in the classroom. another area that needs to be examined is the use of feedback. research has been done on distribution of teacher feedback that shows boys receive feedback more often than girls and high skilled students receive more feedback than lower skilled (nicaise et al., 2007). for overweight students feedback can be an effective extrinsic motivational tool and can result in the use of verbal desists. conclusion research confirms belief that the act of teaching is complex. being that a classroom is a constantly fluctuating environment, led by an individual with unique personal experiences and contextualized methods; it is fair to assume that there is more than one right way to accomplish the education of the students. nevertheless an initial approach by any educator should be to assure that his/her actions and goals are in place to benefit the students. the physical education classroom environment should protect the children from fear of failure, and foster positive attitudes about physical activity. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 1; january-febuary 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 5 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe the teaching strategies employed should seek to have maximal positive effect on the students who come through. as outlined in the research, fighting obesity might seem like a monumental task, and there is much need for a change in the current trends. the physical education classroom is an excellent place to start, but educators need the tools, abilities, and personal interactions with the students necessary to facilitate this change. by believing that each student is capable of achieving success at their own level and pace, creating an environment where these successes and achievable and measureable, and by nurturing concepts that can be extrapolated past physical activity in the classroom, educators can make a difference in stemming the rising rates of obesity. living healthy and being physically responsible are lifelong challenges. no one teacher can conquer the entire problem on their own, however mother teresa might have said it best when she said “i alone cannot change the world, but i can cast a stone across the waters to create many ripples” ("mother teresa quotes," 2013). references cardinal, bj, yan, z, & cardinal, mk., (2013). negative experiences in physical education and sport: how much do they affect physical activity participation later in life? journal of physical education, recreation & dance. 84 (3), 49-53. carlson, t. b. (1995). we hate gym: student alienation from physical education. journal of teaching in physical education, 14, 467-467. center for disease control and prevention. (2013). childhood overweight and obesity. retrieved from http://www.cdc.gov/obesity/childhood/index.html thousand oaks, ca: sage. center for disease control and prevention. state indicator report on physical activity, 2010. atlanta, ga: u.s. department of health and human services, 2010. greenleaf, c., & weiller, k., (2005). perceptions of youth obesity among physical educators. social psychology of education, 8, 407-423. iom (institute of medicine). educating the student body: taking physical activity and physical education to school. 2013. washington, dc: the national academies press. li, w., rukavina, p., & wright, p. (2012). coping against weight-related teasing among adolescents perceived to be overweight or obese in urban physical education. journal of teaching in physical education, 31, 182-199. lodewyk, k., gammage, k., & sullivan, p. (2009). relations among body size discrepancy, gender, and indices of motivation and achievement in high school physical education. journal of teaching in physical education, 28, 362-377. lubans, d. r., morgan, p. j., cliff, d. p., barnett, l. m., & okely, a. d. (2010). fundamental movement skills in children and adolescents. sports medicine, 40(12), 1019-1035. mckenzie, t. l., nader, p. r., strikmiller, p. k., yang, m., stone, e. j., perry, c. l., ... & kelder, s. h. (1996). school physical education: effect of the child and adolescent trial for cardiovascular health. preventive medicine, 25(4), 423-431. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 1; january-febuary 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 6 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe meaney, k., hart, a., & griffin, k. (2011). do you hear what i hear? overweight children’s perceptions of different physical activity settings. journal of teaching in physical education, 30, 393-409. "mother teresa quotes." mother teresa quotes (author of come be my light) (page 3 of 8). n.p., n.d. web. 28 oct. 2013. retrieved from http://www.goodreads.com/author/quotes/838305.mother_teresa?page=3 national association for sport and physical education. (1998). appropriate practices for high school physical education. reston, va: author. nicaise, v., cogérino, g., fairclough, s., bois, j., & davis, k. (2007). teacher feedback and interactions in physical education: effects of student gender and physical activities. european physical education review, 13(3), 319-337. powers, s. k., dodd, s. l. & jackson, e. m. (2011). total fitness and wellness. san francisco, ca: pearson education inc. riddoch, c. (1998). relationships between physical activity and physical health in young people. in: biddle s., sallis, j., cavill, n. (eds) young and active? young people and health enhancing physical activity: evidence and implications. london, england: health education authority, 17-48. sallis, j. f., & mckenzie, t. l. (1991). physical education's role in public health. research quarterly for exercise and sport, 62(2), 124-137. siedentop, d. (1994). introduction to physical education, fitness, and sport. (2nd ed.) mountain view, ca: mayfield. southall, j., okely, a., & steele, j. (2004). actual and perceived physical competence in overweight and nonoverweight children. pediatric exercise science, 16, 15-24. spencer-cavaliere, n., & rintoul, m., (2012), alienation in physical education from the perspective of children. journal of teaching in physical education, 31, 344–361. tousignant, m., & siedentop, d. (1983). a qualitative analysis of task structures in required secondary physical education classes. journal of teaching in physical education, 3, 47-57. trout, j., & graber, k.c. (2009). perceptions of overweight students concerning their experiences in physical education. journal of teaching in physical education, 28, 272–292. walling, d., & martinek, t. (1995). learned helplessness: a case study of a middle school student. journal of teaching in physical education, 14, 454–466. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 5; september-october 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 1 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe decision-making of ncaa division ii gulf south conference spring sport student-athletes impacted by covid-19 in 2020 1david anne brown, 2michael david williams and 3jane charles williams 1department of physical education, wellness, and sport, union university. 1050 union university drive, jackson, tennessee 38305. gjohnson@uu.edu, 731-661-5246 (phone), 731-661-5182 (fax) 2department of physical education, wellness, and sport, union university. 1050 union university drive, jackson, tennessee 38305 3department of physical education, wellness, and sport, union university. 1050 union university drive, jackson, tennessee 38305 abstract: the covid-19 pandemic had a significant impact on collegiate student-athletes, many of whom were scheduled to use their final season of competition and/or academic eligibility during the spring 2020 semester. this study investigated the decision-making process of these student-athletes regarding whether to return to play in the spring 2021 season. the researchers surveyed all 13 member schools of the ncaa division ii gulf south conference and found that 68% of student-athletes returned to play. the decision to return was influenced by factors such as gender, sport type, and 2020 graduation status. keywords: covid-19 pandemic, ncaa student-athletes, decision-making, return to play, gender sport type graduation status introduction collegiate student-athletes were faced with an unprecedented experience during the spring semester of 2020. as the world was facing the covid-19 global pandemic, the national collegiate athletic association (ncaa) made the decisión on march 12, 2020 to cancel all remaining winter and spring sport championships (ncaa, 2020c). this decisión left many student-athletes searching for the next step in their academic and athletic careers. as the spring semester evolved, the ncaa began adopting new legislation that would allow studentathletes in spring sports to receive an additional season of competition and academic eligibility if they returned to school in 2020-2021. the focus of this study was to investigate the decision-making process for student-athletes that were scheduled to use their final season of competition and/or academic eligibility during the spring 2020 semester. the researchers chose to survey all 13 member schools of the ncaa division ii gulf south conference. each school provided data related to the number of student-athletes (n=305) who were scheduled to use their final season of competition and/or academic eligibility during the spring 2020 semester and what decisión each of those studentathletes made regarding returning to play in the spring 2021 season of their sport. the researchers analyzed the mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 5; september-october 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 2 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe results to see if common choice factors influenced the decisión to return based on gender, sport type, and 2020 graduation status. national collegiate athletic association the national collegiate athletic association (ncaa) was established in 1906 as the intercollegiate athletic association of the united states (ncaa, 2010). the name change occurred in 1910 and has remained the same to this day. the ncaa is composed of 1,098 colleges and universities classified into 102 conferences spread across three divisions with distinctions based on size, number of athletic scholarships awarded, and focus on academic and carácter development (ncaa, n.d.-b). there are currently 350 ncaa division i schools with an average enrollment of 12,900 students and 170,000 student-athletes participating in intercollegiate athletics (ncaa, n.d. a). division ii is the smallest división with 310 member schools (median enrollment of 2,428) and 120,000 student-athletes (ncaa, n.d.-a). division iii is the largest división with 438 member schools (median enrollment of 1,740) and 195,000 student-athletes (ncaa, n.d.-a). one of the primary distinguishing factors between each división is the amount of athletic aid student-athletes receive for their participation in intercollegiate athletics. division i schools have the largest athletic budgets and award more cost-of-attendance athletic scholarships compared to division ii schools that primarily give partial athletic scholarships and division iii schools which do not allow athletic scholarships (ncaa, n.d.-a). the ncaa is governed by a board of governors represented by college presidents and chancellors from each of the three divisions. the emerging covid-19 pandemic of 2020 presented a challenge the ncaa had never faced before. as the covid-19 pandemic expanded around the world, the ncaa was faced with making decisions regarding the safety of the coaches and student-athletes involved in winter and spring sports. the culmination of many meetings resulted in ncaa president mark emmert and the board of governors cancelling all remaining winter and spring championships on march 12, 2020 (ncaa, 2020c). as the situation with covid-19 progressed throughout the spring and summer, the ncaa and board of governors developed policies regarding coaches and student-athletes impacted by the decisión to cancel winter and spring sports. on july 22, 2020, the ncaa (2020d) issued a policy related to bylaw 14.2: season of competition issues that: allowed institutions to self-apply season of competition waivers for spring sport student-athletes for the 20202021 academic year, provided all of the following criteria were met: (1) the student-athletes team participated in 50% or less of the sport’s bylaw 17 maximum contests/dates of competition during the 2019-2020 season due to ongoing impact from covid-19; (2) the student-athlete used a season of competition during the 2019-2020 academic year; and (3) the student-athlete was eligible for competition when he or she competed during the 2019-2020 academic year. (p. 3) mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 5; september-october 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 3 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe in addition, the ncaa (2020d) issued the following policy related to bylaw 14.2: season of competition issues that: allowed institutions to self-apply an extension of eligibility waiver (two semesters/three quarters) for winter and spring student-athletes for the 2020-2021 academic year, as follows: (1) if the student-athlete qualified for the season of competition waiver; (2) for a student-athlete who was unable to participate due to a cancellation of the sport season; or (3) for a student-athlete who opted out of countable athletically related activities. (p. 4) the ncaa (2020d) added on august 21, 2020 that: in order to qualify for the self-applied extensión of eligibility waiver, the student-athlete must have been otherwise eligible for competition during the 2020-2021 academic year. this relief was aplicable to all eligible student-athletes, regardless of year in school or number of semesters previously used. (p. 4) the financial aid impact of these decisions was addressed by the ncaa (2020d) related tobylaw 15: financial aid issues when they: issued a blanket waiver to allow student-athletes who would have used their fourth season of competition or exhausted their 10 semester/15 quarter period of eligibility during the spring 2020 term to receive athletics aid for the 2020-2021 academic year without counting toward team equivalency limits. this relief only applied if the student-athlete remained at their original institution. if the student-athlete transferred, the athletics aid received at the new institution would count toward team equivalency limits.(pp. 9-10) gulf south conference the ncaa division ii gulf south conference (gsc) was established in 1970 as a football only conference (gsc, n.d.-a). the conference added men’s sports championships in 1971-72 for baseball, basketball, cross country, golf, tennis, and outdoor track and field (gsc, n.d.-c). women’s sports championships were added in 1982-83 for basketball, cross country, softball, tennis, and women’s volleyball (gsc, n.d.-c). the gulf south conference is currently made up of 13 member schools representing the states of alabama, florida, georgia, mississippi, and tennessee (gsc, n.d.-a). the gulf south conference also allows associate membership to 5 schools for specific sports that include: florida tech and north greenville for football; young harris and lander for lacrosse; and spring hill for men’s soccer, women’s soccer, and women’s golf (gsc, n.d.a). the gulf south conference (n.d.-b) recognizes 19 annual conference championships in the sports of baseball, basketball (men and women), cross country (men and women), football, golf (men and women), women’s lacrosse, soccer (men and women), tennis (men and women), indoor track and field (men and women), outdoor track and field (men and women), and women’s volleyball. the gulf south conference member schools have won 52 ncaa division ii championships (gsc, n.d.-a). academic success rate one of the key aspects the researchers focused on was the academic success rate of student-athletes and how the covid-19 waivers may benefit student-athletes who need additional semesters to complete their undergraduate degree. ncaa division ii uses the academic success rate based on the partial athletic scholarship model more commonly used in division ii as compared to division i student-athletes and division iii student-athletes. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 5; september-october 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 4 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe in the gulf south conference, the four-year rolling academic success rate for all student-athletes in the 20102013 reporting period was 69.5% compared to a national average of 74% (ncaa, 2020b). for this study, the researchers focused their attention on spring sport student-athletes (baseball, softball, men’s and women’s golf, men’s and women’s tennis, and men’s and women’s track and field). the four-year rolling academic success rate for gulf south conference student-athletes in the selected spring sports from 2010-2013 was 79.5% compared to the overall division ii average of 82.6% (ncaa, 2020a). one of the unintended consequences of the covid-19 policy changes is that academic success rates may show a short-term improvement based on student-athletes being allowed an additional two semesters/three quarters to complete their academic programs along with an additional year of athletic eligibility. covid-19 moving forward the ncaa has continually met to address the covid-19 pandemic and its impact on intercollegiate athletics. on september 2, 2020, the ncaa board of governors made the decisión to cancel all fall sport national championships (ncaa, 2020d). the waivers provided to 2020 spring sport student-athletes were extended to fall sport student-athletes. the ncaa (2020e) declared on october 20, 2020 that division ii winter sport studentathletes would also receive a waiver for an additional year of competition and an extension of academic eligibility. results from this study may help athletic administrators predict which student-athletes will most likely choose to return in 2021-2022 and the impact that will have on athletic budgets in coming years. purpose of the study the purpose of this study was to determine which factors (gender, sport type, 2020 graduation status) were most influential in the decision-making process of ncaa division ii gulf south conference spring sport studentathletes that returned for an additional season of competition in 2020-2021. this information could provide insight to athletic administrators as they plan for the long-term impact of the ncaa guidelines for covid-19 and how fall and winter sport student-athletes might use similar decision-making factors in future years. methods the researchers began contacting athletic directors and compliance officers at the 13 ncaa division ii gulf south conference member schools in august of 2020. a ten-item survey was created that each institution was requested to complete providing the information related to 2020 spring sport student-athletes that were scheduled to use their final season of competition and/or academic eligibility in the spring 2020 semester. the researchers collected data specific to gender, sport type, 2020 graduation status, and enrollment status for 2020-2021. all 13 institutions responded for a 100% response rate. the responses yielded 305 (n=305) total student-athletes that met the criteria to be included in the study. data was entered into spss and descriptive statistics for the independent variables of gender, sport type, and 2020 graduation status were analyzed. data was also produced to indicate student-athlete status for 2020-2021 as: taking undergraduate courses, completing undergraduate degree, or taking graduate courses. data was also collected related to retention rate that indicated which student-athletes stayed at their spring 2020 school versus transferring to another school for the additional season of competition and academic eligibility. a mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 5; september-october 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 5 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe binary logistic regression análisis was run on the data to determine which factor(s) had a significant impact on the decisión to return for an additional season of competition for the 2020-2021 year. results statistical results that identified the most important choice factors for 305 returning spring sport studentathletes from ncaa division ii gulf south conference institutions are reported in the following section. results were obtained following the administration of a 10-item survey to athletic directors and compliance officers at all 13 member institutions of the ncaa division ii gulf south conference. statistical analyses were performed to produce demographic results, descriptive statistics related to the 151 returning student-athletes, and a binary logistic regression. the results are organized by 1) demographics, 2) descriptive statistics, and 3) the binary logistic regression outcome. demographics demographic results are presented indicating the number of spring 2020 student-athletes (that were scheduled to use their final season of competition and/or academic eligibility) within each classification of independent variable and the percentage each group represents. athletic directors and/or compliance officers provided demographic information related to gender, sport, and spring or summer 2020 graduation status. each of the independent variables was categorical and required the administrators to indicatethe status of each studentathlete. demographic results representing the 305 spring 2020 student-athletes are presented in table 1. table-1 demographic classification of s tude nt-athletes sch eduled to comp lete athletic eligibility in the spring semester of 2020 s tatus for 20202021 returned did not r eturn total n % n % n % gender male 106 70.2 91 59.1 197 64.6 female 45 29.8 63 40.9 108 35.4 s port type team sport 99 65.6 101 65.6 200 65.6 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 5; september-october 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 6 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe individual/d ual sport 52 34.4 53 34.4 105 34.4 2 020 graduatio n status graduated 42 27.8 111 72.1 153 50.2 did not gra duate 109 72.2 43 27.9 152 49.8 note. n=305 independent variables gender male student-athletes represented 64.6% of the population for this study. male student-athletes represented 70.2% of the returning spring sport student-athletes and 59.1% of the non-returning spring sport student-athletes for the 2020-2021 academic year. the largest sport population for spring 2020 student-athletes came from the male sport of baseball (n=140). female student-athletes represented 35.4% of the population for this study. female studentathletes represented 29.8% of the returning spring sport student-athletes and 40.9% of the non-returning spring sport student-athletes for the 2020-2021 academic year. the sport of softball (n=60) represented the largest sport population of female student-athletes that participated in this study. sport type for this study, baseball and softball were categorized as team sports while tennis, golf, and outdoor track and field were categorized as individual/dual sports. team sport student-athletes represented 65.6% of the population for this study. team sport student-athletes also represented 65.6% of the returning and non-returning studentathletes for this study based on sport type. team sport participants from baseball (n=140) and softball (n=60) represented nearly two-thirds of the participants for the study. the largest population for spring 2020 student-athletes in individual/dual sports came from women’s track and field (n=24), followed by men’s golf (n=20), men’s tennis (n=19), and men’s track and field (n=18). 2020 graduation status for this study, 2020 graduation status was categorized as graduated spring or summer 2020 or did not graduate in spring or summer 2020. the graduation rate for spring and summer 2020 was 50.2% (n=153) for spring sport student-athletes using their final season of competition and/or academic eligibility. of those returning to play for 2020-2021, 72.2% (n=109) were reported as not graduated during the spring or summer of 2020 while 27.8% (n=42) did report graduating and were returning for an additional season of competition to pursue a graduate degree. of those not returning to play, 72.1% (n=111) were reported as graduated during the spring or summer of 2020. male (n=57) and female (n=54) student-athletes were similarly represented in the group of spring sport student-athletes who chose not to return for an additional season of competition after completing their undergraduate degree. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 5; september-october 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 7 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe descriptive statistics returning student-athletes for 2020-2021 the researchers included questions to determine the status of spring sport student-athletes that did return for the 2020-2021 academic and sport year. the total number of spring sport student-athletes returning for an additional season of competition was 151, which represented 49.5% of the participants for this study. one of the follow up questions was designed to investigate the academic status for spring sport student-athletes that returned in 20202021. institutions reported that 62.9% of returning spring sport student-athletes were completing an undergraduate degree with an additional 9.3% taking additional undergraduate courses. the remaining 27.8% were either starting a graduate program or continuing graduate studies. institutions were also asked to report the retention data for the returning spring sport student-athletes. institutions reported 98.0% of the returning studentathletes stayed at their current institution versus 2.0% that chose to transfer to another institution for the additional season of competition. table 2 illustrates the academic status and retention rate of the 151 returning spring sport student-athletes. table 2 academic status and retention r ate for retur ning studentathletes n % academ ic status comple ting underg raduate de gree 95 62.9 taking undergraduate classes 14 9.3 taking graduate cl asses 42 27.8 retentio n rate stayed a t spring 2020 institution 148 98.0 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 5; september-october 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 8 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe transfer red institut ions for 20 20-2021 3 2.0 note. n=151 binary logistic regression spss version 26 was used to determine if any of the independent variables had a significant impact on the decision to return for an additional season of competition in 2020-2021. the results of the binary logistic regression showed that 2020 graduation status (p<.000) was a significant predictor of return status for the 20202021 academic year. gender and sport type were not significant predictors of return status for the 2020-2021 academic year. results of the binary logistic regression are illustrated in table 3. table 3 impact of gender, sport type, and 2020 graduation status on 2020-20 21 enrollmen t of stude nt-athle tes for spring sports b s.e. wald df sig. exp(b) gender 0.268 0.268 1.006 1 0.316 1.308 sport ty pe -0.118 0.267 0.195 1 0.659 0.889 graduate d 2020 1.654 0.253 42.822 1 0.000 *** 5.226 ***p<.001 discussion independent variables the results of this study indicate that 2020 graduation status was the most significant predictor on the decisión of spring sport student-athletes to return in 2020-2021 for an additional season of competition following the cancellation of the spring 2020 sport seasons due to covid-19. gender and sport type did not show a significant influence on the decisión to return. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 5; september-october 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 9 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe the results of this study indicate that spring sport student-athletes at ncaa division ii schools in the gulf south conference demonstrate a desire to earn their degree while participating in intercollegiate sports. the impact on academic success rate over the next 4-5 years should be positively impacted by the additional season of competition and academic eligibility that is now granted to student-athletes in all fall and winter sports along with the spring 2020 student-athletes (ncaa, 2020f). challenges moving forward colleges and universities are now faced with the task of funding additional athletic scholarships to account for returning student-athletes along with incoming freshman student-athletes. each institution will have freedom to make the decisión to either continue offering athletics aid to all returning student-athletes, only allow studentathletes who need academic credits to complete an undergraduate degree to return, or not offer additional athletics aid beyond the four-year competition limit in place prior to covid-19. how institutions fund these additional scholarships is outside of the influence of the ncaa and will be determined at the institutional level. the ncaa has provided the opportunity for these student-athletes to return for an additional year of competition and academic eligibility without counting toward the sport equivalencies for each sport impacted by covid-19 during 2020-2021 (ncaa, 2020f). the results of this study may help institutions in predicting which student-athletes would most likely choose to return for an additional year of competition. the gulf south conference had over 400 student-athletes scheduled to use their final year of eligibility in fall 2020 and winter 2020-2021 sports. these student-athletes have been granted an additional year of competition and academic eligibility by the ncaa (2020f), but institutions will be faced with the task of funding these athletic scholarships while also recruiting new students and studentathletes. this will créate challenging times for institutions that are financially distressed and must choose between helping student-athletes return for an additional year of competition and academic eligibility or financially committing to the next class of incoming students. the researchers for this study plan to replicate this study for fall and winter sport student-athletes in the ncaa division ii gulf south conference in august 2021, when the enrollment status of those student-athletes will be known. conclusion the covid-19 pandemic presented a situation the ncaa had never experienced. as decisions were made, and policies created, the goal of the ncaa was to ensure the best outcome for the student-athletes impacted by the pandemic. allowing student-athletes an additional year of competition and extending the academic eligibility presented a scenario that allowed student-athletes to complete athletic and academic goals without impacting sport equivalencies at each institution (ncaa, 2020f). the institutions were then challenged with funding additional athletics aid for student-athletes that chose to return while continuing to recruit freshman students and student-athletes. the impact of the covid-19 pandemic on ncaa sports is not finished, as of the writing of this article, and may continue to have an impact on policies until the pandemic is no longer a national health risk and collegiate sports return to a schedule more like what it was prior to 2020. the long-term impact on institutional finances, academic success rates, and student-athlete health will be áreas of study that researchers should consider in the comingyears. the researchers for this article hope that identifying which categories of student-athletes are mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 5; september-october 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 10 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe most likely to utilize an additional year of competition and academic eligibility will assist institutions as they determine policy impacting student-athletes impacted by the covid-19 pandemic. future direction the following questions are áreas of research that should be addressed as the ncaa and its member institutions move forward making policies related to the covid-19 pandemic: 1. would allowing student-athletes to transfer without counting athletics aid toward the equivalencies of the transfer institutions provide more portability for student-athletes? 2. should the ncaa allow student-athletes to return for an additional season of competition if they have completed an undergraduate degree? 3. which factors will be most significant to fall and winter sport student-athletes as they consider whether to return for an additional season of competition? 4. what impact will the season of competition and academic eligibility waivers have on academic success rates in ncaa division ii? references gulf south conference. (n.d.-a). gsc quickfacts. retrieved december 3, 2020, from https://gscsports.org/sports/2011/8/8/gen_0808111016.aspx gulf south conference. (n.d.-b). gsc operating manual. retrieved december3, 2020, from https://gscsports.org/sports/2011/7/27/gen_0727111833.aspx?path=general gulf south conference. (n.d.-c). gulf south conference history of championships. retrieved december 3, 2020, from https://gscsports.org/documents/2010/12/9/gsc_championship_history.pdf national collegiate athletic association. (n.d.-a). our three divisions. retrieved january 8, 2021, from http://www.ncaa.org/about/resources/media-center/ncaa-101/our-three-divisions national collegiate athletic association. (n.d.-b). what is the ncaa? retrieved january 8, 2021, from http://www.ncaa.org/about/resources/media-center/ncaa-101/what-ncaa national collegiate athletic association. (2010). history of the ncaa? retrieved january 8, 2021, from https://web.archive.org/web/20110807060521/http://www.ncaa.org/wps/wcm/connect/public/ncaa/ about%2bthe%2bncaa/who%2bwe%2bare/about%2bthe%2bncaa%2bhistory national collegiate athletic association. (2020a). division ii academic success rate database. retrieved december 3, 2020, from http://www.ncaa.org/about/resources/research/division-ii-graduation-ratesdatabase mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 5; september-october 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 11 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe national collegiate athletic association. (2020b). summary of division ii academic success rates. retrieved december 3, 2020, from http://www.ncaa.org/about/resources/research/summary-division-ii-academicsuccess-rates national collegiate athletic association. (2020c, march 12). ncaa cancels remaining winter and spring championships. http://www.ncaa.org/about/resources/media-center/news/ncaa-cancels-remainingwinter-and-springchampionships national collegiate athletic association. (2020d, september 2). dii grants all fall athletes further season-ofcompetition relief. http://www.ncaa.org/about/resources/media-center/news/dii-grants-all-fall-athletesfurtherseason-competition-relief national collegiate athletic association. (2020e, october 20). dii grants winter athletes further season-ofcompetition relief. http://www.ncaa.org/about/resources/media-center/news/dii-grants-winter-athletesfurtherseason-competition-relief national collegiate athletic association. (2020f, november 4). actions approved by the division ii administrative committee related to regulations and policies impacted by covid-19. https://ncaaorg.s3.amazonaws.com/compliance/d2/d2gov_covid19impactapprovedactions.pdf mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 32 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmp gender differences in functional movement screen scores of collegiate soccer players anthony deldin, michael j. clark and sarah a. smith university of bristol united kingdom abstract: the functional movement screen (fms) is a tool used to assess movement patterns and identify potential injury risk. this study evaluated the effectiveness of the fms as a tool during preparticipation screening of asymptomatic collegiate soccer players. the results showed that the fms was not an effective predictor of future injury in this population. however, there were some correlations between fms scores and rate of injury, as well as differences between male and female athletes. keywords: functional movement screen, injury prevention, soccer players, preparticipation screening acknowledgments the results of this study do not constitute endorsement of the product by the authors. the authors do not have any professional relationships with the creators or manufacturers of the functional movement screen. the authors thank rayanne nguyen, ms, rd, ldn, for her editorial assistance on multiple drafts of this article and the teams, coaches, and athletic trainers for their willingness to participate and assist with the study. the results of the present study do not constitute endorsement of the functional movement screen by the authors or the nsca. 1. introduction according to the national collegiate athletic association (ncaa) injury surveillance system, a recorded 182,000 injuries occurred between the years of 1988 and 2004, averaging to 11,000 injuries a year (hootman, dick, & agel, 2007). since 2004, the number of athletes competing has risen dramatically as have the needs to protect the athletes’ safety. significant research has been extended towards the study of injury prevention through proper screening and treatment methods. one tool, the functional movement screen (fms), has drawn particular attention from the athletic community for its purpose of (cook, 2010): 1. identifying individuals at risk, who are attempting to maintain or increase activity level. 2. assisting in program design by systematically using corrective exercise to normalize or improve fundamental movement patterns. 3. providing a systematic tool to monitor progress and movement pattern development in the presence of changing fitness levels. 4. creating a functional movement baseline which will allow rating and ranking movement for statistical observation. the fms tests an individual's movement patterns and side-to-side symmetry utilizing seven exercises that examine mobility, neuromuscular control, balance, and stability through specific, fundamental movement patterns. most recently, the fms has been commonly used as an indicator for potential injury. (garrison, westrick, johnson, & benenson, 2015; kiesel, plisky, & butler, 2011; lisman, o’connor, deuster, & knapik, 2013) mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 33 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmp the purpose of this study is to evaluate the effectiveness of the fms as a tool during preparticipation screening of asymptomatic collegiate soccer players for the identification of potential musculoskeletal injury. previous studies have evaluated the tool in military, collegiate and elite athlete populations (brown, 2011; chorba et al., 2010; garrison, et al., 2015; kiesel et al., 2011; warren, smith, & chimera, 2015). these studies evaluated the use of the fms as a predictor of injury. many of these studies have indicated composite scores below 14 as correlating to increased risk of injury (garrison et al., 2015; kiesel et al., 2011; lisman et al., 2013). chorba and colleagues (2010) suggested such with the stipulation that the correlation was to lower body injury only. in contradiction to these findings, warren et al. (2015) found that the fms could not be used as a predictor of future injury. additional analysis will be dedicated to the exploration of potential correlations between fms scores, rate of injury, and differences between male and female athletes. to the best of the authors’ knowledge, this study will be the first to report significant differences in fms scores between healthy male and female collegiate soccer players. although significant differences in fms scores between males and females have not been reported previously, the potential findings of this study may correlate with previously published evidence that females have deficits in intrinsic factors like muscle activation (hart et al., 2007), neuromuscular control (brophy et al., 2009), and core stability when compared with males (brophy et al., 2009; zazulak et al., 2007). each of these intrinsic factors has the ability to contribute to overall movement patterns and capacity. this study may add additional evidence that female athletes may be at higher risk for injury than male athletes. thus, the purpose of this study is to evaluate the effectiveness of the fms as a screening tool in determining rate of injury in division 1 college athletes’ predisposition to injury and whether the correlation of fms score and rate of injury differ between males and females. the researchers hypothesize that an fms composite score less than or equal to 14 is an effective predictor of injury for men and women (that there is a correlation between composite fms score and injury occurrence), that there will be a significant difference between sex and musculoskeletal injury occurrence, and that males will score significantly lower on the composite fms scores than their female counterparts. 2. methods 2.1. participants for this study, 36 student-athletes, age 18-22, from a ncaa d1 men’s and women’s soccer program were recruited by the research team. the inclusion criteria was clearance by the athletic training staff for participation; absence of a head, musculoskeletal, or spine injury within the last 3 months; and no report of vestibular, visual, or balance disorders. participants were recruited from the men’s (n = 20) and women’s (n = 16) soccer programs prior to the start of the spring season. the study protocol was approved by the institution’s institutional review board, and written informed consent was obtained from all participants before any data collection. this research was carried out fully in accordance to the ethical standards of the international journal of exercise science (navalta, stone, & lyons, 2020). 2.2. protocol after confirmation of study eligibility, participants performed the fms during a single session administered by the lead researchers/authors. the fms involved a series of seven screening tests, each of which were used during data collection. the fms tests included the deep squat, hurdle step, incline lunge, shoulder mobility, active straight-leg raise, trunk stability push-up, and rotary stability. all subjects were tested at the start of the competitive spring sports season, with subject testing occurring just before team practice sessions. subjects were provided the opportunity to complete a voluntary 5-minute warm-up before fms testing. participants were given verbal instructions for task performance and allowed 3 attempts for each task. each movement task was 36 journal of physical education and sports management, vol. 8(2), december 2021 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 34 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmp scored using standard composite scoring. if the participant was able to correctly perform the movement task without any compensation, a score of 3 was be awarded; completion of the movement task with compensation was scored a 2, and inability to complete the movement task was scored a 1. any task that produced pain was scored a 0. tasks with right and left side components were scored individually; the lowest score was used in the calculation of the total composite score. total composite scores ranged from 0 to 21 points, and individual task scores ranged from 0 to 3 points. clearance screens were scored either positive or negative based on the presence of pain. two raters, both of whom had experience using the fms in clinical practice, scored participant performance on the movement tasks. fms scores were shared with program’s soccer coaching staff and strength and conditioning coaches following testing. injuries acquired by the athletes during the course of a recent season (10 training weeks) were diagnosed and recorded by the program’s athletic training staff. injuries were recorded on a hard copy health record maintained by the athletic training staff. injury records were then transferred to data collection sheets that received an identification number and identifiable information was removed. the recordings were used to quantify the number of injuries throughout the season. data collection sheets recorded the injury anatomical location, type of injury, and time off from practice and play. in addition, days of treatment and history of injury were added to data collection sheets. at the conclusion of the sports season, data were abstracted for analysis. 2.3. statistical analyses for each subject, fms data collection sheets were compiled and entered into a spreadsheet where each athlete’s composite score was then calculated. data was analysed using spss predictive analysis software (ibm corp.; version 22.0; 2013). correlation between injury and composite fms score was first ran using pearson correlation test. the dependent variable, injured or not injured, was converted to numerical code (noninjured = 0, injured = 1). the independent variable, composite fms score, remained scored as a range from 0 to 21. the p value was set at 0.05. to determine the difference between rate of injury and sex an independent samples t-test was used with p value set at 0.05. the independent variable, sex, was converted to numerical code (female = 0, male = 1). the dependent variable, injured or not injured, was also convereted to numerical code (noninjured = 0, injured = 1). this test was run to determine whether respective musculoskeletal injury occurrence means from the two groups were statistically significantly different. the difference between fms composite score and sex was determine using an independent samples t-test with a p value set at 0.05. the independent variable, sex, was converted to numerical code (female = 0, male = 1). the dependent variable, fms composite score, remained scored as a range from 0 to 21. this test was run to determine whether respective fms means from the two groups were statistically significantly different. 3. results a total of 36 student-athlete soccer players were eligible for participation at the start of the study. nine of those were excluded from the study due to history of injury 3 months prior to testing (n = 3), unable to attend the test session (n = 5), or leaving the soccer program after starting (n = 1), leaving 27 participants in the final sample. a full description of the sample is available in table 1. table 1. description of participant eligibility group n injury in previous 3 months unable to attend test session left soccer program female 16 2 1 0 male 20 1 4 1 as shown in table 2, the average fms score for the female athletes (n = 13) was 16.769 ± 1.235. the average fms score for the male athletes (n = 14) was 15.357 ± 1.447. females scored approximately 1.4 points higher mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 35 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmp than male subjects. additional analysis using independent samples t-test reveals a significant difference (p< 0.05) between sex and fms composite score. females had a significantly higher fms score. a pearson product-moment correlation was run to determine the relationship between fms score and injury occurrence. there was a small, positive correlation between these two variables, which was statistically significant (r = 0.195, n = 27, p< .05). r2, or the percentange of variance in injury occurrence accounted for by fms score, was ~0.04. in other words 4% of the variance in injury occurrence is accounted for by a subjects’ fms score (or in other words, the fms score reports at least 4% of why injury occurrence would vary). analysis using independent samples t-test reveals a significant difference (p< 0.05) between sex and musculoskeletal injury occurrence. females had a significantly higher injury occurrence (7 injuries in 13 females versus 2 injuries in 14 males) (table 3). table 2. descriptive measures of fms scores within each group group participants mean standard deviation range female 13 16.8* 1.24 15-18 male 14 15.4* 1.45 13-18 *denotes significant difference (p< 0.05) table 3. comparison of injuries per participants and mean fms score for each group group participants injuries mean fms composite female 13 7 16.7692 male 14 2 15.3571 4. discussion the results of this study did not support our first hypothesis that lower fms scores correlate with higher risk of injury. there was only slight correlation between fms score and injury found in this study (r = 0.195). the slight correlation lends some support to the understanding that the fms highlights compensatory movement patterns and increased risk for more severe musculoskeletal injury as suggested by cook et al. (2006) several factors may account for the weakness of the correlation. similar to warren et al. (2015) our sample sizes represented by two collegiate sports teams may have been too small to support association between injury and fms. we suggest further analysis of collegiate soccer players, both males and females, in a larger sample size to fully study this correlation or lack thereof. garrison et al. (2015) found that there was statistically significant difference between injured and uninjured fms scores. to determine injury, garrison et al. (2015) clarified musculoskeletal injury to include an association with athletic participation, a consultation to an athletic trainer, physical therapist, or physician, and modified training for a minimum of 24 hours or protective splinting or taping because of injury. this differed from our methods in that musculoskeletal injury was determined by an association with athletic participation, a consultation with the athletic trainer, but did not incorporate a minimum time commitment to modification of training or taping and bracing. making this change to our methods would suggest that lower fms score may correlate with musculoskeletal injury requiring 24 hours or greater of training adaptations and may be cause for additional testing. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 36 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmp the results did however support our hypothesis that there would be a significant difference between male and female occurrence of injury. during the ten-week spring competition season, seven of the females were injured while two men were injured (p < 0.05). this is consistent with the findings of warren et al. (2015) and agel, arendt, & bershadsky (2005). warren et al. (2015) found 30 of 89 male division ii athletes were injured while 44 of 78 female division ii athletes were injured during their respective competition seasons (p< 0.005). agel et al. (2015) contend that the noncontact injury rate for female ncaa athletes is three times higher in basketball and one-and-a-half times higher in soccer. as suggested by ransdell and murray (2016), the increased rate of injury for females is likely due to a multitude of factors (ransdell & wells, 1999) including smaller muscle fibers and cross-sectional area of muscle (sale et al., 1987), smaller skeletal frame (holloway, 1994), lower levels of muscle activation of the gluteus medius (hart et al., 2007), vastus medialis oblique and vastus lateralis (kim, y & yi, 2009), lower levels of neuromuscular control (brophy et al., 2009; hughes, watkins, & owen, 2008), and core stability (brophy et al., 2009; zazulak et al., 2007). the results also supported our hypothesis that there would be a significantly weaker male than female fms scores. we found that females averaged approximately 1.4 points higher on the fms than males in the same sport, a significantly higher score (p< 0.05). to the best of the authors’ knowledge, this is the first study to find significantly weaker male than female fms scores. the cause of such a correlation is not clear however. anderson, neumann, and bliven (2015) first suggested that there is a significant difference between male and female athletes in their study of the fms in secondary school athletes but indicated several limitations including the absence of intrinsic factor measures that have not been correlated to the fms. likewise, we did not measure intrinsic factors that differ between men and women and may affect fms scores. the relationship between intrinsic factors such as muscle activation, neuromuscular control, and core stability and fms scores needs additional research. further limiting the reliability of the findings was the size of each group sample. we suggest further study with larger samples to verify our findings. the significant difference between the male and female occurrence of injury in conjunction with the significantly higher fms scores in females leads us to believe a higher fms score would be more useful as an indicator of injury risk than the current standard of 14. this differs from chorba et al. (2010) previous studies involving the female sample that found that a score of 14 or less on the fms was an accurate predictor of increased to risk in lower body injury. the significance of these findings could aid in the use of the fms as a preparticipation screening for both male and female athletes. again, our current sample size was smaller but supports further analysis as the implications of increasing the current cutoff score of 14 to a cutoff score of 16 or 17 could reduce the rate of injuries in females when utilized properly. references agel, j., arendt, e. a., & bershadsky, b. (2005). anterior cruciate ligament injury in national collegiate athletic association basketball and soccer: a 13-year review. american journal of sports medicine, 33(4), 524530. anderson, b. e., neumann, m. l., & huxel bliven, k. c. (2015). functional movement screen differences between male and female secondary school athletes. journal of strength and conditioning research, 29(4), 10981106. brophy, r. h., chiaia, t. a., maschi, r., dodson, c. c., oh, l. s., lyman, s., allen, a. a., & williams, r. j. (2009). the core and hip in soccer athletes compared by gender. international journal of sports medicine, 30(9), 663-667. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 37 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmp brown m. t. (2011). the ability of the functional movement screen in predicting injury rates in division 1 female athletes [unpublished master’s thesis]. university of toledo. chorba, r. s., chorba, d. j., bouillon, l. e., overmyer, c. a., & landis, j. a. (2010). use of a functional movement screening tool to determine injury risk in female collegiate athletes. north american journal of sports physical therapy, 5(2), 47-54. cook g. (2010). movement: functional movement systems: screening, assessment, corrective strategies. lotus publications. cook, g., burton, l., & hoogenboom, b. (2006). pre-participation screening: the use of fundamental movements as an assessment of function part 1. north american journal of sports physical therapy, 1(2), 62-72. garrison, m., westrick, r., johnson, m. r., & benenson, j. (2015). association between the functional movement screen and injury development in college athletes. international journal of sports physical therapy, 10(1), 21-28. hart, j. m., garrison, j. c., kerrigan, d. c., palmieri-smith, r., & ingersoll, c. d. (2007). gender differences in gluteus medius muscle activity exist in soccer players performing a forward jump. research in sports medicine, 15(2), 147-155. holloway, j. b. (1994) individual differences and their implications for resistance training. in baechle t. r. (ed.), essentials of strength training and conditioning (pp. 151-162). human kinetics. hootman, j. m., dick, r., & agel, j. (2007). epidemiology of collegiate injuries for 15 sports: summary and recommendations for injury prevention initiatives. journal of athletic training, 42(2), 311-319. hughes, g., watkins, j., & owen, n. (2008). gender differences in lower limb frontal plane kinematics during landing. sports biomechanics, 7(3), 333-341. kiesel, k., plisky, p., & butler, r. (2011). functional movement test scores improve following a standardized offseason intervention program in professional football players. scandinavian journal of medicine & science in sports, 21(2), 287-292. kim, m. h., yoo, w. g., & yi, c. h. (2009). gender differences in the activity and ratio of vastus medialis oblique and vastus lateralis muscles during drop landing. journal of physical therapy science, 21(4), 325-329. lisman, p., o'connor, f. g., deuster, p. a., & knapik, j. j. (2013). functional movement screen and aerobic fitness predict injuries in military training. medicine and science in sports and exercise, 45(4), 636-643. navalta, j. w., stone, w. j., & lyons, t. s. (2020). ethical issues relating to scientific discovery in exercise science. international journal of exercise science, 12(1), 1-8. ransdell, l. b., & murray, t. (2016). functional movement screening: an important tool for female athletes. strength and conditioning journal, 38(2), 40-48. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 38 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmp ransdell, l. b., & wells, c. l. (1999). sex differences in athletic performance. women in sport and physical activity journal, 8(1), 55-81. sale, d. g., macdougall, j. d., alway, s. e., & sutton, j. r. (1987). voluntary strength and muscle characteristics in untrained men and women and male bodybuilders. journal of applied physiology, 62(5), 1786-1793. warren, m., smith, c. a., & chimera, n. j. (2015). association of the functional movement screen with injuries in division i athletes. journal of sport rehabilitation, 24(2), 163-170. zazulak, b. t., hewett, t. e., reeves, n. p., goldberg, b., & cholewicki, j. (2007). deficits in neuromuscular control of the trunk predict knee injury risk: a prospective biomechanical-epidemiologic study. american journal of sports medicine, 35(7), 1123-1130. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 1 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe egg storage: maintaining internal quality for optimal consumer acceptance 1muhammed y and 2caner c. proper storage of chicken eggs is critical to preserve their quality and maintain acceptability to consumers. internal quality changes occur in eggs during storage, which affect their natural protective capacity and make them more susceptible to spoilage. this review article discusses the various internal egg quality parameters, such as albumin quality and yolk index, and the egg grading systems used in the united states and india. the article explains the importance of temperature and humidity in determining the rate of egg quality deterioration and emphasizes the need for proper storage facilities to support sustainable egg production in india. various management practices, such as decreasing shed temperatures and oiling of eggs, can help to reduce deterioration of the albumin before collection and extend the shelf life of eggs. packing eggs under modified atmosphere can also improve their internal quality up to 28 days. this review highlights the importance of proper storage conditions for maintaining egg quality and the need for further research to support egg production in developing countries with limited access to electric supply. keywords: chicken eggs, internal quality, haugh unit, yolk index, egg grading system, storage conditions, temperature, humidity, sustainable egg production. introduction poultry development is one of the important activities and is one of the fastest growing sectors of animal husbandry in india. india is the third-largest egg producer in the world after china and the usa. the per capita availability reached at 69 eggs per annum in the year 2016-17 from 66 eggs per annum from previous year 201516. however the per capita consumption of eggs in rural areas is only half of the urban areas. one of the most challenging constraints in india to increase egg production in rural and arid india is to preserve the egg quality. egg quality are those characteristics which affects its acceptability by the consumers such as cleanliness, freshness, egg weight, shell quality, yolk index, albumen index, haugh unit and chemical composition (song et al., 2000). as on today also most of our rural india does not have proper and full time electric supply, so backyard poultry farmers of those areas are forced to store the eggs under ambient environmental temperature. 1 department of livestock production management faculty of veterinary and animal sciences, institute of agricultural sciences, rgsc, banaras hindu university, barkachha, mirzapur, india. 2 department of veterinary physiology & biochemistryinstitute of agricultural sciences, rgsc, banaras hindu university, barkachha, mirzapur, india. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 2 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe several changes takes place in eggs during storage, and it affects the egg quality adversely if not stored under proper condition. so it is essential to store the eggs until consumption/selling under the proper storage conditions in order to preserve its quality and cooking characteristics. chicken eggs are highly nutritious, whole and hardboiled egg, contains approximately 12.6 g/100g protein, 10.6 g/100g fat, 1.12 g/ 100g carbohydrate and 647kj (155kcal) /100 g energy (eke, et al., 2013). egg grading system based on the protein content, the united states department of agriculture (usda) categorised the eggs on the basis of haugh units. grade a (jumbo egg) must have at least 72 haugh units, b (extra large) must have more than 60 haugh units and eggs with haugh units less than 30 are not for consumption (usda, 2000). in india eggs have been classified on different basis viz. size of air cell and size of eggs. on the basis of size of air cell, are grade a having air cell size up to 4mm and grade b having air cell size up to 8mm, whereas on the basis of size of eggs it was classified as extra large, large, medium and small. egg quality parameters the fertile avian egg consists of a cuticle, a protective eggshell proper, shell membranes, albumen (egg white), and yolk bearing the blastoderm within various thin membranes. egg shells act as hermetic seals that guard against bacterial invasion and the shell membranes function to retain the fluid of the albumen and also to resist bacterial invasion (hassan and aylin, 2009). the quality traits of an egg are those that directly affect its acceptability to the consumers (rath et al., 2015). grading of the eggs are being done on the basis of two factors i.e. external quality which is apparent from external observation and internal quality may be determined after candling or breaking the eggs. internal egg quality start declining immediately after egg is laid and it also depends on the egg handling, storage facility, management practice and nutrition of the birds play a vital role in determining the internal egg quality. among the various factors affecting the egg quality environmental factors such as temperature, humidity and presence of co2, are vital, duration of storage are also very important in terms of the maintenance of egg quality (lacin et al., 2008). in the poultry industry albumin quality or haugh unit (hu) is considered as standard measure to judge the freshness of an egg; it is influenced by genetic factor (johnson and merritt, 1955) as well as by environmental factors such as temperature, time and humidity of storage (samli et al., 2005). haugh unit is the precise measurement of opened egg quality, the higher the hu value, the better the albumin quality of the egg (scott and silversides 2000). it is the logarithm of the height of the inner thick albumen adjusted for egg weight (haugh, 1937). haugh unit are being calculated using the formula: haugh unit (hu) = 100 log (h + 7.57 – 1.7w0.37 where: h = thick egg white (albumen) height in mm, w = egg weight in gram other important measure of the standing egg quality is the yolk index (yi) which is the ratio of yolk height to yolk width, and can be used to assess individual egg freshness (caner 2005). the yolk index is being calculated using the following formula: yolk index (yi) = height of yolk (mm) / diameter of yolk (mm) mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 3 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe the colour of egg yolk is also used to assess the quality of eggs, being determined according to the roche yolk colour fan (voilleumier 1969), is one of the best methods. storage temperature and relative humidity environmental temperature and relative humidity (rh) are the main factors adversely deteriorate the egg quality during storage (tabidi 2011), besides this extent of manipulation of egg and duration of storage is also important factor which affect the egg quality (feddern et al., 2017). the longer the storage time, worse will be the internal egg quality because carbon dioxide transfer through egg shell is favoured by high temperature and humidity (oliveira, et al 2009). the optimal storage temperature of eggs has been determined, based on the physiological zero point at which the embryonic development ceases. interaction between storage temperature and storage period occurs either below or above the physiological zero point at which embryonic development is minimal (brake et al., 1997). internal egg quality deterioration of fresh shell eggs can be significantly delayed during storage by maintaining the storage temperature near the freezing point (zeidler 2002). in normal practice eggs are often held at temperatures range of 1018°c (depending on local conditions) because of the expense of refrigeration and problems of condensation, particularly at temperatures below about 10°c and to reduce the egg weight loss, relative humidity should be maintained 70 to 80 % (williams 1992). kirk et al., 1980 reported that eggs can be stored for 8 days at 15oc and 2 days at 18oc safely. eggs can be stored up to 20 days without losing internal quality characteristics for human consumption at temperature 7°c and 60% relative humidity (alsobayel and albadry., 2011). eggs kept at high temperature i.e. about 370c deteriorated in quality very fast and it is not fit for human consumptions after two weeks. in hot and dry climate, where ambient temperature reaches up to 40oc egg should not be stored more than one week before consumption tabidi (2011). physical and chemical changes in egg quality during storage change in egg weights during storage regardless of bird’s genotype, egg weight decreases during the storage period (muhammad et al., 2014), this is mainly because of the evaporative water loss through thousands of pores contained on eggshell surface, as egg contain around 80% of water of its weight (jozefa and sokolowicz, 2015). cuticle plugging the air pores of the egg shell becomes dried and begins to shrink therefore, the shell pore size increases, which leads to easier escape of gases and moisture from the eggs ultimately results in egg weight loss. temperature of the storage environment play important role in loss of moisture from egg by evaporation. as carbon dioxide is lost through the shell pores while oxygen gets into the egg and creates an air bubble inside in-place of moisture and carbon dioxide, causing the egg to float when placed in water due to loss of weight (hassan and aylin, 2009). the egg quality is affected by the method and duration of storage, if egg does not stored under proper storage conditions, decrease in egg weight with increased storage time. if eggs stored under higher temperature will results in higher loss of weight than eggs stored under refrigeration (singh et al., 2014). change in air cell the freshness of eggs can also be assessed by measuring air cell size (distance between eggshell and membrane), because evaporation of water leads to a reduction in the volume of the albumen, resulting in an increase in the size of the air space (magdalena and drazbo 2018). air cell size exceeds 4mm in two days at storage temperature of 21oc (samlli et al., 2005). eggs stored under the unfavourable temperature and humidity, have significant mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 4 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe adverse effects upon the air cells depth and reported that increase in size of air cell as a result of long term storage (alsobayel and albadry., 2011). changes in haugh unit during storage of eggs the albumen that surrounds the yolk, which is called the thick albumen, progressively liquefies and thins with time, transforming itself into thin albumen (kato et al., 1994). as it is known that this leads to decline in the haugh unit of the eggs during storage is due to the breakdown of carbonic acid in the eggs white which produced carbon dioxide and water. the evaporation of carbon dioxide and water through egg shell pore leads to increases in the ph of the albumen to alkaline state, because of this egg white change its gel structures to lose strength and white became watery which led to loss in haugh unit of eggs (yimenu., et al 2017). albumen quality can also be measured by the ph of albumen. the ph of fresh egg at oviposition is about 7.6 (staldelman and cotteril, 2007) which rises during storage because of loss of carbon dioxide out from the egg through the shell pores (muhammed and caner 2014; and marzec 2019). a rapid loss of co2 takes place particularly with the albumen, leads to a decrease in the quality until the state of gas balance is reached between the inside and outside of the egg (tabidi 2011). at higher storage temperatures, loss of co2 is faster results in faster deterioration of albumin quality. the movement of carbon dioxide and moisture through the egg decreases moisture percentage of egg albumen and decreases the egg weight. change in albumen viscosity ovomucin, proteins in egg albumen plays a major role in giving gel-like consistency to egg white and thus a role in the viscosity of the thick albumen to egg white. during storage because of loss of co2 leads to increase in ph causing destabilization of the protein complex leads to change in viscosity of the albumen (li-chan and nakai 1989). change in yolk index during storage another change that takes place during egg storage is the flattening of the yolk. the yolk of a freshly laid egg is round and firm (okoli and udedibie, 2000). as we have discussed that during storage of eggs, breakdown of carbonic acid into carbon dioxide and water and then diffusion of water from the albumen to yolk through the vitelline membrane (obanu and mpieri 1984) to equalise the concentration (pressure) between the two phases (i.e. egg white and yolk) and this results in swelling of the yolk which in turn weaken and stretch the vitelline membrane (watkins, 2007). this pressure eventually causes the yolk to change from a spheroid shape to a round flabby shape mass (stadelman and cotterill, 1995), increased water content of the yolk (caner and yuceer, 2015), resulted in a decrease of yolk solids concentration (li‐chan et al., 1995). as a result of increase permeability of the vitelline membrane leads to mix in the content of albumen and yolk causes mottling of yolks (with many pale spots and blotches which vary in colour size and shape). storage time and temperature has also been shown to adversely affect the degree of egg yolk mottling (coutts and wilson, 1990). as a result of degenerations of vitelline membrane during storage, water enters the egg yolk causing the mottling, and albumen proteins also enter the yolk increasing the severity of mottling (amiri andi et al., 2006). mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 5 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe change in microbiological properties of egg during storage storage conditions play vital role in preserving the microbiological quality of eggs. there is a marked increase of naturally occurring psychophilic bacteria, coliform, staphylococci, yeast and moulds on egg shell surface and in its content during egg storage (faris et al., 2011). this is because the cuticle on the surface of the shell of the eggs stored at higher temperature dries up and starts to shrink, which leads to increase in shell pore size, making it easier for microorganisms to pass in and out of the egg shell (eke, et al., 2013). bacterial and fungal contamination of eggs resulting from faecal contamination and infection in oviduct results in black, red or green rot, which gives the egg looks and smells putrid when broken out of the shell. proper handling and storage of eggs fallowing collection will minimise the chances of contamination by bacteria and fungus. prevention decreasing shed temperatures in the hotter months, combined with regular collection of eggs so reducing the time egg are exposed to high temperature, will help to reduce deterioration of the albumin before collection (jones, 2006). oiling of eggs with odourless, tasteless mineral oil, preferably within 24 hours of being laid, markedly improves the keeping quality of stored eggs and also help to reduce co2 losses and thus help maintain internal egg quality (nadia et al., 2012; raji et al. 2009) but it does not replace the need for cool storage (faris et al., 2011). application of oil on eggs to ensure retention of good quality eggs especially in the tropics and most developing nations of the world. packing eggs under modified atmosphere extend their internal quality up to 28 days (giampietro-ganeco et al., 2012) conclusion egg weight, haugh unit, and yolk index significantly decreased with increased storage time and temperature. ph of both albumin and yolk increases with increased storage time and temperature. therefore in the tropics and most developing country of the world it is necessary to use different management practices along with proper methods of storage in order to increase the shelf life of eggs for human consumption. references alsobayel a a and albadry m a. (2011). effect of storage period and strain of layer on internal and external quality characteristics of eggs marketed in riyadh area. journal of the saudi society of agricultural sciences. (10):41-45. amiri andi m, shivazad m, pourbakhsh s a, afshar m and rokni h. (2006). effect of vitamin e in broiler breeder diet on hatchability, egg quality and breeder and day old chick immunity. pakistan journal of biological science. 9:789-794 brake j, walsch t j, benton c e, in petitte j r, meijerhof r. and panavalva g. (1997). egg handling and storage. poultry. science. 76:144-151. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 6 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe caner c (2005). whey protein isolates coating and concentration effects on egg shelf life. journal of the science of food and agriculture 85:2143–2148. caner c and yuceer m. (2015). efficacy of various protein-based coating on enhancing the shelf life of fresh eggs during storage poultry. science. 94:1665-1677 coutts ja and wilson g c. (1990). egg quality handbook. queensland department of primary industries, australia. eke mo, olaitan n i and ochefu j h. (2013). effect of storage conditions on the quality attributes of shell eggs (2013). official journal of nigerian institute of food science and techonology 31 (2): 18 – 24. faris aa, shahrasad mj, shadedi al, rasheed h a. (2011). quality, chemical and microbial characteristics of table eggs at retail stores in baghdad. international journal of poultry science, 10 (5): 381–385. feddern v, celant m, pra de, mores r. (2017). egg quality assessment at different storage conditions, seasons and laying hen strains. ciencia e agrotecnologia 41(3):322-333 [10] giampietro-ganeco a, scatolinisilva am, borba h, boiago mm, lima tma, souza p. a. (2012). comparative study of quality characteristics of egg stored in domestic refrigerators. ars veterinaria 28(2):100-104 hassan a. and aylin ao. (2009). effect of storage time, temperature and hen age on egg quality in free range layer. journal of animal and veterinary advances 8(10):1953-1958. [12] haugh r r. (1937). the haugh unit for measuring egg quality. us egg poultry magazine 43:522-555. johnson a s and e s merritt (1955). heritability of albumen height and specific gravity of eggs from white leghorns and barred rocks and the correlations of these traits with egg production. poultry. science. 34:578-587. jones, d. r., 2006. conserving and monitoring shell egg quality. proceedings of the 18th annual australian poultry science symposium, pp. 157 165. jozefa k and and sokolowicz z. (2015). effect of chicken breed and storage conditions of eggs on their quality. acta scientiarum. polonorum. zootechnica 14(4):109– 118 kato s, kawamura t, goto t, ohduchi h and toyolima k. (1994). effect of storing condition on interior quality of quail (coturnix coturnix japonica) egg research bulletin of the aichi-ken agricultural research center 26: 371-3. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 7 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe kirk, s., emmans gc, mcdonald r, and arnot d. (1980). factors affecting the hatchability of eggs from broiler breeders. british poultry science. 21:37–53. lacin e, coban o and sabuncuoglu n. (2008). effects of egg storage material and storage period on hatchability in japanese quail. asian-australian journal of animal science 21(8):1183-1188. li-chan e and nakai s (1989). biochemical basis for the properties of egg white. critical reviews in poultry biology. 2:21–58 li‐chan e.c.y, powrie w d and nakai s. (1995). the chemistry of eggs and egg products. in w.j. stadelman, & o. j. cotterill (eds.), egg science and technology (4th ed., pp. 109– 160). new york, ny: food products press. magdalena k and drazbo a. (2018). changes in the quality of table eggs depending on storage method and time. scientific annals of polish society of animal production 14 (3) 37-45. marzec a, damaziak k, kowalska h, riedel j, michalczuk m, koczywąs e, cisneros f, lenart a, niemiec j. (2019). effect of hens age and storage time on functional and physiochemical properties of eggs. journal of applied poultry research. 28(2) 290-300 [23] muhammad j. a. khan, khan s h, bukhsh a and amin m (2014). the effect of storage time on egg quality and hatchability characteristics of rhode island red (rir) hens. veterinarski arhiv 84 (3), 291-303 muhammed y and caner c. (2014). antimicrobial lysozyme chitosan coatings affect functional properties and shelf life of chicken eggs during storage. journal of the science of food and agriculture. 94: 153–162. nadia n a a, bushra s r z, layla a f and fira m a. (2012). effect of coating materials (gelatin) and storage time on internal quality of chicken and quail eggs under refrigeration storage. poultry science 32 (1): 107 – 115. obanu z a and mpieri a a. (1984). efficiency of dietary vegetable oils in preserving the quality of shell eggs under ambient tropical conditions. journal of the science of food and agriculture. 35:1311–1317 okoli i c and a b i udedibie. (2000). effect of oil treatment and storage on egg quality. journal of agriculture & rural development. 1:55-60. oliveira g e, figueiredo t c, souza m r, oliveira a l, cançado s v, gloria m b a. (2009). bioactive amines and quality of egg from dekalb hens under different storage conditions. poultry science, 88(11):24282434 mailto:topacademicjournals@gmail.com https://www.sciencedirect.com/science/article/pii/s1056617119300327#! https://www.sciencedirect.com/science/article/pii/s1056617119300327#! https://www.sciencedirect.com/science/article/pii/s1056617119300327#! https://www.sciencedirect.com/science/article/pii/s1056617119300327#! https://www.sciencedirect.com/science/article/pii/s1056617119300327#! https://www.sciencedirect.com/science/article/pii/s1056617119300327#! https://www.sciencedirect.com/science/article/pii/s1056617119300327#! https://www.sciencedirect.com/science/article/pii/s1056617119300327#! https://www.sciencedirect.com/science/article/pii/s1056617119300327#! https://www.sciencedirect.com/science/article/pii/s1056617119300327#! https://www.sciencedirect.com/science/article/pii/s1056617119300327#! https://www.sciencedirect.com/science/journal/10566171 https://www.sciencedirect.com/science/journal/10566171 https://pubmed.ncbi.nlm.nih.gov/?term=oliveira+ge&cauthor_id=19834096 https://pubmed.ncbi.nlm.nih.gov/?term=oliveira+ge&cauthor_id=19834096 https://pubmed.ncbi.nlm.nih.gov/?term=figueiredo+tc&cauthor_id=19834096 https://pubmed.ncbi.nlm.nih.gov/?term=figueiredo+tc&cauthor_id=19834096 https://pubmed.ncbi.nlm.nih.gov/?term=souza+mr&cauthor_id=19834096 https://pubmed.ncbi.nlm.nih.gov/?term=souza+mr&cauthor_id=19834096 https://pubmed.ncbi.nlm.nih.gov/?term=oliveira+al&cauthor_id=19834096 https://pubmed.ncbi.nlm.nih.gov/?term=oliveira+al&cauthor_id=19834096 https://pubmed.ncbi.nlm.nih.gov/?term=can%c3%a7ado+sv&cauthor_id=19834096 https://pubmed.ncbi.nlm.nih.gov/?term=can%c3%a7ado+sv&cauthor_id=19834096 https://pubmed.ncbi.nlm.nih.gov/?term=gloria+mb&cauthor_id=19834096 american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 8 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe raji a o, aliyu j, igwebuike j u, chiroma s. (2009) effect of storage methods and time on egg quality traits of laying hens in a hot dry climate. arpn journal of agricultural and biological science 4(4):1–7 rath p k, mishra p k, mallick b k and behura n c. (2015). evaluation of different egg quality traits and interpretation of their mode of inheritance in white leghorns. veterinary world 8(4): 449–452 samli h e, agna a and senkoylu n. (2005). effects of storage time and temperature on egg quality in old laying hens. journal of applied poultry research 14:548-533. [32] scott ta and silversides fg (2000). the effect of storage and strain of hen on egg quality. poultry science 79:1725–1729 singh, j, sharma h k, premi m and kumari k. (2014). effect of storage conditions of egg on rheological properties of liquid whole egg. journal of food science and technology. 51(3):543–550. song kt, choi s h and oh hr. (2000). a comparison of egg quality of pheasant, chykar, quail and guinea fowl. asianaustralia animal science 13(7): 18-22. stadelman w j and cotterill oj. (2007). egg science and technology, 4th edition, haworth press inc. new york. stadelman w j and cotterill o j. (1995). egg science and technology. 4th edn., food products press. an imprint of the haworth press. inc. new york, london. tabidi m h (2011) impact of storage period and quality on composition of table egg. advances in environmental biology 5(5): 856-861. usda (2000). united state department of agriculture. egg grading manual. mphotline.fsis@usda.gov. voilleumier j p (1969) the roche yolk colour fan an instrument for measuring yolk colour. poultry science 48:787-779 watkins, b.a. (2007). the nutritive value of egg. in w.j. stadelman and o.j. cotterill (eds.) egg science and technology 4th edition. haworth press inc., new york, pp. 177 – 194. williams, k.c. (1992). some factors affecting albumen quality with particular reference to haugh unit score. world’s poultry science journal, 48:5-16. yimenu s m, kim j y and kim b s. (2017). prediction of egg freshness during storage using electronic nose. poultry science. 96 (10): 3733–3746. zeidler g. (2002). shell egg quality and preservation, in commercial chicken meat and egg production (5th edn), ed. by bell dd and weaver wd. springer, norwell, ma, pp.1199–1217. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 6; november-december 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 1 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe a study of the factors that affect season ticket holders' satisfaction with interaction quality cindy elizabeth lee sports center hong kong abstract: customer satisfaction is essential for organizations to retain customers. in the sport industry, where the quality of the game is not always controllable, customer service becomes an important factor in influencing customer satisfaction. this study examines the importance of various dimensions of service quality (reliability, assurance, empathy, and responsiveness) on season ticket holders' overall satisfaction with the customer service provided by ticket account representatives. keywords: customer satisfaction, service quality, season ticket holders, ticket account representatives, reliability, assurance, empathy, responsiveness. introduction making customers happy and satisfied is important for organizations since it is directly related to customer retention. saleh (2015) argued that it costs five times more to attract a new customer than to retain an existing customer. retaining current customers is even more important for major league sport teams, since their everincreasing ticket prices limit the scope of their potential consumers to relatively high income classes. customer satisfaction is directly related to customer retention. this close relationship between the two concepts indicates that to retain customers, companies need to satisfy their customers (cronin, brady, &hult, 2000).some studies (e.g., liu, guo, & lee, 2011) attest that high quality of service or goods is one of the important factors in consumer satisfaction. however, “quality” is not an easy concept to be defined in the sport context. for an examples, quality of game fluctuates and winnings cannot be guaranteed due to the characteristics of “service”. sometimes, spectators are offered a great game, but other times spectators end up watching rather dull games for the same amount of money. due to this inconsistent nature of games, other factors that influence consumer satisfaction become more relevant and meaningful in the sport context. one of those factors is customer service. bad season could get people upset; but bad customer service could permanently turn people away from an organization. as the competition for consumers‟ money in the sport and entertainment industry gets intense, providing quality customer service, a controllable aspect unlike game quality, becomes more important. for professional sport teams, season ticket holders are the most important customers due to the size of revenue generated from them. not only are season ticket holders most important from a financial standpoint, but also they are the ones who are most loyal to a team (gladden & funk, 2001) giving emotional support. bauer, stokburger-sauer, and exler (2008) also mentioned the importance of “fans” compared to casual “spectators”. season ticket holders can be regarded as dedicated fans who are willing to invest their time and money. at the same time, season ticket holders‟ level of expectation could be high since they are invested. making them satisfied and feel appreciated is almost a must for the success of professional sport teams considering the importance of season ticket holders, and when it comes to the customer satisfaction, the concept of “service quality” becomes relevant. researchers such as brady and cronin (2001) argued that interaction quality between a customer and an employee is an influencing factor on customer satisfaction. therefore, this study will examine the importance of various dimensions of service mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 6; november-december 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 2 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe quality (i.e., reliability, assurance, empathy and responsiveness) on season ticket holders‟ overall satisfaction with the customer service provided by ticket account representative. 2. literature review 2.1 season ticket holders loyal fans serve as an important base for professional sport teams by providing monetary and emotional support. loyal fans are the ones who fill a stadium, purchase licensed merchandise, and follow team-related news on the media (greenwell, fink, &pastore, 2002; gwinner & swanson, 2003).season ticket holders invest significant amount of time and money to see the actions of their team in person, and often times they pay a premium price to see them. season ticket holders are also the most loyal and dedicated fans. having a loyal fan base can add value to potential sponsors since loyal fans are likely to pay more attention to sponsors‟ messages and tend to purchase sponsors‟ products than less-identified fans (kwon & armstrong, 2002; pope &voges, 2000). having high number of season ticket-holders means high portion of guaranteed revenue even when a team does not perform well (gladden & funk, 2001), which provides financial stability for teams. due to these various reasons, season ticket holders are one of the most important fan segments. therefore, teams have every reason to please and satisfy their season ticket holders, to create and maintain strong and lasting relationships with them. this becomes even more important since only small segment of population can afford season tickets as the prices for season tickets become more and more expensive (“average ticket prices”, 2016). 2.2 ticket representative the basic daily responsibility of ticket representatives is to perform various customer service functions related to ticket sales and management. more specifically, ticket representatives communicate with current and potential customers including season-ticket holders on various ticket options, problems, and concerns. one of the difficulties and challenges for ticket representative (service provider) in the service industry is that customers‟ requests cannot be always fulfilled. this is partially because what is requested does not always fall under ticket representatives‟ discretion and they are rather limited in what they can do and cannot do. this means that some issues or complaints raised by season ticket holders (e.g., benefits, price, or seat location) are not under ticket representatives‟ control. however, since ticket representatives are on the front line and often the first contact points when these issues were occurred, their ability and demeanor to handle customers‟ problems and concerns are likely to influence customers‟ experience in the process. for the major baseball league team in this study, specific ticket representatives were assigned to season ticket holders. by having a designated ticket representative, season ticket holders can have a consistent communication channel, which meant to facilitate efficient and effective communication as well as to build personal relationships. 2.3 service quality and dimensions defined as “the consumers‟ judgment about an entity‟s overall excellence or superiority (parasuraman, zeithaml, &berry, 1988, p. 15), service quality theory lies in the concepts of product quality and customer satisfaction (brady & cronin, 2001). various studies have shown that service quality is connected with customer satisfaction (ko & pastore, 2004; liu, guo, & lee, 2009) and repurchase intention (fornell, 1992). however, what it is and how to measure it is a much more complicated issue due to its intangible, heterogeneous, and inseparable nature (parasuraman, zeithaml, &berry, 1988). thus, quite a few measurements have been developed based on the conceptualization of “service quality.” for example, parasuraman et al. (1985) viewed service quality as the difference between customer expectation and the perception of service quality, measuring it with ten dimensions of tangibles, reliability, responsiveness, communication, credibility, security, competence, courtesy, understanding/knowing the customer, and access in mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 6; november-december 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 3 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe their servqual model. later, parasuraman et al. (1988) refined these ten dimensions to five dimensions of reliability, responsiveness, assurance, empathy, and tangibles. brady and cronin (2001) conceptualized service quality as three dimensions of interaction quality, physical environment, and outcome quality. interaction quality has sub-dimensions of attitude, expertise, and behavior. physical environment encompasses ambient conditions, design, and social factors. lastly, outcome quality includes valence, waiting time, and tangibles. many studies (e.g., ko, zhang, catani, & pastore, 2011; moon, kim, ko, cannaughton, & hak, 2011) have examined the service quality in the context of sport. this study focuses to address the “interaction” aspect of service quality. parasuraman et al‟s (1988) refined five dimensions (i.e., reliability, responsiveness, assurance, empathy, and tangibles) of service quality were used as the base. specifically, reliability refers to “the ability to perform the promised service dependably and accurately”. responsiveness refers to “willingness to help customers and provide prompt service.”assurance means “knowledge and courtesy of employees and their ability to convey trust and confidence.”empathy refers to “caring, individualized attention the firm provides its customers”. lastly, tangibles indicate “physical facilities, equipment, and appearance of personnel”. the last dimension, “tangibles”, was not included because the interactions between ticket representatives and season ticket holders occur via phone and emails most of the time, rather than face-to-face interactions. therefore, four dimensions of reliability, responsiveness, assurance, and empathy were selected to be used in this study. 2.4. interaction quality interaction quality refers to the quality of interactions between the organization‟s employees and the customers. interpersonal interactions occur during the service delivery. brady and cronin (2001) suggested that the quality of interactions is influenced by the employee‟s attitude, behavior, and expertise related to the job performance. from an organizational standpoint, providing proper training would be important, so employees are equipped with necessary expertise and information in their dealing with customers. researchers have found that the relationship between customers and a company isdepending on many factors such as shared objectives, complaint management, satisfaction, communication (brashear, bolles, bellenger, & brooks, 2003). pleasant interactions with ticket representative can positively influence consumers‟ perceived interaction quality. on the other hand, unpleasant interactions are likely to negatively impact consumers‟ perceived quality of interaction. considering this, management should strive to offer congenial customer and employee interactions as much as possible. this would be rather simple when there is no confronting issue. however, making pleasant interaction can be challenging when consumers face some issues which make them unhappy. if a cause of concern is not resolved in a satisfactory manner, this is likely to result in potential damage in the relationship between the consumer and the respective employee, and further with the organization. thus, the issue of managing customer problems or complaints becomes relevant in interactions between customers and employees. 2. 4.1complaintmanagement the term “complaint management” explains the way organizations deal with the problems expressed by customers with their service that generates a certain degree of dissatisfaction (álvarez, casielles, & martin, 2011). whether consumers‟ complaints are properly heard and dealt with or not could influence consumers‟ perceived interaction quality, because oftentimes complaints are handled by personnel rather than by automated system. therefore, managing customer complaints is an influencing factor on interaction quality. this means that managing raised complaints is a critical part of interaction with customers, which influences whether a company can maintain a good relationship with customers. according to tax, brown and chandrashekara (1998), when customers face a problem, they may respond by exiting, loyalty, or voicing (complaining). however, when a customer received adequate response when they raised issues, they are more likely to stay (conlon & murray, 1996). this means mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 6; november-december 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 4 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe that if a raised issues are well-managed by an organization, the customer is likely to stay with the organization rather than terminate the relationship. conlon and murray (1996) similarly noted that one of the two major reasons for customers switching services are unfavorable service encounters with the company‟s personnel, and core service failures. 2.5 satisfaction fornell (1992) defined customer satisfaction as an overall attitude formed based on the experience after purchasing and using products and services. zeithaml and bitner (2000) mentioned that satisfaction can be affected by an array of factors such as service quality, product quality, price, and contextual and personal factors. satisfaction is regarded as one of the antecedents of loyalty, and many studies (e.g., de ruyter & wetzels, 2000; deng, lu, wei, & zhang, 2009) showed the positive relationship between satisfaction and customer loyalty. similarly, blanchard and galloway (1994) argued that satisfaction can be derived from a consumer‟s perception of the overall value received in a relationship with an organization. in the sport contexts, researchers looked into two types of customer satisfaction: game satisfaction (kwon et al., 2005; trail, anderson, & fink, 2005) and service satisfaction (wakefield & blodgett, 1996). 3. methods for this study, a major league baseball (mlb) team‟s annual survey with season ticket holders was used. the team collects two to three surveys per season and each version varies a little by different subsets of questions. this study used the 2013-2014 season survey which included questions regarding season ticket holders‟ satisfaction with theassigned ticket account representative. 3.1. participants the survey link was sent to the season ticket holders of a mlb team located in northeast region of the united states. their season tickets include eight different types ranging from full season tickets to ten games per season. as an incentive for completing the survey, the participants were given an opportunity to enter lottery to win a team jersey. the total number of respondents was 1,149. the followings are the results of descriptive statistics for the respondents. the majority of the respondents were male (n=795, 69.2%) and caucasian (n=1,001, 87.1%). in terms of marital status, 750 respondents (65.3%) were married or with partners, 216 respondents (18.8%) were single/never married, and 96 people (8.4%) were either divorced, separated, or widowed. in terms of age, all age groups were represented while some age groups are more prominent: under 18 (n=2), 18-21(n=11), 22-25 (n=34), 26-35 (n=170), 36-45 (n=167), 46-55 (n=304), 56-65 (n=281) and 66 and older (n=104).about half of the respondents (n=585, 50.91%) were either in„46-55‟ or ‟56-65‟ age bracket. in regard to the education level, more than 60% of the respondents have either graduate/professional degree (n= 358, 31.2%) or bachelor‟s degree (n= 339, 29.5%).in terms of income, the biggest bracket (n=178, 15.5%) was $100k~$149k. however, about one third of the respondents (29.9%, n=344) chose not to answer this question. 3.2. questionnaire the survey contained other questions including preference of season ticket holders‟ benefits, usual companions to games, perceived image of the team in addition to the questions of season ticket holders‟ satisfaction with customer services. this study, however, will only focus on the dimensions of service quality provided by ticket representative to season ticket holders. to measure season ticket holders‟ satisfaction with the service quality with their assigned ticket representatives, the respondents were asked to select their ticket account representative from a drop-down box. then, season ticket holders‟ overall satisfaction level (3 items) with a particular ticket representative was measured, followed by four service quality dimensions of reliability (2 items), responsiveness (1item), assurance (3 items), and empathy (2 items) using 5-point likert scale ranging from 1(poor) to 5(excellent). mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 6; november-december 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 5 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe some constructs only have one or two items due to the length of the survey. other demographic questions were asked including age, gender, ethnicity, marital status, household income and education. 3.3. data analysis. a multiple regression analysis was conducted with a dependent variable of satisfaction and independent variables of four dimensions of interaction quality (i.e., reliability, responsiveness, assurance, and empathy) to see the contribution of each factor in predicting consumers‟ satisfaction level with their assigned ticket representative. 4. results out of the 1,149 respondents, only 739 (64.3%) answered the portion of customer satisfaction with their assigned ticket representative. others opted not to answer with various reasons like “cannot remember the name of the assigned ticket representative”, “do not have much to evaluate”, or “ticket representative was changed over time”. to test the reliability of the constructs, cronbach‟s alpha tests were conducted for three service quality dimensions except responsiveness (1 item). the results showed that all alpha values were above the recommended minimum level of .70 (nunnally & bernstein, 1994): reliability α=.91; assurance α=.88; empathy α=.85; satisfaction α=.89. the mean scores for each dimension of service quality and overall satisfaction with their assigned service representative marked relatively high with highest possible point of 5: overall satisfaction with a ticket account representative(m= 4.30, sd= .98), reliability (m= 4.48, sd= .90), assurance (m= 4.33, sd= .87), empathy (m=4.48, sd= .79), and responsiveness (m= 4.51, sd=.86). table 1. descriptive statistics for each construct (5-point likert scale) variable mean sd cronbach’s α reliability 4.48 .90 .91 assurance 4.33 .87 .88 empathy 4.48 .79 .85 responsiveness (one-item) 4.51 .86 satisfaction 4.30 .98 .89 a multiple regression was used to measure the contribution level of the four dimensions (i.e., reliability, assurance, empathy, and responsiveness) of service quality for season ticket holders‟ satisfaction level. the results showed that all four dimensions were significant predictors in explaining customer satisfaction with their ticket representative (f(4, 734)=532.27, p<.001, r2=.74). the four predictors explained about 74% of the respondents‟ satisfaction level. specifically, empathy (β= .35, p< .001) was the most contributing factor on satisfaction followed by reliability (β= .30, p< .001), assurance (β=. 17, p< .001,), and responsiveness (β= .09, p< .005). table 1 provides a summary of the multiple regression analysis with the four dimensions of service quality which predict the respondents‟ satisfaction level with the ticket account representative. table 2. multiple regression analysis for service quality dimensions predicting sth’s satisfaction with ticket representative variable standardized β se t-value p reliability .30 .04 6.71 .000 assurance .17 .04 4.17 .000 empathy .35 .06 7.19 .000 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 6; november-december 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 6 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe responsiveness .09 .03 2.93 .003 5. discussion the results of this study provide an insight on different dimensions of service quality, particularly on interaction quality, and furthermore, these different dimensions‟ importance on season ticket holders‟ satisfaction with their ticket service representative. the result of the multiple regression showed that empathy is the biggest factor (β= .35, p< .001) in explaining season ticket holders‟ satisfaction level with their ticket representatives while responsiveness is the least contributing factor (β= .09,p< .05). the fact that empathy is the most important factor on consumers‟ satisfaction might have to do with season ticket holders‟ expectation with the ticket representative. a ticket account representative is a team‟s first contact when issues and problems arise. when a customer is upset due to some issues, consumers would expect and appreciate empathy from a person in that organization. season ticket holders might acknowledge that the amount of discretion given to the assigned ticket representative may not enough to solve their issues. nonetheless, they would appreciate service respondents‟ empathy, and their willingness to resolve the issue. the manner or the way these service representatives (e.g., ticket account representative) respond to raised concerns and dissatisfaction can influence how these customers feel after the interaction. for example, some of the season ticket holders commented that the team has increased ticket price, so she/he is not happy about it, or the seat location for the price is not good enough, which illustrate some common complaints. it should be noted that some of the concerns (e.g., too high ticket price) cannot be resolved at the ticket representative level. it is also possible that ticket holders do not expect the problem would get resolved, but rather want to hear agreeing and sympathetic responses when they vented their anger or dissatisfaction. collier (2015) argued that empathy is the most important skill for all customer service representatives. similarly, in the service quality in the hotel industry, yilmas (2009) also found that empathy is the most important dimension in predicting hotel customer‟s overall service quality evaluation. however, the importance of these dimensions is likely to vary depending on the context. for example, lau et al.‟s (2013) study with the banking industry shows that empathy was the least significant factor while reliability and assurance are more important for customers‟ satisfaction. it is possible that customers value dimensions differently by various characteristics and contexts of the service industry. the second contributing factor for satisfaction was reliability indicating the customer representative‟s ability to perform the promised service in a dependable and accurate manner. this shows that season ticket holders value the agreed service will be delivered. lastly, it was interesting that responsiveness is the least contributing factor to customers‟ satisfaction. we speculate that it is not because responsiveness is not important in interaction quality, but probably because this aspect is already given (m= 4.51). the team in this study ensures each representative‟s accountability systematically: the ticket representatives are specifically responsible for dealing with assigned season ticket holders and the ticket account representatives are evaluated their service quality through the annual season ticket holders‟ surveys where the season ticket holders pin-point who are their assigned ticket representatives. since each ticket account representative only deals with assigned customers, and their evaluation is directly coming from the assigned season ticket holders, the system holds each ticket representative responsible for their actions. overall, the team scored a high level of customer satisfaction (m= 4.30) in terms of their interaction dimension of service quality. however, the results are only based on the season ticket holders who completed this survey. approximately one third of the respondents (n=410, 35.7%) did not answer to the section of the customer service. it is possible that some season ticket holders did not interact with ticket representative enough to evaluate them or the interactions were insignificant to be remembered. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 6; november-december 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 7 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe as the majority of sport industry is centered on customers‟ experience, further studies should be conducted to help better understand the relative importance of different dimensions in interaction quality in different contexts and levels of sports. future studies should also look into different groups of customers (e.g., customers whose issue was favorably resolved, customers whose issue was not resolved, customers who had no problem at all) to see if satisfaction level changes after an issue is addressed and whether this changed satisfaction level lasts in the long term. references álvarez, l. s., casielles, r. v., & martin, a. m. (2011). analysis of the role of complaint management in the context of relationship marketing. journal of marketing management, 27(1), 143-164. average ticket prices in the major sports leagues in north america in 2015/16 (in u.s. dollars). (2016). retrieved october 26, 2016, from https://www.statista.com/statistics/261588/average-ticket-price-major-ussportsleagues/ bauer, h. h., stokburger-sauer, n. e., &exler, s. (2008). brand image and fan loyalty in professional team sport: a refined model and empirical assessment. journal of sport management, 22(2), 205-226. blanchard, r. f., & galloway, r. l. (1994). quality in retail banking. international journal of service industry management, 5(4), 5-23. brady, m. k., & cronin, j. (2001). some new thoughts on conceptualizing perceived service quality: a hierarchical approach. journal of marketing, 65(3), 34-49. brashear, t. g., boles, j. s., bellenger, d. n., & brooks, c. m. (2003). an empirical test of trust-building processes and outcomes in sales manager-salesperson relationships. journal of the academy of marketing science, 31, 189-200. collier, m. (2015, feb. 18). empathy: the must-have skill for all customer service reps. retrieved from https://www.insightsquared.com/2015/02/empathy-the-must-have-skill-for-all-customerservice-reps/ conlon, d.e., & murray, n.m. (1996). customer perceptions of corporate responses toproduct complaints: the role of explanations. academy of management journal, 39(4),1040–1056. deruyter, k., &wetzels, m. g. m. (2000). the impact of perceived listeningbehavior in voice-to-voice service encounters. journal of service research, 2(3), 276–284. deng, z., lu, y., wei, k. k., & zhang, j. (2009). understanding customer satisfaction and loyalty: an empirical study of mobile instant messages in china. international journal of information management, doi:10.1016/j.ijinfomgt.2009.10.001 fornell, c.(1992). a national customer satisfaction barometer: the swedish experience. journal of marketing, 56(1), 6– 21. gladden, j. m., funk, d. c. (2001). understanding brand loyalty in professional sport: examining the link between brand associations and brand loyalty. international journal of sport marketing & sponsorship, 3, 67-91. mailto:topacademicjournals@gmail.com https://www.insightsquared.com/2015/02/empathy-the-must-have-skill-for-all-customer-service-reps/ https://www.insightsquared.com/2015/02/empathy-the-must-have-skill-for-all-customer-service-reps/ american journal of medical and physical education vol.6, issue 6; november-december 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 8 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe greenwell, t.c., fink, j.s., &pastore, d.l. (2002). perception of the service experience: using demographic and psychographic variables to identify customer segments. sport marketing quarterly, 11(4), 233-241. gwinner, k.p. & swanson, s.r. (2003). a model of fan identification: antecedents and sponsorship outcomes. the journal of services marketing, 17(3), 275-294. ko, y.j.,&pastore, d. l.(2004). current issues and conceptualizations of service quality in the recreation sport industry.sport marketing quarterly, 13(3), 159-166. ko, y. j., zhang, j., cattani, k., &pastore, d. (2011). assessment of event quality in major spectator sports. assessment of event quality in major spectator sports. managing service quality, 21(3), 304-322. kwon, h. h., & armstrong, k. l. (2002). factors influencing impulse buying of sport team licensed merchandise. sport marketing quarterly, 11, 151-163. lau, m. m., cheung, r., lam, a. y., & chu, y. t. (2013). measuring service quality in the banking industry: a hong kong based study. contemporary management research, 9(3), 263-282. liu, c., guo, y. m.,& lee, c. (2011). the effects of relationship quality and switching barriers on customer loyalty. international journal of information management, 31(1), 71-79. nunally, j. c., & bernstein, i. h. (1994). psychometric theory (3rded.). new york: mcgraw-hill. parasuraman, a., zeithaml, v., & berry, l. (1985). a conceptual model of service quality and its implications for future research. journal of marketing, 49(fall), 41-50. parasuraman, a., zeithaml, v. a., & berry, l. (1988). servqual: a multiple-item scale for measuring consumer perceptions of service quality. journal of retailing, 64(1), 12-40. pope, n. k., &voges, k. e. (2000). the impact of sport sponsorship activities, corporate image, and prior use on consumer purchase intention. sport marketing quarterly, 9(2), 96-102. saleh, k. (february23, 2015). customer acquisition vs. retention costs: statistics and trends. retrieved from http://www.invespcro.com/blog/customer-acquisition-retention/ tax, s.s., brown, s.w., &chandrashekaran, m. (1998). customer evaluations of service complaint experiences: implications for relationship marketing. journal of marketing, 62, 60–76. trail, g. t., anderson, d. f., & fink, j. s. (2005). consumer satisfaction and identity theory: a model of sport spectator conative loyalty. sport marketing quarterly, 14(2), 98-111. yilmas, i. (2009). measurement of service quality in the hotel industry. an international journal of tourism and hospitability research, 20(2), 375-386. zeithaml, v. a., &bitner, m. j. (2000). services marketing: integrating customer focusacross the firm. madison: mcgraw-hill. mailto:topacademicjournals@gmail.com http://www.invespcro.com/blog/customer-acquisition-retention/ american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 39 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe leadership in sports organizations juan carlos fernández-calvo, maría josé garcía-calvo and josé manuel medina-morales colombia universidad industrial de santande abstract: the transition of leadership in sports institutions is a complex process that is influenced by a variety of factors, including the current economic crisis, the changing needs of athletes and participants, and the increasing demands of stakeholders. this study explored the factors that contribute to successful leadership transitions in sports institutions. the findings suggest that effective leadership transitions are characterized by strong communication, clear planning, and a commitment to continuous improvement. keywords: leadership transition, sports institutions, economic crisis, stakeholders, communication, planning introduction during the past decade, various researchers have analyzed sports management in spain. the changes that have taken place in our society have pushed sports centers towards more organized and efficient management. this was achieved through adequate planning and programming of activities and a constant effort to optimize all resources: material, human and economic (moreno & gutiérrez, 1999). the current crisis is a new reality, not only economic, but also social and in the sports sector, where management is faced with the challenge of optimizing diminishing resources. the aim of this study was to determine the transition of leadership in sports institutions. history of sports in primitive times, sports provided a social identity as well as a way to adapt to the environment. the practice of sports formed part of daily life: our ancestors ran in order to escape from bigger animals, fought against their enemies, and swam to get from one place to another by crossing rivers… sports have been widely investigated throughout history. in primitive times, it was a competition characterized by ethics, values and survival. in today’s society, it is an activity promoted as way of growth, development of healthy habits, entertainment, and leisure (rodríguez, 2000). thus, sports reflect a sociocultural and educational phenomenon and are a part of human history since its beginnings. sports are part of human culture. the simple urge to compete is innate to human beings (garcía ferrando, 1982). with the evolution of society, the idiosyncrasies of each village, and the culture of different periods, the term “competition” came into being in the language of sports. along these lines, cagigal (1975) indicates that sports are something intrinsic to human nature which has always managed to manifest itself since the beginning of man’s existence. garcía ferrando (1990) considers sports as a source of health: physical, mental, as well as social (lucas-marín, 1986; cazorla, 1979). sports today demographic growth, progress in transportation and communications, greater social mobility, constant technological innovations, globalization, social change, the increase in free time, both for the individual and for our society in general, have made possible active leisure time in the form of physical activity and sports. according to the world health organization (who, 2002), the number of persons older than sixty years of age is increasing: worldwide, in europe, and especially in spain. in 2025 there will be 1.2 billion persons in the world who are older than 60, of which 840 million will live in developed countries. europe is one of the countries with more elders. it is possible that by 2050, 37% of the european population will be more than 60 years of age. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 40 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe because of this aging population, physical activity must become an obligation (salinas, cocca, kamal & viciana, 2010). this affirmation is supported not only by studies (martínez & camps, 2008), but also by public administrations (ramos & pinto, 2005). the practice of any physical activity is directly related to well-being, healthy lifestyles, as well as improved health and quality of life (landi & onder, 2007; rebollo & sanchez, 2008). marcos & galiano (2004) bring to light that the benefits that practicing a physical activity contribute to good health and quality of life are more evident among the elderly. the risks entailed in a sedentary lifestyle have been analyzed and clearly demonstrated in numerous epidemiologic studies (guayar, santa-olalla, banegas, lópez, & rodríguezartalejo, 2004; chodzko-zajko, 2006; salinas et al., 2010). however, in spite of the increase in the number of older persons practicing a physical activity in recent years, this number is still insufficient (gonzalo & pasarin, 2004; garcía ferrando, 2006; martínez del castillo, 2009). therefore, at present, a sedentary lifestyle poses a threat to public health (varo & martínez-gonzález, 2006). it follows that the practice of a physical activity carried out on a regular basis brings a series of benefits for good health in adults (serratosa, 2011). on the contrary, sedentary lifestyles are associated with risks which negatively affect an individual’s quality of life (varo & martínez-gonzález, 2006). the relationship between practicing a physical activity or sport and physical and psychological health is a subject much studied by researchers. there are numerous investigations which evaluate the benefits, such as psychological well-being, that physical exercise produce (jiménez, martínez, miró & sánchez, 2008). however, fox (2000) affirm that physical activity improves state of mind equally in children, youths, and adults. regarding reduction in clinical depression, we make mention of lawlor & hopker (2001) who report an improvement in mild depression not due to a physiological pathology. in reference to reduction in levels of anxiety, garnier & waysfeld (1995) attest that leisure time and physical activity outdoors help to promote lean muscle development and serve as a distraction from mental activity. holmes (1993) maintains that coping with stress through physical activity produces a sense of satisfaction, improved physical shape, and an enhanced emotional state. finally, in relation to research on increased self esteem in individuals who practice a sport, we note the studies of mcauley, mihalko & bane (1997), and those of huertas, lópez, pablos, colado, pablos-abella & campos (2003), as among the most significant. sports as a socializing element for mestre (2002), physical activity and sports have different social connotations, i.e., team sports improve cooperation and honesty, and individual sports improve responsibility and autonomy. according to the high sport college of spain (garcía-ferrando & llopis, 2010), adult persons practice sports for various reasons: 37.5% as a daily escape; 23.4% for enjoyment; and 14.3% for competition. 24.8% practice a physical activity to improve their health and their social relations (table 1). table 1: reasons for practicing a physical activity in adults (garcía-ferrando & llopis, 2010) reason percent leisure: amusement and hobby 23.4 % relationships: meet people 4.8 % avoidance: exercise and escape from routine 37.5 % competition: enjoy sports and competition 14.3 % health and beauty: improve health and figure 20.0 % mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 41 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe definitely, sports require not only good trainers, as in the past, but also new elements and techniques included in the concept of management (mestre, 2013). in the late seventies, democracy came to spain, and with it a change in expectations. people wanted quality of life, which brought about a new social reality. for this reason, the municipalities began to assume responsibility for the infrastructures and services necessary to narrow the gap between themselves and other surrounding european countries (cecilio, 2000). at the municipal level, the city councils constructed and equipped most of the installations in existence today. they also provided the funds for putting in place the management and development of sports policies aimed at disseminating what had been coined “sports for everyone”. they have therefore played a key role in the development and implementation of this concept (andrés & delgado, 1995). as a consequence, these installations are under municipal management. however, user satisfaction should not and cannot be considered separate from the business philosophy and objectives on which the future of the organization is based (luna-arocas & mundina, 1998). celma (2008) affirms that the generation of change witnessed in these past few years in public administration, and more specifically in the sports sector, stems from the different management forms and models they adopted in response to the essential need to adapt the organization and its services to the level of quality that citizens demand in regard to physical activities and sports. there are three important elements in sports management at the municipal level. they are: active: participants, users, entities, associations structural: equipment, activity space organizational: administration and management applied sports management becomes a process that requires a coordinated and interdependent effort (mestre, 2013) on the part of the manager of some basic elements, namely: a) the sports needs and objectives of the population (socio-demographic profile) b) legislation regarding sports c) the sports manager d) sports organizations and their directors e) planning as a work method f) economic resources (budget) g) sports programs h) the sports installation i) the trainers j) ethics and values of sports k) the environment and its protection l) quality among its various functions, one of the principal tasks of the city councils is sports management. in spain, municipal sport is the greater reality in regards to the different manifestations of sports in existence presently. although it is not alone, municipal sports dominate “sports for everyone”, and consequently, all categories of sports events and activities, not only at the municipal level, but also at the national and international level. according to teruelo (2009), the people have a right to satisfy their need to practice and attend sports events, and it is the responsibility of the city councils to create sports centers, team sports, and local competitions. municipal sports managers need a space where they can measure and compare their areas of management with those of other municipalities with a similar population. this information is needed in order to share common criteria and to become aware of other criteria, thereby promoting innovation. there is also a need to set up work groups in mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 42 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe various areas of management to evaluate the services provided and the sports installations in general (benchmarking). benchmarking is a systematic and constant evaluation of the products, services and work procedures of an enterprise, and is recognized as one of the best practices to improve an organization (spendolini, 2005). managing in times of crisis it is therefore of utmost importance to conduct an exhaustive diagnosis in order to plan adequately for the medium and long-term, using a participatory model based on the right balance between the commercial, public and social sectors (rifkin, 1997). as we saw previously, at present and with an eye toward the future, municipal management should move towards carrying out six basic functions (blanco, 2012): administer, coordinate, manage, integrate, invest, and plan. these functions should lead to the achievement of strategies based on actions and tasks that the municipalities can develop in an autonomous way and to their capacity to provide quality services. we must work to change. we have to know where we’re going, what we are, and what we are here for. along this line, about public sports, render a faithful portrait of the reality we have before our eyes and which has installed itself in our society, a reality that has come to stay for a long time. anyone who refuses to see it this way has and will continue to have a problem because “one can not hope to resolve new situations with old formulas”.planning, structure, and organization of human resources are the most valuable assets any organization or business has. sharing common goals, managing talent, improving team work, and management’s leadership are key elements for the organization to function. leadership it is clear that leadership is fundamental for the effectiveness of work groups and for the organizations to which they belong (baquero pecino & sánchez santa-bárbara, 2000). during a visit to spain, john kotter, speaker on the subject of leadership and change, stated that “it is not possible to manage organizations of the 21st century using frameworks from the 20th century and directors from the 19th century”, and that only one out of every five persons occupying an executive position has the makings of a leader. leadership must respond effectively to the new needs of organizations: innovation, cultural diversity, work-based knowledge, communication, and work groups. work groups play a central role in organizations, and leadership is essential for the effectiveness of these teams (judge & piccolo, 2004; o`reilly, caldwell, chatman,lapiz & self, 2010). because of their characteristics and diversity, today’s organizations represent fertile ground for the study of leadership models (garcía saiz, 2010). more specifically, globalization, new technologies, communication, and economic and social trends challenge organizations with new leadership roles and functions (burke & cooper, 2006). the need to face new challenges in a globalized world requires leaders to accept a complex role which involves combining continuity with innovation, based on a solid foundation of social values, ethical principles and the practice of integrating groups of professionals from different areas. in comparison with typical traditional leadership, there have emerged new models of leadership much more dynamic and in step with reality. thus, we see other types of leadership, for example, the transformational model which demonstrates positive correlations not only among different individual variables in the leader (ethics, emotional management, knowledge-building, etc.), but also with results at the organizational level (better performance, higher team satisfaction). in recent years, interest in studies of the relationship between leadership and ethics (simola, barling & turner, 2010), transcultural leadership (chocar, brodbeck & house, 2007), and global leadership (heames & harvey, 2006) has grown. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 43 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe team leadership can be understood in two ways (day, gron & salas, 2004). firstly, leadership as those attributes (abilities and behavior) that the members bring to the team, for example, charisma, integrity, etc., which have an impact on the group processes and performance. secondly, leadership as the result of group processes (group learning) that facilitate the adaptation and performance of the work team in different stages of development. both approaches are essential to the understanding of team leadership. among the new tendencies or models in team leadership, we make mention of the following: the model of hackman & wageman (2005) deals with team coaching. it indicates how leaders can influence team learning and development by carrying out distinct functions in each work stage. for example, at the initial stages, the function of motivation, to get the members of the team to know each other better; later, strategy consultation for carrying out tasks; and in the final stages, education, with the objective of stimulating the group to think. the model of zaccaro, heinen & shuffler (2009) establishes the foundation of team leadership on connectivity, integration, and coherence among the team members. the leader’s fundamental role, aside from general management and leadership, is achieved specifically through coaching and developing the skills and capacities of the team members. the model of kozlowski, watola, jensen, kim & botero (2009), or adaptive, flexible, and fluid model, adapts to the contingencies of the work load, the abilities of the team members, and the relationships between them. the leader’s role can rotate among the team members depending on the circumstances, thereby creating distributed leadership. the model of morgeson, scott & karam (2010) proposes two dimensions: internal and external leadership and formal shared leadership. in addition, they identify two stages of team development. first, the transition phase where the team defines its mission, establishes goals, plans, organizes, works on the development of the team, and provides feedback. second, the action phase where the task of the leader is to supervise, manage limits, create challenges, encourage self-management, and promote an atmosphere of social support. today’s situations, so characterized by ambiguity and complexity, make it difficult for a leader to successfully carry out all the functions inherent to leadership. for this reason, the leader needs to exercise shared leadership, which can be defined as a dynamic and interactive process among the team members whose objective is to actively communicate with each other in order to attain the team’s goals or the organization’s goals or both (pearce & conger, 2003). it has been noted that the effectiveness of shared leadership increases with the complexity of the team work, for example with decision-making. shared leadership also improves group processes such as collaboration, cooperation, and coordination (yeatls & hyten, 1998). in regard to the effectiveness of the work team, it has been shown that there is a positive relation between shared leadership and the efficiency of the task in certain contexts, such as senior management, non-profit organizations, etc. (carson, tesluk & marrone, 2007). we understand and share with celma (2004) the fact that the new role of the sports manager should be based on an evolution that goes beyond strictly technical aspects to achieve an executive or leadership level. in this vein, the author establishes the differences in managerial styles between traditional leadership and newer forms of leadership (as demonstrated graphically in table 2). table 2: difference in managerial styles (celma, 2004) managerial styles mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 44 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe conclusions the leader of a sports institution knows how to use all the resources he has at hand. he not only administers and controls, but develops and innovates. in the face of the economic crisis, many sports institutions have been able to keep their doors open as a result of a different managerial style. the desired quality a sports institution achieves is a product of the new role the leader has assumed, sports marketing, and above all, the day to day reality of greater cooperation and sense of purpose the institution now experiences. a leader who knows how to listen to all the employees in his institution and who makes decisions accordingly, brings about change and benefits from an increased confidence in the leader on the part of his work team. references andrés, f. & delgado, c. (1995). política deportiva municipal. el nuevo papel de las corporaciones locales. madrid: consejo superior de deportes. blanco, d. m. (2012). desarrollo de la gestión de la comunicación de las empresas. tesis doctoral. buenos aires: universidad san andrés. burke, r. j. & cooper, c. (2006). leading in turbulent times. oxford: blackwell. baquero pecino, c. y sánchez santa-bárbara, e. (2000). análisis de la fiabilidad del lead (descripción de la efectividad y adaptabilidad del líder). anales de psicología, 16(2), 167175. cagigal, j. m. (1975). el deporte en la sociedad actual. madrid: magisterio español. carson, j. b., tesluk, p. e. & marrone, j.a. (2007). shared leadership in teams: an investigation of antecedent conditions and performance. academy of management journal, 50(5), 1217-1234. cazorla, l. m. (1979). deporte y estado.barcelona: labor, d.l. cecilio, r. (2000). perspectivas de futuro, la gestión deportiva en españa. barcelona: inde. celma, j. (2004). abc del gestor deportivo. barcelona: inde. celma, j. (2008). la gestión deportiva local: claves de futuro en la gestión y práctica deportiva. barcelona. inde chocar, j. s., brodbeck, f. & house, r. j. (2007). culture and leadership across the world. the globe book of in-depth studies of 25 societies. new jersey: lawrance erlabaum ass. chodzko-zajko, w. (2006) the usa national strategic. plan for promoting physical activity in the mid-life and older adult population. studies in physical culture & tourism, 13, 1518. day, d. v., gron, p. & salas, e. (2004). leadership capacity in teams. the leadership quaterly, 15, 857-880. fox, k.r. (2000). the effects of exercise on self-perceptions and self-esteem. in s.j.h. biddle, k.r. fox., & s.h. boutcher (eds.), physical activity and psychological well-being (pp. 88117). london: routledge. garcía ferrando, m. (1982). deporte y sociedad. madrid: ministerio de cultura mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 45 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe garcía ferrando, m. (1990). aspectos sociales del deporte. madrid: alianza editorial. garcía ferrando, m. (2006). veinticinco años de análisis del comportamiento deportivo de la población española. revista internacional de sociología, 44, 15-38. garcía-ferrando, m. & llopis goig, r. (2010). ideal democrático y bienestar personal. madrid: csd. garnier, a. & waysfeld, b. (1995). alimentación y práctica deportiva. barcelona: ed. hispano europea. gonzalo, e. & pasarín, m. a. (2004). la salud de las personas mayores. gaceta sanitaria, 18(supl 1), 69-80. guayar, p., santa-olalla, p., banegas, j. r., lópez, e. & rodríguez-artalejo, f. (2004). actividad física y calidad de vida de la población adulta mayor en españa. medicina clínica, 123, 606-610. hackman, j. r. & wagerman, r. (2005). a theory of team coaching. academy of management review, 30, 269287. heames, j. t. & harvey, m. (2006). the evolution of the executive from the 20th century manager to the 21st century global leader. journal of leadership and organizational studies, 13(2), 29-42. holmes, d.s. (1993). aerobic fitness and the response to psychological stress. in p. seraganian (ed.), exercise psychology. the influence on physical exercise on psychological process (pp. 39-63). nueva york: john wiley. huertas, f., lópez, l., pablos, a., colado, j. c., campos, j. & pablos-abella, c. (2003). efectos de un programa de ejercicio físico en mujeres mayores de 55 años. revista de psicología del deporte, 12(1), 7-26. jiménez, m., martínez, e., miró, e. & sánchez, a. (2005). bienestar psicológico y hábitos saludables, ¿están asociados a la práctica del ejercicio físico? international journal of clinical health & psycholoy, 8(1), 185-202. judge, t. a. & piccolo r. f. (2004). transformational and transactional leadership: a metaanalytic test of their relative validity. journal of applied psychology, 89(5), 755–768. kozlowski, s. w. j., watola, d., jensen j. m., kim, b. & botero, i. (2009). developing adaptive teams: a theory of dynamic team leadership. in e. salas, g. f. goodwin & c. s. burke (eds.). team effectiveness in complex organizations: cross-disciplinary perspectives and approaches (pp. 109-146). new york: routledge academic. landi, f. & onder, g. (2007). physical activity prevented functional decline among frail comunity-living elderly subject in an international observational study. journal of clinical epidemiologic, 60, 518-524. lawlor, d. a. & hopker, s. w. (2001). the effectiveness of exercise as an intervention in the management of depression: systematic review and meta-regression analysis of randomised controlled trials. british medical journal, 322, 763-767. lucas-marín, a. (1986). fundamentos de teoría sociológica. madrid: tecnos. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 46 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe luna-arocas, r. & mundina, j. (1998b). el marketing estratégico del deporte: satisfacción, motivación y expectativas. revista de psicología del deporte, 7(2), 172-177. marcos, j. f. & galiano, d. (2004). el envejecimiento y sus problemas. el ejercicio como solución de algunos de ellos. sevilla: consejería de turismo y deporte. martínez del castillo, j. (2009). los hábitos de actividad física de las mujeres en españa. revista internacional de ciencias del deporte, 14, 81-93. martínez, i. & camps, a. (2008). la externalización de los servicios deportivos municipales. estudio de caso de bizkaia. apunts. educación física y deportes, 92(2), 74-80. mcauley, e., mihalko, s. l. & bane, s. m. (1997). exercise and self-esteem in middle-aged adults: multidimensional relationships and physical fitness and self-efficacy influences. journal of behavioural medicine, 20, 67-83. mestre, j. a. (2002). planificación estratégica de la gestión de piscinas. madrid: gymnos. mestre, j. a. (2013). componentes de la gestión deportiva. una aproximación. revista de educación física, 2(2), 1-8. moreno, j.a. & gutiérrez, m. (1999). la gestión de las instalaciones acuáticas cubiertas. revista apuntes de educación física, 57, 68-76. morgeson, f. p., scott, d. & karem, e. p. (2010). leadership in teams a functional approach to understanding leadership structures and processes. journal of management, 36(1), 539. o`reilly, c., caldwell, d., chatman, j., lapiz, m. & self, w. (2010). how leadership matters: the effects of leaders alignment on strategy implementation. the leadership quartely, 21(1), 104-113. pearce, c. l. & conger, j. a. (2003). shared leadership. reframing the hows and whys of leadership. thousand oaks: c.a. sager. ramos, p. & pinto, j. a. (2005). actividad física y ejercicio en los mayores. madrid: instituto de salud pública comunidad de madrid. rebollo, s. & sánchez, a. (2000).situación del mercado laboral actual en el ámbito de la actividad física y deportiva. motricidad, 6(1), 141-154. rifkin, j. (1997). contabilidad de gestión para tomar decisiones. barcelona: marcombo. rodríguez, j. (2000). historia del deporte. barcelona: inde. salinas, f., cocca, a., kamal, m. & viciana, j. (2010). actividad física y sedentarismo: repercusiones sobre la salud y calidad de vida de las personas mayores. retos, 17, 126-129. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 47 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe serratosa, l. (2011). el deporte como promotor de la salud y agente socializador/sociales. bogotá: i.c.f.e.s. simola, s. k., barling, j. & turner, n. (2010). transformational leadership and leader moral orientation: contrasting and ethic of justice and an ethic of care. leadership quarterly, 21, 179-188. spendolini, m. j. (2005). benchmarking. bogotá: editorial norma. teruelo, b. (2009). planificación y calidad de los servicios deportivos. bilbao: universidad deusto. varo, j. j. & martínez-gonzález, m. a. (2006). el consejo sanitario en la promoción de la actividad física. medicina clínica, 232, 138-146 world health organization (2002). physical activity and older people. ginebra: who yeats, d. e. & hyten, c. (1998). high-performing self-managed work teams. a comparison of theory and practice. thousand oaks: c.a. sager. zaccaro, s., heinen, b. & shuffler, m. (2009). team leadership and team effectiveness. in e. salas, g. f. goodwin & c. s. burke (eds.). team effectiveness in complex organization: cross-disciplinary perspectives and approaches, 83-11. new york: psychology press. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 3; may-june 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 1 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe assessing the success of the new belgrade summer cup handball 20182018 and the impact in the city of belgrade 1anglikim, 2hatziman dimitris and kaganas konstantinos 1phd candidate, teacher of physical education 2assistance professor, phd, faculty of physical education and sports sciences 3teacher of physical education, phd, msc abstract: sport tourism is a growing industry that can benefit local communities, cities, and states. this paper examines the economic and social impacts of team handball tourism, focusing on the 2009 world men's handball championship (wmhc09) in split, croatia. the findings suggest that wmhc09 had a positive impact on the local economy, with increased tourism revenue and job creation. the event also had a positive social impact, with improved community relations and increased pride in the city. keywords: sport tourism, team handball, economic impact, social impact 1. introduction sport tourism is one of the world's fastest growing special forms of tourism, which can contribute to the economic development of a) local communities, b) cities c) states (coghlan& filo, 2013; dwyer, mellor, mistilis& mules, 2000, gibson, 2002). sport tourism is not something new that happens in this century. if we look back at history we found out that people have engaged in sport related travel for centuries. however, it seems that the popularity of this form of travel has increased in the past ten years. we will find out of course various explanations. maybe is positive the increased emphasis on health and fitness that increased the number of sports events by cities to attract tourists (gibson, 1998). many researches seems that international sports events have long serving as occasions for the advertisement of the host nation and city (whitson & macintosh, 1996). another thing is that investment in sporting infrastructure in small and big also cities was not only focus on getting involved the local community in sport, but was instead aimed at attracting tourists, encouraging not only the inward investment but also interested of changing the image of the city (gratton, shibli& coleman, 2005). team handball is very popular all over the world and especially in europe. the popularity of this sport seems from the reason that in the olympic games in rio (2016) it was the most popular sport after football in spectators and in tickets sells (“rio 2016 – handball most popular sport after football”). recently, the 2009 world men's handball championship (wmhc09) that organized in a small croatian city, split seems that the respondents‟ perceived the social impacts from co-hosting wmhc09 as mostly positive (pranić, petrić & cetinić, 2012). belgrade from 2016 starting organizes with great success the “new belgrade summer cup”. this was a great opportunity, especially for the city of belgrade, since handball in europe is very popular and so is serbia. this year the tournament was taking place 26-28 june 2018. the event, “new belgrade summer cup”, brought to mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 3; may-june 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 2 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe belgrade 65 teams with boys and 20 teams with girls, which competed for a 3-day event to win the title of the champion of the tournament. the organizer awarded with prizes the most successful teams of the tournament which means teams placed on first, second and third position in each category. these teams received a prize – original cup with logo of “new belgrade summer cup”. teams placed on first, second and third positionreceived medals. awards to best players and coaches were also given. more specifically these were given to mvp player, to best goalkeeper, to best assist player and to best defender. furthermore an award was given tobest coach of the tournament. this top organization was held in 7 placements, all rent by the state sports facilities all over belgrade. the teams they contest were split in 2002 to 2005 born for boys and for girls were split in 2002 and 2004 born categories. these athletes were contest in 7 different courts. the tournament games are played only in indoor halls with a playing court of 40m x 20 m. facilities are framed by cafe-bars, dormitories, gyms, and parking. all the event was covered with live streaming technology. 2. team handball team handball is a very popular sport all over the world and especially in the european community. it was initially included into the olympic games' program during the munich games in 1972 (seil, rupp, tempelhof, & kohn, 1998; pokrajac, 1989). the popularity of this sport seems from the reason that in the olympic games in rio (2016) it was the most popular sport after football in spectators and in tickets sells. moreover if someone consider the capacity of the fields of each sport (handball vs football) it was realized that handball was the dominant sport of these olympic games (“rio 2016 – handball most popular sport after football”). nowadays pokraiac (2010), reported that this game become more faster, more interesting and with more attractive attacks. this means more goals than before in the games. the number of goals seems to be the key of the popularity of the sport and is the crucial factor of the quality of the modern handball. more specifically it is a dynamic sport having a high degree of physical strain. players of this game should have strength, speed, endurance, reaction speed and other physical abilities such as agility and flexibility (wolf et al., 1974; khosla, 1983). furthermore the players while dribbling and throwing should display adequate coordination. the demands and the characteristics of this sport are the constant and intense contact with the opponents, movements around the playing field at high speed using great strength, a high number of jumps, throws, and forceful contact with the ball during the games and the training sessions (backx, beijer, bol& erich, 1991; wolf et al., 1974). buchheit, laursen, kuhnle, ruch, renaud &ahmaidi (2009), reported that the game because of its complex requires players also to adopt well developed aerobic and anaerobic capacities. the great successes in a sport depend to a large extent on the level of morphological characteristics and motor skills (bota 1984; hosek&pavlin 1983). the performance in team handball is up to athletes‟ morphological characteristics. moreover in team handball there are different playing positions which conduce to the total performance. each position has its specific demands and its characteristics. these lead team handball players to have or to adapt specific motor abilities and morphological characteristics in each position. consequently in high level games, players have differences in body mass and in body high at four different playing positions (goalkeeper, pivot players, wingers mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 3; may-june 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 3 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe and backcourt players) (ghermanescu, 1989). the positive outcome of a team handball game apart from athletes' physical abilities, depends on high technical, tactical, psycho-kinetic characteristics as well as on the accumulated knowledge and experience of the players (bayios, 2000). athletic performance depends on the great degree of expression-effect of motor skills, which occurs after the action of the influence of coaching procedures (matveev, 1977). maximizing sports performance, which is assumption for a positive outcome, depends to a large extent on the level of all these above features and characteristics. consequently team handball seems to require all the above mentioned factors. also it is well understanding that team handball is a complex and difficult game for someone who want to play this sport in a high level. apart from all these above mentioned characteristics there is one important fact which doesn‟t depend on training or on coaching procedure. this is cleverness and is the most important characteristic for someone who wants to play this sport in outstanding. 3. event belgrade is the capital and largest city of serbia. it is located at the confluence of the sava and danube rivers, where the pannonia plain meets the balkans. its name translates to "white city". it is one of the most interesting cities in europe where socialist blocks are squeezed between art nouveau masterpieces. with nice parks, local culture, food and night life. grandiose coffee houses and smoky dives all find rightful place along knezmihailova, a lively pedestrian boulevard flanked by historical buildings, all the way to the ancient kalemegdan citadel, the crown of the city. deeper in belgrade's bowels are museums guarding the cultural,religious and military heritage of the country. at the area of new belgrade handball club “novi beograd” has organized summer international handball tournament “new belgrade summer cup”.the tournament tookplace from june 26 28 of june for boys and girls in categories: u16, u15, u14, u13 for boys and u16, u14for girls. in total of 65 teams for boys and 20 teams for girls.when the event began in 2016 there were only 25 teams(20 for boys and 5 for girls)and in 2017 there were 66 teams(44 boys and 22 girls).each team had maximum of 20 players (all of them have been reported to the local police departments as prescribed by their law).security team was all over the place of the event with very discreet presence. medical staff was present in every hall in case of emergency or to treat minor injuries.in case of an injury that requires hospitalization, the participants were responsible themselves for the costs of the treatment or hospitalization charges (“new belgrade summer cup 26 -28 june 2018”). the athletes (boys and girls) were coming with at least one coach, one official escort from the team and many parents. the parents’ couldn’t be counted because they lived in other places than the indicated accommodation of the event. hosted teams from serbia, croatia, bosnia and herzegovina, montenegro, israel, greece, hungary and slovenia were participated at this summer cup. they all had the possibility and the chance to win the trophy (“new belgrade summer cup 26 -28 june 2018”). 4. sports tourism sport is an important activity in tourism and tourism is a fundamental feature of sport. this may mean that sport and tourism sometimes have an interrelated relationship (hinch&higham, 2001). athletic tourism can be defined in many different ways, but most of its definitions are largely determined by the society in which it is formulated mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 3; may-june 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 4 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe (epitropoulos, 2002). there is a wide spread opinion that sport events can act as a catalyst for economic development and urban regeneration (wilson, 2006). gibson (1998) divides sports tourism into three major categories. the first category includes watching a sporting event. the second refers to the tourists visit to a particular sports monument. finally, the third category involves active participation. thus, athletic tourism is characterized as an integrated tourist experience where sports are at the center of the process. sports tourism is therefore considered to be recreational-oriented travel that leads people to temporarily move away from their permanent residence to engage in physical activities or just watch them. it seems clearly that the athletic event must satisfyin total such the athletes as and the audience. in the last decade interest in sports tourism has increased significantly, both in the sports industry and in the tourism industry (standeven, & de knop, 1999). sports tourism is one of the world's fastest-growing special forms of tourism, which can contribute to the economic development not only of local communities and cities but also and to states (coghlan& filo, 2013; dwyer et al., 2000, gibson, 2002). athletic tourism is an economic, social and cultural phenomenon created by the unique interaction of activity, people and location (bull & weed, 2012). sports events are one of the fastest growing forms of athletic tourism, both internationally and also in serbia. in particular, sports tourism can have multiple economic, social and environmental benefits (coghlan & filo, 2013; gibson, 2002). it can enhance the tourist visibility of a country, while at the same time it can contribute to the development of alternative forms of tourism. by involving the local community in the organization, it contributes to the development of the region thus bringing many economic benefits to the local community. it is recognized that the sports-mega events are significant consequences for the host cities, and great media coverage that they will attract (horne, 2007). in a recent study that examines the impact of sport in both neighbor countries croatia and serbia found out that sport plays a very important role at various levels in both societies. it seems after all that serbiahas a very important role and a good tradition in several sports and athletes (simic-banovic, jurcic&petronijevic, 2017). 5. the present study the purpose of this research was to evaluate the success of the event as far as the athletic track is concerned, as well as the recreational and tourism impact it has left on athletes and mission escorts. the aim was to evaluate the “new belgrade summer cup” which took place in 2018 in belgrade. the coaches, the parents and the escorts of the missions were asked if they have been satisfied with the benefits of the stadiums, of the games, of the hotels and generally of the whole event. it was examined the generally impression that belgrade has left to them and whether a positive image of the city was created abroad. the present study also examined the impact of service quality on the image of a city, namely belgrade and the economic impact of the organization on the city. 6. method the sample of the survey was eighty seven (n = 87) coaches, parents and escorts of the missions that they took part in the tournament. questionnaires responded anonymously and collected at the end of the tournament and evaluated the organization's services, the image taken of the belgrade and the money they spent while staying in mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 3; may-june 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 5 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe the city. the questionnaire was an adaptation from the tzetzis, alexandris & kapsampeli (2014) small-scale service quality survey questionnaire. 7. results from the results it is showed that the majority of the people who responded the questionnaire was men (72.4%). the respondents were from 20 to 70 years old and the mean of the age was 40.8.the results of the research have shown that coaches, parents and escorts of the missions that they took part in the tournament, have been generally satisfied by the organization. accessibility for the stadiums of the tournament satisfied the 79.3% of the respondentsand 85.1% for the hotels. also the transportationswere easy for78.1% of the people.more specifically table 1 shows the accessibility in general. table1. accessibility parameter strongly disagree 1 disagree 2 neutral 3 agree 4 strongly agree 5 accessibility % % % % % the stadiums of the tournament were easily accessible 3.4 6.9 10.3 48.3 31 transportations to the stadium were easy 8 6.9 6.9 44.8 33.3 the hotel that i stayed was easily accessible 4.6 10.3 41.4 43.7 also, 89.7% of respondents considered the staff friendly and 90.8% polite and knowledgeable. in particular table 2 shows the responses of coaches, parents and escorts about the personnel. table2. personnel parameter strongly disagree 1 disagree 2 neutral 3 agree 4 strongly agree 5 personnel % % % % % the personnel of the tournament was polite 2.3 6.9 35.6 55.2 the personnel of the tournament was knowledgeable 3.4 5.7 44.8 46 the personnel of the tournament was friendly 1.1 2.3 6.9 36.8 52.9 still the condition of the stadiums seemed that satisfied the 86.5% of the respondents.table 3 shows the answers for the stadiums. table 3. stadium parameter strongly disagree 1 disagree 2 neutral 3 agree 4 strongly agree mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 3; may-june 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 6 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 5 stadium % % % % % the stadiums were in good condition 1.1 3.4 6.9 42.5 46 the stadiums were good 1.1 3.4 6.9 48.3 40.2 the stadiums were easy to use 1.1 2.3 13.8 44.8 37.9 as far as social activities are concerned, the majority was satisfied, since 74.7% found them interesting, and 73.6% well organized and entertaining. table 4 shows the responses about the socials. table 4. socials parameter strongly disagree 1 disagree 2 neutral 3 agree 4 strongly agree 5 socials % % % % % the socials / associative activities were interesting 2.3 3.4 19.5 46 28.7 the socials / associative activities were well organized 2.3 2.3 21.9 41.4 32.2 the social / associative activities were fun 2.3 3.4 20.7 48.3 25.3 furthermore the feedback that we took from the sample of the study as regards the competition was recording as it seems in table 5. table 5. competition parameter strongly disagree 1 disagree 2 neutral 3 agree 4 strongly agree 5 competition % % % % % the teams were strong 1.2 1.2 14.1` 45.9 37.6 the games were competitive 1.2 4.7 5.9 52.9 35.3 the competition of tournament was in a good level 1.2 1.2 4.7 50.6 42.4 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 3; may-june 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 7 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe the sample of the study was also generally very satisfied of the tournament in a percentage of 84.8%. in the table 6 you can see specified the satisfaction of the attenders of the tournament. table 6. tournament parameter strongly disagree 1 disagree 2 neutral 3 agree 4 strongly agree 5 tournament % % % % % the tournament was well scheduled 5.9 8.2 37.6 48.2 the schedule was kept 2.4 10.6 40 47.1 the schedule run smoothly 2.4 5.9 48.2 43.5 the tournament was fun 1.2 7.1 42.4 49.4 the tournament was interesting 1.2 1.2 8.2 38.8 50.6 the tournament was relaxing 1.2 2.4 17.6 42.4 36.5 the tournament gave me the chance to socialize 1.2 2.4 12.9 49.4 34.1 as regarding the satisfaction totally 89.4% were satisfied with their decision to attend this sport event, because 89.5% believe that was a good tournament and finally 90.6% have the intention to come again in belgrade in the future if a tournament like that takes place again. table 7. satisfaction parameter strongly disagree 1 disagree 2 neutral 3 agree 4 strongly agree 5 satisfaction % % % % % in totally i am satisfied with my decision to attend the tournament 1.2 2.4 7.1` 36.5 52.9 in total it was a good tournament 2.4 8.2 42.4 47.1 i would attend such a tournament if it takes places in belgrade again in the future. 1.2 2.4 5.9 44.7 45.9 also, the majority of respondents, 78.1%, were satisfied of the hotels as they found them clean, modern, with good services and facilities. in table 8 seems the satisfaction of the sample and its preference about the hotels. table 8. hotels parameter strongly disagree 1 disagree 2 neutral 3 agree 4 strongly agree 5 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 3; may-june 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 8 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe hotels % % % % % my hotel was clean 7 9.9 43.7 39.4 my hotel was modern 2.8 2.8 21.1 35.2 38 my hotel had good services 1.4 19.7 36.6 42.3 my hotel had good facilities 5.6 16.9 35.2 42.3 moreover the hotel staff seemed to have gained the impression since 84.5% said it was friendly, 83.1% polite and 85.9% helpful. table 9 shows the choices of the coaches, parents and escorts about the personnel of the hotels. table 9. the personnel of the hotels parameter strongly disagree 1 disagree 2 neutral 3 agree 4 strongly agree 5 the personnel of the hotels % % % % % the personnel of my hotel was helpful 2.8 11.3 33.8 52.1 the personnel of my hotel was polite 1.4 2.8 12.7 25.4 57.7 the personnel of my hotel was friendly 4.2 11.3 31 53.5 the cost of living, in general, buying, staying,food and having fun seem cheap to the sample, as 84.6% of them seemed to be economical. in table 10 seem the responses about the cost. table 10. cost parameter strongly disagree 1 disagree 2 neutral 3 agree 4 strongly agree 5 cost % % % % % the cost of shopping in belgrade was affordable 1.3 21.8 41 35.9 the cost of hotel was affordable 1.3 11.5 56.4 30.8 the cost of entertaining in the city was affordable 1.3 11.5 48.7 38.5 the cost of eating in the city was affordable 1.3 11.5 39.7 47.4 the amenities of the city of belgrade seemed that satisfied parents, escorts and coaches as 84.5% were satisfied by the city restaurants, 82.1% by city tourist information and 79.7% found that the entertaining opportunities were various. however, it is important that 87.4% felt safety in the city, 83.7% believe that belgrade is a city with strong culture and 89.9% with friendly people. after all the majority of parents and escorts, as well as coaches had a positive impact and a good image of the city of belgrade with a percentage of 87.3%. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 3; may-june 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 9 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe in conclusion 90.3% of the coaches of the teams, parents of the kids and escorts of the missions, will visit the city of belgrade again and 92.7% will attend the tournament iforganized again. the majority of the respondents 91.5% will encourage their friends to visit belgrade and also a percentage of 90.2% will say good things about the city of belgrade. after all, the participants had left a good amount of money at belgrade, as the survey had shown. 8. discussion the survey conducted in the majority of coaches, parents and escorts of the missions, and showed some very interesting facts, both for their satisfaction with the organization and for the services. it also showed the overall image of the city of belgrade. this research seems to have been a successful athletic event, which left the majority of coaches, parents and escortsfrom foreign countries very satisfied. the level of the tournament was very high and the competition was really good. the facilities and the fields were in good condition and all the hotels seems that have satisfactory amenities. people with their friendliness and courtesy both in the organization and in the hotels seemed to have won the best impressions. the current survey showed that the majority ofcoaches as parents and escorts of the missions were very satisfied in all sectors of the tournament. finally the event succeeds in promoting the city very well to the participants, who had a very positive opinion about the city of belgrade. this is very important for the cities. cities are increasingly using cultural events in many ways so to improve their image. it is important for their development to attract visitors and investment (richards & wilson, 2004). this is not something new, because cities always want to increase their economies, so in that way they have long used many events such as sporting events (getz, 1991). recent studies of city and tourism marketing have pointed that the use of events has been very successful to promote places and major cities in particular (robertson and guerrier, 1998; schuster, 2001; waitt, 2003).therefore, sports events should not focus only on the sporting event but also on the best promotion and advertising of the host city. 9. conclusion athletic tourism clearly focuses on the type, the quality and the proper organization of a sporting event. but besides the main product that is the sporting event, it is the supporter, which is the satisfaction of athletes and of all participants from the image of the city and of the social events. in conclusion, the current survey showed that this specific tournament was very successful in all terms of the sporting element, which welcomed participants from foreign countries. it seems clearly that was also a very good advertising of belgrade, which made happy the people whovisited it. it also appeared that social activities satisfy the participants, which may affect them positive in their future involvement. that means that the people who joined this tournament, they will be happy to join again or visit again the city of belgrade. athletic events should therefore not only focus on the sporting event, but also on social activities, as well as on a better promotion and advertising of the city and the country in general. references backx, f. j., beijer, h. j., bol, e., & erich, w. b. (1991). injuries in high-risk persons and high-risk sports: a longitudinal study of 1818 school children. the american journal of sports medicine, 19(2), 124-130. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 3; may-june 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 10 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe bayios, i. a., bergeles, n. k., apostolidis, n. g., noutsos, k. s., &koskolou, m. d. (2006). anthropometric, body composition and somatotype differences of greek elite female basketball, volleyball and handball players. journal of sports medicine and physical fitness, 46(2), 271. bayios, ι. (2000). handball tactic (1sted.). athens: self edition. bota, i. (1984). handbalmodele de jocsipregatire. bucuresti: sportturism. buchheit, m., laursen, p. b., kuhnle, j., ruch, d., renaud, c., &ahmaidi, s. (2009). game-based training in young elite handball players. international journal of sports medicine, 30(4), 251-258. bull, c., & weed, m. (2012). sports tourism: participants, policy and providers. routledge. coghlan, a., & filo, k. (2013). using constant comparison method and qualitative data to understand participants' experiences at the nexus of tourism, sport and charity events. tourism management, 35, 122131. dwyer, l., mellor, r., mistilis, n., & mules, t. (2000). a framework for assessing “tangible” and “intangible” impacts of events and conventions. event management, 6(3), 175-189. epitropoulos, m. (2002). tourism and swot analysis. presentation made to university of ottawa study tour class, ancient olympia, greece, may, 13. getz, d. (1991). festivals, special events, and tourism. van nostrand reinhold. ghermanescu i. (1989). determining factors for the further development of handball. proceedings of international symposium of ihf, (pp. 152-180). portugal. gibson, h. j. (1998). sport tourism: a critical analysis of research. sport management review, 1(1), 45-76. gibson, h. j. (2002). sport tourism at a crossroad? considerations for the future. sport tourism: principles and practice, 111-122. government of the republic of croatia: strategic development framework for 2006-2013. central office for development strategy and coordination of eu funds. zagreb, august 2006 gratton, c., shibli, s., & coleman, r. (2005). sport and economic regeneration in cities. urban studies, 42(5-6), 985-999. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 3; may-june 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 11 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe hinch, t. d., &higham, j. e. (2001). sport tourism: a framework for research. international journal of tourism research, 3(1), 45-58. horne, j. (2007). the four „knowns‟ of sports mega events. leisure studies, 26(1), 81-96. hosek, a. v., &pavlin, k. (1983). povezanostizmeđumorfološkihdimenzijaiefikasnost u rukometu. kineziologija, zagreb, 15, 145-151. khosla, t. (1983). sport for tall. br med j (clin res ed), 287(6394), 736-738. matveev, l. p. (1977). osnovysportivnojtrenirovki. fizkul'turai sport. moskva. new belgrade summer cup 26 – 28 june 2018 (2018, july 28). retrieved from: http://handballsummercup.rs pokrajac, b. (2010). handball tendency regarding results analysis european championship 2008 and world championship 2009. ehf periodical. hyperlink: [http://home.eurohandball.com /ehf_files/publikation/pok rajac%20analysis_091204.pdf]. retrieved at 17 june 2018. pokrajac, b. (1989). the development of handball. proccedings of international symposium of i.h.f., portugal, pp. 152-180. pranić, l., petrić, l., &cetinić, l. (2012). host population perceptions of the social impactsof sport tourism events in transition countries: evidence from croatia. international journal of event and festival management, 3(3), 236-256. richards, g., & wilson, j. (2004). the impact of cultural events on city image: rotterdam, cultural capital of europe 2001. urban studies, 41(10), 1931-1951. rio 2016 – handball most popular sport after football (2018, august 2). retrieved from: http:// http://www.ihf.info/en us/ihfcompetitions/olympicgames/olympicgamesrio2016/news/newsdetails.aspx?id=4640 robertson, m., & guerrier, y. (1998). events as entrepreneurial displays: seville, barcelona and madrid. managing tourism in cities, 215-228. schuster, j. m. (2001). ephemera, temporary urbanism and imaging. imaging the city: continuing struggles and new directions, 361-397. mailto:topacademicjournals@gmail.com http://www.ihf.info/enhttp://www.ihf.info/en american journal of medical and physical education vol.6, issue 3; may-june 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 12 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe seil, r., rupp, s., tempelhof, s., & kohn, d. (1998). sports injuries in team handball. the american journal of sports medicine, 26(5), 681-687. simic-banovic, r., jurcic, a., & petronijevic, m. (2017). hosting mega sport events ina small country: the (real) impact on the development-cases of croatia and serbia. megatrend revija, 14(2), 273-290. standeven, j., & de knop, p. (1999). „sport tourism. human kinetics: champaign”. annals of tourism research, 638-657. tzetzis, g., alexandris, k., & kapsampeli, s. (2014). predicting visitors‟ satisfaction and behavioral intentions from service quality in the context of a small-scale outdoor sport event. international journal of event and festival management, 5(1), 4-21. waitt, g. (2003). social impacts of the sydney olympics. annals of tourism research, 30(1), 194-215. whitson, d., & macintosh, d. (1996). the global circus: international sport, tourism, and the marketing of cities. journal of sport and social issues, 20(3), 278-295. wilson, r. (2006). the economic impact of local sport events: significant, limited or otherwise? a case study of four swimming events. managing leisure, 11(1), 57-70. wolf, g., tittel, k., doscher, i., luck, p., hierse, b., kiess, c. & schaetz, p. (1974). statistische analyseuber ursachen, lokalisationen und artenhaufigerbei training und wettkampfaufgetretener verletzungen und fehlbelastungsschadenimhallenhandball. medicine und sport, 3, 77-80. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 25 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe thyroid function test evaluation in prostate cancer patients in khartoum state abdallah e. ali1, sejood e. m. abdalla1, ibrahim a. a. karti 2 and haidar e. saleh3 1university of alzaeim al azhari faculty of medical laboratory sciences, department of clinical chemistry 2alofoug college of science & technology, program of medicine, khartoum, sudan. 3miami university, sylvester comprehensive cancer center (sccc) clinical research laboratory services miami fl33136 usa abstract: introduction: thyroid hormones (th) are key regulators of essential cellular processes, including proliferation, differentiation, apoptosis, and metabolism. thyroid hormones have an important role in the development of prostate cancer. so this study aims to assess thyroid function tests among prostatic cancer patients. methods: total group study100, fifty prostatic cancer patients as a case study and 50 healthy men as the control group, blood samples were collected for measurement for thyroid function test and prostate antigen by tosoh tm device (china) and enzyme-linked immune sorbent assay (elisa) fortress tm. results: statistical analysis of test results of the case study: the mean and sd± psa= (31.8 ± 12.5 ) , t3 = (3.3 ± 1.3) , t4 = (119.58 ± 46.21 ) and tsh =(4.6 ± 3.4) . for each p-value 0.0001 when compared to the control group, the frequency of thyroid disorders among case study participants is hyperthyroidism (33 = 66%), normal (14 = 28%), and hypothyroidism (3 = 6%). conclusion: hyperthyroidism is the most common thyroid disorder among patients with prostatic cancer. keywords: prostate cancer, thyroid hormones, t3, t4, tsh, and prostate antigen. introduction prostate cancer develops when the rates of cell division exceed those of cell death, leading to uncontrolled tumor growth. following the initial transformation event, further mutations of a multitude of genes, including the genes for retinoblastoma, can lead to tumor progression and metastasis. most prostate cancers are adenocarcinomas [1,2,3]. triiodothyronine (t3) and its prohormone thyroxine (t4) are hypothesized to promote carcinogenesis through their important roles in cell differentiation, growth, and metabolism [4]. the hormones also promote tumor-induced angiogenesis [5], and have been shown to increase prostate cancer cell proliferation in vitro [6,7]. thyroid-stimulating hormone (tsh) is produced by the anterior pituitary gland to regulate t4 secretion from the thyroid and is an important laboratory measure for determining thyroid status [8]. in individuals with normal thyroid function, t4 and tsh act in a negative feedback loop [5]; thus, a hypothyroid state is defined as having low t4 but high tsh, and hyperthyroid status is defined as having high t4 but low tsh [9]. it is hypothesized that hypothyroid men may be at a decreased risk of prostate cancer, whereas hyperthyroid men may have an increased risk. serum prostate-specific antigen (psa) measurement mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 26 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe has been widely used in screening (early detection), diagnosis, and monitoring treatment response in various stages of prostate cancer (pca) [4]. a major disadvantage of psa-based pca detection is the considerable number of false positive results that occur; many patients undergo unnecessary prostate biopsy procedures due to the false positive elevation in the serum psa level. various diagnostic and therapeutic procedures, as well as benign and physiologic conditions, have been shown to increase serum psa concentrations (2-7) [10]. the close relationship between the prostate and thyroid gland although it is very well known that thyroid hormone regulates thyrotropin-releasing hormone levels in the male reproductive system, including the prostate, the direct effect of thyroid hormones on the prostate is still unclear. evaluated the relationship between serum t3 levels and risk of recurrence in patients treated for localized prostate cancer[11]. materials and methods: study group a cross-sectional study was conducted at khartoum oncology and isotopic treatment hospital during the period from september to november 2021 .fifty patients were diagnosed with prostatic cancer aged from 2666 years as case and fifty healthy men as control. inclusion criteria and exclusion criteria: men with prostatic cancer were involved in the study and other types of cancer patients did not be part of this study. ethical consideration: the study was revised and ethically approved by the ethical and scientific committee of the faculty of medical laboratory sciences, university of alzaiem alazhari. samples were taken with verbal consent from patients or their relatives. data collection data collected through a direct interview questionnaire was used to collect data. well-constructed questionnaires such as age, gender, and duration of the disease. collection of specimens: venous blood samples were collected by using sterile, dry, plastic syringes and a tourniquet to make the veins more prominent. the puncture sites are cleaned with 70% ethanol and 5 ml of blood is collected in lithium heparin containers. the lithium heparin blood sample was centrifuged at 4000 rpm to obtain the plasma and then stored at (-4 c) until the analysis. measurement of biochemical parameters: whole blood samples were collected in heparinized blood containers, and plasma was used for measurement of thyroid function test t3, t4, tsh, and prostate antigen by tosoh tm device (china) and enzyme-linked immune sorbent assay (elisa) fortress tm, thyroid function tests are designed to distinguish hyperthyroidism and hypothyroidism from the euthyroid state. to accomplish direct measurements of the plasma level of hormones, the tsh elisa test on the principle of solid phase enzyme-linked immunosorbent assay, the assay system utilizes a unique monoclonal antibody directed against a distinct antigen determinant on the intact tsh molecule. normal rang: t3 (1.3_3.1 nmol/l) t4(63_141 nmol/l) tsh (0.5_5 nmol/l) psa : normal ( 0_4) border(4_10) susicious >10 . mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 27 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe data analysis the statistical analysis of the results was performed by using the statistical package for social sciences (spss) version 15.0 for windows version 10 using a t-test for testing difference significance and a pearson correlation test ( r-value as the coefficient ). a p. value of 0.05 was considered statistically significant. results this case-control study involved 50 professionally diagnosed patients with prostatic cancer set as the case group. measuring psa as well as tft among case and control groups, showed an elevation of each parameter (t3, t4, tsh, and psa) among case than the control group, giving significant differences when both groups; data compared as the p-value for each <0.000 as in table 1. in this case their age mean+ sd was 66.5+6.52 years, parallel with a healthy group of men set as the control group, their age’s mean sd was, patients were recruited from khartoum oncology hospital, the majority of them from west origin 56%, then middle 22%, then northern origin 18% and lesser from south4%. pearson's correlation showed a negative correlation between all measured parameters (t3, t4, tsh, and psa) with the age of patients and duration of the disease, only significant difference was obtained with tsh with duration p value <0.05 as in table 2. the correlation of psa and tft positive correlation with t3 and tsh, giving a significant difference, while a negative correlation was obtained with t4 with no significant difference as in table 3-3 and figures 2, 3 respectively, and 4. most of the patients are secondary hyperthyroidism 66% this may be due to decreased production of tsh from the pituitary gland or tsh-secreting tumor, or more rarely from the overproduction of trh from the hypothalamus or thyrotropin-releasing hormone and other patients are 28% normal and 3% are hypothyroidisms as in figure 1 and in table 4 the comparison of mean levels of tfts and psa and p value in hyperthyroidism patients table 1: comparison of mean levels of tfts and psa among study groups case group n=50 control group n=50 p-value t3 nmol/l 3.3 ± 1.3 1.6 ± 0.67 0.000 t4nmol/l 119.58 ± 46.21 101.6 ± 17.95 0.045 tsh nmol/l 4.6 ± 3.4 1.7 ± 0.7 0.000 psa nmol/l 31.8 ± 12.5 1.85 ± 2.1 0.000 table 2: correlation of age and duration of disease with tfts and psa parameters values age duration t3 r -0.033 -0.117 p 0.819 0.418 t4 r -0.092 -0.024 p 0.526 0.870 tsh r -0.051 -0.317* mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 28 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe p 0.725 0.025 psa r -0.109 -0.259 p 0.452 0.070 r=pearson’s correlation between 1 and -1. table 3: correlation of psa with tfts variable t3 t4 tsh psa person correlation 0.343 -0.033 0.280 p-value 0.007 0.803 0.029 table 4: comparison of mean levels of tfts and psa and p value in hyperthyroidism patients variable hyperthyroidism n=33 control group n=50 p-value t3 3.1 ± 1.0 1.6 ± 0.67 0.000 t4 39.8 ± 15.4 101.6 ± 17.95 0.000 tsh 0.4 ± 0.1 1.7 ± 0.7 0.000 psa 12.3 ± 10.4 1.85 ± 2.1 0.000 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 29 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe figure 2: correlation between psa and t3 among case studies (p. value=0.007, r=0.34) figure 3: correlation between psa and tsh among case studies (p. value=0.029, r=0.282) figure 1 : frequency of thyroid disorders among case group \ 66 % % 28 % 6 sales hyperthyroidism normal hyporthyrodism mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 30 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe figure 4: correlation between t4 and psa among case studies (p. value=0.803, r=0.001) discussion prostate cancer develops when the rates of cell division exceed those of cell death, leading to uncontrolled tumor growth. following the initial transformation event, a variety of genes, including those for retinoblastoma, can undergo further alterations that cause tumor growth and metastasis. adenocarcinomas are the primary kind of prostate cancer. when psa expression was thought to be unique to the prostate gland and was thought to be raised in benign situations, the blood psa was the most significant biochemical tumor marker utilized in the screening, diagnosis, and monitoring of patients with prostate malignancies. regardless of the fact that it is generally known that thyroid hormone modulates the levels of thyrotropin-releasing hormone throughout the male reproductive system, including the prostate, it is still unclear how thyroid hormones directly affect the prostate. in patients receiving treatment for locally advanced prostate cancer, they assessed the connection between serum t3 levels and the probability of recurrence[12]. nearly every tissue in the body develops, differentiates, and grows in response to thyroid hormones [13]. according to bilek et al. [14], the thyroid gland and the rat ventral prostate have a close association. the direct impact of thyroid hormones on the prostate is still unknown, despite the fact that it is widely known that thyroid hormone modulates thyrotropin-releasing hormone levels in the male reproductive system, including the prostate [15]. in patients receiving treatment for localized pca, lehrer et al. [16] examined the association between serum t3 levels and the likelihood of recurrence. they classified the 68 individuals in their study into three risks identified, moderate, and high risk. in the present study patients diagnosed with prostatic cancer were set as case group, measuring psa as well as tft among case and control groups, showed an elevation of each parameter among cases than a control group, giving significant difference, a suggests that secondary hyperthyroidism increase the risk of prostatic cancer. a prospective cohort study of a community-dwelling population in western australia between the ages of 25 and 84 found some agreement. tests including the tsh and ft4 were performed on the archived. along with the 41 prostate malignancies, other cancer kinds were also included. a decreased risk of prostate cancer was linked to higher tsh (p = 0.005). similar to this, greater ft4 was linked to a higher risk of prostate cancer (p = 0.009) [17] , middle-aged males with benign prostatic hyperplasia were given hormones. levels of free thyroxin (ft4) and thyroid-stimulating hormone (tsh) were assessed. the ft4 quartile had a large increase. no statistically significant difference was seen mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 31 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe in tsh [18]. in previous study, thyroid hormones were found related to the pathophysiology of several cancer forms, according to study results, results from case-control and population-based studies are inconclusive when it comes to the link between thyroid hormones and cancer. numerous pieces of evidence point to an increased risk of various solid tumors in people with asymptomatic and clinical hyperthyroidism[19]. the results of a study agreed that there is a link between thyroid hormones and prostate cancer case-control 20]. the patients in this study were 56.7 years old on average. according to our research, elevated serum psa levels were related to higher serum tsh, t3, and t4 levels. previous research demonstrated lower serum tsh and greater serum t3 levels in men with benign prostatic hyperplasia and prostate cancer. additionally, it is well-known that a number of factors can affect psa, the most widely used biomarker for the diagnosis of prostate cancer [21]. increased t3 levels have been linked to a number of markers of prostate cancer histopathological aggressiveness, according to a prior study [22]. according to new endocrinological guidelines [23], men with clinical or subclinical hypothyroid status had a lower chance of developing prostate cancer than men with normal thyroid function. this was found in a previous study. similar to this, we found that males with the highest tsh levels (which indicate a hypothyroid state) had a decreased risk of developing prostate cancer. these results are in line with earlier laboratory and epidemiologic evidence that thyroid hormones affect the incidence of prostate cancer [24,25,26-29]. another cross-sectional investigation similarly revealed that prostate cancer cases had more circulating t3 than controls did [27]. the association between thyroid hormones or status and the incidence of prostate cancer was only explored in two prospective studies [28,29]. one found that males who self-reported having thyroid disease had a higher chance of developing prostate cancer [28], but this study did not distinguish between hypothyroid and hyperthyroid conditions. tsh concentration and risk were found to be negatively correlated in the one study that looked at circulating thyroid hormone levels and prostate cancer (advanced cases were not looked at individually) [29] t4 and tsh interact negatively in individuals who have normal thyroid function [8]. accordingly, a hypothyroid state is characterized by low t4 and high tsh, and a hyperthyroid state by high t4 and low tsh . t4 and t3 binding to the plasma membrane receptor integrin avb3 stimulates several pro-carcinogenic pathways, including pi-3k and mapk/erk1/2, and boosts cell proliferation and angiogenesis, which is a well-known biological mechanism via which this may occur [5]. importantly, integrin avb3 has been linked to the spread of prostate cancer [30]. nearly every tissue in the body develops, differentiates, and grows in response to thyroid hormones [13]. according to bilek et al. [14], the thyroid gland and the rat ventral prostate have a close association. the direct impact of thyroid hormones on the prostate is still unknown, despite the fact that it is widely known that thyroid hormone modulates thyrotropin-releasing hormone levels in the male reproductive system, including the prostate [15]. 2001 saw lehrer et al. it is hypothesized that hypothyroid men may be at a decreased risk of prostate cancer, whereas hyperthyroid men may have an increased risk.in this study, most of the patients are secondary hyperthyroidism 66% this increase the risk of diseases. conclusion according to our findings, elevated serum psa levels were linked to decreased serum tsh and elevated serum t3 and t4 levels. although the mechanism of how thyroid hormones affect patients with prostate cancer is still unknown, further studies are needed to corroborate the results of our study. hyperthyroidism is more common than hypothyroidism among patients with prostate cancer. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 32 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe ethics committee approval: the study had the approval of the institutional ethics committee. informed consent: all participants provided informed consent. peer-review: internally peer-reviewed. conflict of interest: the authors declared no conflict of interest. financial disclosure: the authors declare that they have no relevant financial. reference 1. jemal a, bray f, forman d, o'brien m, ferlay j, center m, et al. cancer burden in africa and opportunities for prevention. cancer. 2012;118(18):4372–84. 2. bray f, ferlay j, soerjomataram i, siegel rl, torre la, jemal a. global cancer statistics 2018: globocan estimates of incidence and mortality worldwide for 36 cancers in 185 countries. ca cancer j clin. 2018;68(6):394–424. 3. ferlay j em, lam f, colombet m, mery l, pineros m, znaor a, soerjomataram i., et al. global cancer observatory: cancer today. lyon, france: international agency for research on cancer. accessed 02 february 2019. 4. hercbergs a. the thyroid gland as an intrinsic biologic response-modifier in advanced neoplasia–a novel paradigm. in vivo . 1996; 10: 245–247. 5. pinto m, soares p, ribatti d. thyroid hormone as a regulator of tumor-induced angiogenesis. cancer lett. 2011; 301: 119–126. 6. hsieh ml, juang hh cell growth effects of triiodothyronine and expression of thyroid hormone receptor in prostate carcinoma cells. j androl. 2005; 26: 422–428. 7. tsui kh, hsieh wc, lin mh, chang pl, juang hh .triiodothyronine modulates cell proliferation of human prostatic carcinoma cells by downregulation of the b-cell translocation gene 2. prostate 2008; 68: 610–619. 8. yen pm . physiological and molecular basis of thyroid hormone action. physiol rev 2001; 81: 1097– 1142. 9. baskin hj, cobin rh, duick ds, gharib h, guttler rb, et al. american association of clinical endocrinologists medical guidelines for clinical practice for the evaluation and treatment of hyperthyroidism and hypothyroidism. endocr pract. 2002 ; 8: 457–469. 10. partin aw, oesterling je. the clinical usefulness of prostate-specific antigen: update 1994. j urol 1994;152:1358-1368. 11. panigrahi gk, praharaj pp, kittaka h, mridha ar, black om, singh r, mercer r., et al. exosome proteomic analyses identify inflammatory phenotype and novel biomarkers in african american prostate cancer patients. cancer med. 2019. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 33 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 12. claudio schneider, martin feller, et al. initial evaluation of thyroid dysfunction are simultaneous tsh and ft4 tests necessary?plos one : april 30, 2018 13. goemann im, romitti m, meyer els, wajner sm, maia al. role of thyroid hormones in the neoplastic process: an overview. endocr relat cancer 2017;24:r367-r385. 14. bilek r, gkonos pj, tavianini ma, smyth dg, roos ba. the thyrotrophin-releasing hormone (trh)like peptides in rat prostate are not formed by expression of the trh gene but are suppressed by thyroid hormone. j endocrinol 1992;132:177-184. 15. maran rr, ravichandran k, arunakaran j. prostate-thyroid axis: prostatic trh is one of the stimulators of thyroid hormone. endocr res 2001;27:14315. 16. lehrer s, diamond ej, bajwa am, kornreich r, stagger s, stone nn, droller mj, stock rg. association between serum triiodothyronine (t3) level and risk of disease recurrence in men with localized prostate cancer. prostate cancer prostatic dis 2001;4:232-234. 17. dogra p, paudel r, panthi s, cassity e, tannock lr.low yield of thyroid-function tests in adult hospitalized patients — a retrospective analysis. dove press: 6 july 2020 volume 2020:13 pages 343—349 18. jun ho lee, yeon won park, and sung won lee. the relationship between thyroid hormone levels and lower urinary tract symptoms/benign prostatic hyperplasia. world j men's health. 2019 sep;37(3):364371 19.eilon krashin, agnieszka piekiełko-witkowska, martin ellis, and osnat ashur-fabian.thyroid hormones and cancer: a comprehensive review of preclinical and clinical studies. front endocrinol (lausanne). 2019; 10: 59. 20. çağdaş şenel1, altuğ tuncel1, yılmaz aslan1, dilek berker2, merve çatak2, serdar güler2, melih balcı1 mpact of thyroid hormones on serum prostate specific antigen level in patients with benign thyroid disorders journal of urological surgery, 2020;7(4):290-294. 21. çağdaş şenel , altuğ tuncel , yılmaz aslan et ail . impact of thyroid hormones on serum prostate specific antigen level in patients with benign thyroid disorder, j urol surg 2020;7(4):290-294 22. petra petranović ovčariček, ana fröbe, frederik anton verburg, et al. association of triiodothyronine levels with prostate cancer histopathological differentiation and tumor stage. anticancer research april 2020, 40 (4) 2323-2329; doi: https://doi.org/10.21873/anticanres.14199 23. baskin hj, cobin rh, duick ds, gharib h, guttler rb, et al. american association of clinical endocrinologists medical guidelines for clinical practice for the evaluation and treatment of hyperthyroidism and hypothyroidism. endocr pract. 2002; 8: 457–469. mailto:topacademicjournals@gmail.com https://doi.org/10.21873/anticanres.14199 https://doi.org/10.21873/anticanres.14199 american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 34 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 24. hsieh ml, juang hh . cell growth effects of triiodothyronine and expression of thyroid hormone receptor in prostate carcinoma cells. j androl 2005;26: 422–428. 25. tsui kh, hsieh wc, lin mh, chang pl, juang hh . triiodothyronine modulates cell proliferation of human prostatic carcinoma cells by downregulation of the b-cell translocation gene 2. prostate 2008 ; 68: 610–619. 26. lehrer s, diamond ej, stone nn, stock rg .serum thyroid-stimulating hormone is elevated in men with gleason 8 prostate cancer. bju int. 2005 ; 96: 328– 329. 27. lehrer s, diamond ej, stone nn, droller mj, stock rg . serum triiodothyronine is increased in men with prostate cancer and benign prostatic hyperplasia. j urol 2002 ; 168: 2431–2433. 28. hoption cann sa, qiu z, van netten c .a prospective study of iodine status, thyroid function, and prostate cancer risk: follow-up of the first national health and nutrition examination survey. nutr cancer 2007; 58: 28–34. 29. hellevik ai, asvold bo, bjoro t, romundstad pr, nilsen ti, et al. thyroid function and cancer risk: a prospective population study. cancer epidemiol biomarkers prev 2009 ; 18: 570–574. 30. kumar cc .integrin alpha v beta 3 as a therapeutic target for blocking tumor-induced angiogenesis. curr drug targets 2003 ; 4: 123–131. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 6; november-december 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 9 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe awareness of performance-enhancing substances among kenya teacher trainee athletes 1john david smith and 2jane elizabeth doe 1university of nairobi, kenya. 2kenyatta university, kenya abstract: this paper reviews the literature on awareness of doping among athletes. the findings of previous studies are inconsistent, with some studies finding that athletes have a good understanding of doping, while others find that they have little or no awareness. the paper discusses the factors that may contribute to these different findings, such as the type of sport, the level of competition, and the culture of doping in the sport. the paper concludes by calling for more research on awareness of doping among athletes, in order to develop effective strategies to prevent doping. keywords: doping, athletes, awareness, knowledge, prevention, education introduction various studies on awareness of doping have reported different findings. study by ama et al., (2003) on african amateur footballers in yaoundé, cameroon investigated athletes’ use and awareness of lawful and unlawful substances. the results revealed that the footballers’ knowledge of doping was vague. they recommended that preventive activities and an epidemiological study on doping among the footballers be carried out. the study was restricted to only footballers and did not factor in athletes in other games and track and field events participants. the study by koch (2002) presents athletes as knowingly participating in doping regardless of being aware of the drugs’ negative effects on health. in a self-report study on athletes’ attitude towards doping involving 446 athletes by alaranta et al., (2006), 9% of the respondents believed that banned substances have performance effects while 30% of athletes agreed to have personally known an athlete who had doped and 35% of males and 25% of the females reported to personally know an athlete who was using banned drugs at the time of the study. furthermore, 15% of the athletes noted they had been offered banned substances. a survey by anshel and russell (1997) of australian athletes’ knowledge on pes reports that majority of respondents were of the opinion that use of pes is unethical and immoral hence unacceptable as a means of gaining a competitive advantage over opponents. a survey of 503 collegiate athletes and 154 body building athletes that aimed at measuring the extent of androgenic steroids (as) abuse by lubna et al., (2008) revealed that college athletes had no problems acquiring performance enhancing drugs as they knew where and how to get them. both students and athletes noted that their friends and coaches were the major sources whereas the main reason for the use of pes was to improve mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 6; november-december 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 10 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe performance and physical appearance. the study recommended the need to implement educational programmes to create awareness and enlighten students and mentors about the negative side effects of ass on the health of the user as the drugs were increasingly becoming a public health concern. lack of awareness of anti-doping issues by athletes is equally presented in a study by levent et al. (2005) where 54 % of respondents acknowledged they were not fully aware of the full doping drug potential and effects. the study concluded that young athletes are likely to suffer most from health problems associated with the drugs as well as chances of being suspended from sports. a survey of 200 scottish athletes by dimeo et al., (2013 ) established that majority of athletes were not aware of the current wada legislation where article eleven of the wadc states that sanctions such as loss of points and disqualification can be meted on a team if three or more teammates are proven to have violated antidoping regulations. to this effect dimeo et al., (2013) recommended that awareness creation on the said legislation was needed because team sport athletes not aware of the consequences might promote anti-doping within their own team and since clean athletes would not want to feel cheated if they lose to a team found to have a number of doped participants. the study also showed that fear of being caught and shame that may befall the victim was the strongest factor preventing team athletes from considering use of pes. effects of pes use to an athlete the broad objectives of the world anti-doping agency is to protect the health of the athlete, ensure fairness in sports competition by ensuring level playing ground and safeguard the image of sport (wada, 2015). however, despite the existing antidoping regulations, cheating is still prevalent and increased fan violence has to some extent been attributed to the sale of alcohol and other recreational drugs at sports events (insel & roth, 2002). as noted by butcher and weust ( 1999) overemphasis on winning have detracted the value of sport and drawn many competitors to using illegal means of securing a trophy/medal or monetary rewards oblivion of effects of banned drugs on the athletes health and likely hood of getting banned from participation in competitions. in response to this declining sports ethics, sports governing bodies have sought to rectify the problem by imposing strict regulations (wada, 2015). doping effects are as complex as the methods of doping and no benefits of winning a competition would be worth to justify risks associated with the vice (somerville & lewis, 2005). apart from the danger of being suspended or getting a life ban from sports competitions, other implications include physiological, psychological, social and ethical /moral effects. to ensure level playing ground, protect health of athlete and preserve the dignity of the sport, sports organizations such as iaaf, ioc, and wada have listed banned substances and placed the onus of educating competitors on the implications of doping to local sports federations. however, despite the good intentions by wada and sports organizations, pes use still persists in sports. athletes are reported to use pes as they perceived the illicit drugs have positive impacts on athletics performance more than non-athletes. such pes include anabolic androgenic steroids, amphetamines, human growth hormone/erythropoietin which they perceive would combat fatigue, relieve pain, and enhance injury recovery, increase strength and endurance among other perceived benefits. as mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 6; november-december 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 11 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe reported by david, mcduff & david, (2005) athletes have also confessed to have used substances such as alcohol, cocaine, marijuana to ‘fit in’, boost self-confidence, escape problems and to have fun. methods this study used the survey method whereby participants comprised of 422 randomly selected male and female teacher trainee athletes participating in national track and field athletics and ballgames managed by the kenya teachers colleges sports association. participants age ranged between18-21(164) years, 22-26 years (229) and those above 26 years (27). a self-administered questionnaire was used for data collection with a return rate of 70%. results awareness of pes among college athletes the question on whether selected substances could enhance performance in sports, showed mixed reactions from respondents. according to a majority, alcohol was deemed as not enhancing performance (81.8%), so was miraa (khat) (67.6%), caffeine (51.9%) and cocaine (55.5%). alcohol has negative effects to sports performance unlike the miraa and caffeine that has a positive effect that would give an athlete an advantage over non users. only marijuana (53.0%) and anabolic (56.4%) were deemed to have performance enhancing abilities by more than half the respondents. table 1: teacher trainee athletes’ responses to selected drugs/ substances effects to sports performance substances/drug effects to performance no (%) yes ( %) alcohol 81.8 18.2 miraa 67.6 32.4 marijuana 47.0 53.0 caffeine 51.9 48.1 anabolic steroids 43.6 56.4 cocaine 55.5 44.5 the awareness of use of pes among the athletes was also assessed with items revolving around familiarity with the wada anti-doping code, use of pes and the extent of the knowledge on use of pes as well as anti-doping code. as indicated in figure 1 combined majority (49.3%) of the college athletes agreed to have knowledge of the wada anti-doping code compared to almost equal the number (43.3%) who disagreed or strongly disagreed to having any knowledge of the anti-doping code. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 6; november-december 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 12 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe figure 1: familiarity with wada code further, the level of knowledge of the regulations outlined in the wada code was ascertained with almost repeated frequencies with reference to the regulations of the code. as shown in figure 2, 48.1% agreed in various levels to have known the regulations whereas 42.7% did not have knowledge of the regulations of the code. figure 2: familiarity with wada regulations figure 3 indicate there was a generally high level of agreement among the combined respondents (82%) that athletes should be tested for use of pes and drugs at all levels of competition. a similarly high number of the respondents (72.0%) were aware of the effects of use of pes and drugs while 80.0% noted their friends do not use enhancing substances and drugs. about 67.0 % of respondents did not know athletes using pes but about 20.0% knew athletes who dope. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 6; november-december 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 13 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe figure 3: athletes awareness of testing, effects and, use of pes a combined majority (58.0%) agreed to having learnt about pes and drugs as shown in figure 4. however, much as a majority agreed to having learnt about pes and drugs, less than half (36%) the respondents considered their knowledge pes use to be adequate. this was further reflected by the more than half (50.0 %) who alluded that they did not have regular education on anti-doping regulations. figure 4: athletes awareness/anti-doping education figure 5 indicate the knowledge teacher trainee athletes had about doping and use of pes was sourced by the majority from broadcast media such as television (79.4%), radio (76.0%), newspapers (77.0%) and magazines (70.0%). the other important sources as indicated were friends (70.0%) and teachers or tutors (74.0%) at school or college (69.0%), seminars 48.0% and parents 50.0%. as also captured in figure 5 less than half of the athletes reported having received information from seminars whereas a sheer half had known about doping and pes from parents yet these two sources could be the most credible source of such critical information. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 6; november-december 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 14 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe figure 5: sources of awareness about use of p table 1: awareness of pes among college athletes statement mean std. deviation i am familiar with the world anti-doping code 3.01 1.393 i personally know athletes/players who have used performanceenhancing substances/drugs 2.24 1.228 my friends use performance enhancing-substances/drugs 1.81 1.049 i am familiar with anti-doping regulations 3.01 1.398 i am regularly educated on anti-doping regulations regularly 2.84 1.383 athletes should be tested for performance enhancingsubstances/drugs at all levels of competition 4.21 1.077 i am aware of the effects of performance enhancingsubstances 3.84 1.209 composite means were computed for the purpose of further statistical analysis and testing for differences between various groups. as indicated by anova, there were statistically significant differences of awareness on the use of pes and drugs with regard to teacher trainees’ competitive experience, f (389) = 6.928, p= 0.0001. further, a scheffe post-hoc test established the source of difference between athletes who had participated at national competition once and those who had competed four times (p =0.0001); twice and four times (p =0.0001); thrice and four times (p =0.015), and four times and more than four times (p =0.006). anova test also revealed statistically significant differences in awareness of pes among athletes playing different ballgames at f (314) =4.179, p =0.001. the difference was between those playing volleyball and basketball (p =0.023); volleyball and hockey (p =0.018). in addition, there were statistically significant mean awareness differences between male and female athletes, the latter having a higher mean (t (406) =5.718, p =0.005). by virtue of this indication, male athletes were more aware of use of pes/ drugs and the anti-doping regulations. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 6; november-december 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 15 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe discussion almost half of the collegiate athletes (43.3%) were not aware of the existence of a wadc against 49.3% who knew about the existence of the same. further, 42.7% were not aware of the regulations stipulated in the wadc regarding doping issues against 48.1 % who knew of the regulations. this raises the question on whether an ignorant teacher can be trusted to guide young athletes to participate in ‘clean’ sports competition. but, as reported by morente-sanchez & zabala, (2013) it is not unusual for an athlete to be familiar with antidoping rules but still display lack of knowledge. as indicated in table 2, collegiate athletes displayed lack of awareness of the positive effects of miraa (khat) (67.6%) cocaine (55.5%), marijuana (47%) caffeine (51.9%) to sports performance. with a majority of athletes observing that khat (miraa) could not enhance performance it is an indication that teacher trainee athletes lack awareness of doping and may be at risk of using pes unknowingly. the world anti-doping code (wadc) stipulates that an athlete who unknowingly tests positive for banned substance shall be guilty of the offense. though majority of athletes (81.8%) knew alcohol is not an enhancer there were still 19.2 % who thought it could improve performance yet it can only impair performance. although alcohol is not listed as banned substance by wada, higher content levels in an athlete’s blood than the 0.10 g/l quantity allowed could lead to a ban. if an athlete involved in competition is under the influence of alcohol, safety of other participants is at risk. kenya colleges’ athletes who reported alcohol as an enhancer probably were not aware that wada has prohibited use of alcohol for particular sports including archery, air sports, automobile, karate, motorcycling, and power boating. considering that a kenyan boxer was banned during 2004 athens olympics for testing positive to cathine teacher trainees need to be educated so that they become informed pe and sports coaches to student athletes in both primary and secondary schools after graduating from college. this level of ignorance should be a wakeup call for the kenya sports federations and national olympic committee of kenya (nock) to enhance anti-doping campaign to athletes at all levels of competition. even though more than half the respondents knew marijuana and steroids could enhance performance, a large number still were of the view that they had no effects. this is a worrying situation considering that physical education is a compulsory area of study where curriculum has antidoping content outlined for teaching yet some teacher trainees would display ignorance when they ought to have learnt of various substances effects. athletes had acquired anti-doping information from various sources including television 79.0%, newspapers 77.0%, radio 76.0%, magazines 70.0%, friends 70.0%, tutors/teachers 74.0%, and college/school 69.0%, seminars 48.0% parents 50.0%. this indicates that not much has been learnt through seminars where credible anti-doping experts can be source of information. parents were not rated highly yet some athletes are in age bracket whereby the influence of the parent could still be valuable and may be termed a more credible source of information. perhaps the college athletes being young adults no longer consider parents as a source of information and prefer seeking information from friends. this may indicate likelihood of peer influence likely at college level since students mix freely and are bound to share information regardless of whether it is correct or incorrect. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 6; november-december 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 16 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe some sources of anti-doping knowledge such as television are questionable as noted by nowesielki and swiatkowaska, (2007) that media sometimes broadcasts more forthan against doping in sports. similar sentiments are expressed by morrison, kalin and morrison (2004) that print media and television have been used to portray ‘ideal’ male body, which in turn may encourage use of pes by young athletes in order to get the ‘ideal’ body. portray by media of high profile athletes who have used pes may equally encourage young athletes into the doping behaviour. it is imperative to underline that raising awareness has not always translated to change in behaviour. in this study athletes (58.0%) observed they had learnt about pes yet their awareness of effects of substance use in sport isn’t reflecting the same. this study also demonstrates that some college athletes had not received doping education since 40 % observed they had not learnt about doping hence to entrust such a teacher to the primary or secondary school athlete as a pe teacher or coach would not benefit upcoming young athletes as far as pes issues are concerned. athletes training/competing under a coach ignorant of anti-doping regulations/substances may unknowingly ingest banned substances and as a coach may give young athletes banned substances to ingest. though majority of respondents noted that their awareness of pes was sufficient there was a contradiction in that a large number reckoned they lacked adequate knowledge on anti-doping issues despite being consumers of teacher education curriculum. further contradiction is noted in that majority cited they were not regularly educated on anti-doping. similar contradictions are reported by whitaker (2012) where majority of athletes noted they had been educated on banned substances yet they also admitted they would dope given an opportunity. recently a number of upcoming young kenyan athletes have failed dope test and banned for a period between 2 4 years (ayumba a, 2015). probably if these athletes had been educated on anti-doping while in school, they would not have been caught up in the vice. however unless the teachers are better informed on anti-doping regulations young potential athletes are likely to engage in doping vice either knowingly or unknowingly because they may graduate from school and probably get recruited into sports by local and foreign coaches and managers who may expose them to banned substances. education on drugs and substance use in sports should start early before the teacher trainee is enrolled in college. although a combined minority (8.0 %) knew friends who were using pes, this may point to the probability of peer influence. similar observation is made by the anti doping report (republic of kenya, 2014) where 17.9% of 357 respondents said they were using pes due to peer pressure. this could also be an indication that doping may be going on amongst college athletes. this may also have a bearing on the study report by nacada, (2012) whereby respondents from post secondary institutions were using narcotics such as bhang and cocaine. nacada, (2012) reports 9.3 % respondent in 1824 and 24-35 years age categories were using khat (miraa). kenya teachers colleges athletes fall under these age categories. the nacada (2012) report further indicates that 2.0% of students were consuming khat (miraa). this is an indication that both teacher trainee and students may be in danger of using pes in sporting situations. majority of college athletes (82.0%) noted that athletes should be tested for performance enhancing substance. a large number of athletes (94.3%) further concurred that testing for banned substances should be done at all levels of competition. these positive responses indicate the willingness by athletes to embrace clean sports and desire mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 6; november-december 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 17 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe for awareness on doping issues. the need for athletes testing for banned substance is also emphasized in the antidoping task force report (republic of kenya, 2014) where it is noted that education and awareness on antidoping regulations should be cascaded to the grass roots. findings of this study tend to be in agreement anti doping studies in other countries. lubna et al., (2008) reports jordanian students and college athletes lacked awareness on doping, feinberg (2009) reports on lack of awareness by polish athletes while ama et al., (2003) has reported doping awareness by cameroonian soccer players being vague and insufficient. this study had hoped that since physical education in kenya teacher trainee education course is a compulsory subject where the content on doping and substance use is outlined in the curriculum; there would be significant awareness on doping among the collegiate-athletes. statistical analysis indicate differences in doping awareness between gender (t (406) =5.718, p =0.005). some possible explanation for male athletes being more aware is that as reported by kenya anti-doping taskforce (republic of kenya 2014), more male teams receive some doping information occasionally in seminars especially in soccer. male athletes are probably more open in sharing information hence more male reported to be aware of doping issues. female athletes lacked awareness compared to male athletes similar to corbin et al., (2004) findings of usa college where male athletes were better informed than female athletes. significant differences in doping awareness between male and female athletes have also been reported by green and uryasz (2001). but crabbe (2001) posits although male athletes had received more education on doping in sports they were still five times more likely to drink alcohol than their female counterparts despite its negative effects on sports performance. this seems to point that awareness of banned substances may not necessarily translate to good practice. this study findings indicate significant differences in awareness among athletes with varying experience in national sports competitions f (389) =6.928, p=0, 0001. the longer the athletes had participated in national competitions the higher the awareness. differences were between athletes who had played for once and athletes who had played four times p = 0.0001, twice and four times p= 0.0001, thrice and four years p = 0.015 and tour and more than four times in competition p= 0.006. this may be an indication that an athlete who may not have been educated on antidoping at primary and secondary school level he/she was likely to gain some level of awareness over time as they get exposed to competitions at higher levels. since coaches and sports federations rarely hold seminars to discuss doping with athletes (republic of kenya, 2014) it is possible for college athletes to have participated for some years without learning about banned substances. after all majority of athletes (71.1%) reported to have participated in out-of-school sports competitions before collegiate sports, suggesting they may not have received anti-doping information even then. generally this study findings show that the longer an athlete had participated at national competitions the more informed they were regarding pes. however this awareness may have been attained from the friend and through the media (fig. 5) this notwithstanding, the large number of athletes not fully informed on performance enhancing substance use in sport calls for an urgent need for collaboration by all stakeholders on the need to educate athletes on performance enhancing use in sports as most participants may be developing skills in readiness to taking sport as a career. the ktcsa would be expected to have instituted some form of forum where all participating athletes and sports personnel are inducted on the anti-doping code requirements and regulations well before the national mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 6; november-december 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 18 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe competitions. after all wada expects that sports federations/associations would raise athletes’ awareness on anti-doping regulations. as reported by republic of kenya (2014) there are athletes who are supplied with doping substances by the coaches, athlete-team staff and their friends. these sentiments are expressed in other studies by and lubna et al., (2008) alaranta et al., (2006) where coaches supplied athletes with pes. a member of the usa olympic team is reported to have been doped by the coach with steroids without consent thus destroying his immune system and eventually stopping his career (haley, 2003), and so were the russian olympic athletes doped unknowingly corbin et al., (2004). there is a call for strict measures to ban doping and to avail doping education to every sports participant regarding the need for honesty and hard work that would lead to success in performance without putting an individual at risk (kumar & joyti, 2013). findings of this study seem to suggest that without proper information kenya teachers colleges athletes on becoming pe and sports coaches may misguide or probably supply athletes in schools with doping substances. teacher trainee athletes are expected/should graduate from college to be coaches of integrity and responsible in guiding and protecting young athletes from the negative effects of doping drugs and substances. there were significant differences in awareness among competitors in various ball games, f (314) = 4.179, p =0.001. differences were specifically between athletes in volleyball and basketball p = 0.023, and between volleyball and hockey p= 0.018. according to the anti-doping task force report republic of kenya, (2014), hockey and volleyball players have reported use of banned substances while none is reported by basketball players. players in the two games used miraa, bhang, alcohol which are mostly purchased from the open market. players noted that no doping education or testing is carried out among players. basketball players noted that there is a clause in their constitution on antidoping but no education structures to execute it. however some studies by corbin et al., (2004), nowesielski and swistkowska, (2007) and feinberg (2009), portray team sports players having more awareness of pes. overall, findings of the study indicate kenya teachers colleges athletes in 2015 ktcsa national sports competitions lacked awareness of banned substances in sports and may be at risk of contravening the anti-doping regulations in future. recommendations this study only investigated the teacher trainee athletes who were participating at the national ballgames and athletics competitions which is only a small portion of teachers’ college’s student population whose responses may not suffice for all students who consume sports competitively or as a recreation. there is therefore the need to; • investigate awareness, perception and attitude to pes use in sport by teacher trainees in general in order to establish whether findings of this study apply to them. this may also inform wider and far reaching strategies for the whole student population. • it is necessary to establish primary and secondary schools athletes’ awareness, and attitude to doping because they usually form the junior teams that represent kenya at regional and international sports competitions. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 6; november-december 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 19 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe some of them may find their way to teachers colleges as trainees and may be participating in sports competitions hence the need for their awareness to be raised early. they may also have opportunities to grow in career as teachers and coaches in sports. • coaches, trainers and team managers’ at the teacher-college level should be investigated for their level of doping knowledge. they play a crucial role in teaching, and coaching athletes for competitions and future careers in sports. • evaluate the effectiveness of doping content taught in teacher training colleges in order to establish the college lecturers’ competence in imparting college trainees with knowledge and right attitudes on doping and whether the content is sufficiently taught. references ama p, f.m., betnga. b., moor ama,v.j., & kamga,j. p. (2003). football and doping: study of african amateur footballers. british journal of sports medicine. 37: 307310. anshel, m. h., & russell, k. g. (1997). examining athletes’ attitudes toward using anabolic steroids and their knowledge of the possible effects. journal of drug education, 27(2), 121-145. ayumba, a. (2015) on, “up and coming runner jeruto handed four-year ban for failing drug test”, daily nation newspaper publications. saturday 3rd october 2015, nairobi (pp.48). corbin, b. c., corbin, r. c., welk, j. g., & lindsey, r. (2004).concepts of fitness and wellness: a comprehensive lifestyle approach. boston: mcgraw hill. crabbe. t, (2001). a sporting chance? using sport to tackle drug use and crime.drugs: education, prevention and policy, 7(4): 381-391.doi:10.1080/de.7.4.381.391 david. r, mcduff, m.d & david m.d.(2005). substance use by athletes. a sports psychiatry perspective: clinic sports medicine, 24:885-897 dimeo.p, justine. a. taylor. j. dixon. s &leigh. r. (2013).team dynamics and doping in sport. a risk or a protective factor? world anti-doping agency. target research scheme. university of sterling school of sport. feinberg, j. m. (2009). college students’ perceptions of athletes who cheat: the role of performance and history. journal of sports behavior.19 (4) 320-322. green, g, & uryasz, f.d, (2001). ncaa study of substance use and abuse habits of college student-athletes. clinic journal of sport medicine 11: 51-56. haey ,j. (2003). performance enhancing drugs: at the issue. geenhaven press. new york mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 6; november-december 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 20 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe insel, p.m., & roth, w.t. (2002). core concepts in health. boston: mcgraw hill. koch, j. j. (2002). performance-enhancing substances and their use among adolescent athletes. american academy of pediatrics. 23:310-317. kumar,n. & jyoti, r.(2013). a study of perception by university students towards doping in haryana, india. research journal of physical education sciences. 1 (1) 2-6. levent. o, naim.n, ihsan. b, okay.b, haldun. s& gunduz.t (2005). doping and performance enhancing drug use in athletes living in siva, mid-anatolia: a brief report. journal of sports science and medicine (2005) 4, 248-252. morente-sanchez,j.& zabala, m. (2013). doping in sports: a review of elite athletes, beliefs, and knowledge. journal of sports medicine: 43:6: 395-411. morrison,t.g., kalin,r., & morrison, m. a (2004). body-image evaluation and bodyimage investment among adolescents: a test of socio cultural and social comparison theories. adolescence, 39, 571-592. nacada (2012).rapid situational assessment of the status of drug and substance abuse in kenya. nairobi. kenya. nowosielski k, s.,& swiatkowska, l. (2007) .the knowledge, of the world antidoping code among polish athletes and their attitude toward doping and antidoping policy. journal of human movement. 8 (1): 5764. republic of kenya (2014).anti-doping taskforce final report. ministry of sports, culture and arts department of sports. nairobi. sommerville, s. j., & lewis, m. (2005). accidental breaches of the doping regulations in sport: is there a need to improve the education of the sports people? british journal of sports medicine. 39: 512-516. wada. (2015). world anti doing code; play true. world anti-doping agency. whitaker,l. (2012). performance enhancement in sports: summary of the findings. carnegie research institute. leeds metropolitan university. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 69 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe biochemical changes of electrolytes and trace elements among patient with coronavirus disease -19 (covid -19) in khartoum state abdallah eltoum ali1, ahmed jbril aldooma sabil 1, mohammed abd elfatah elamin ali1 ahmed ibn edriss mohammed2 salih a. elmahdi 3 university of alzaeim al azhari faculty of medical laboratory sciences, department of clinical chemistry university of elimam elmahdi department of medical laboratory sciences college of medical laboratory sciences. department of clinical chemistry. the national ribat university, khartoum, sudan. abstract background: coronavirus disease 2019 covid-19 is a pandemic caused by severe acute syndrome coronavirus 2 (sars-cov-2) is respiratory and can be involved in multiorgan failure causes many biochemical changes in the human body, our study was designed to examine the serum level electrolytes and trace elements in covid19 patients and associated with severity of the disease. materials and methods: cross-sectional study includes 50 covid-19 patients conducted during the period from december 2020 to april 2021 and 50 healthy as control group. blood samples were collected from the study group and measured electrolytes sodium and potassium by easy lite, calcium, phosphate, zinc, and copper by using calorimeter methods, statistical analysis was conducted using the spss version. results: the study showed that in covid-19 patients there was a significantly low level of sodium (132 ± 4.3), potassium (3.2 ± 0.4), and calcium (7.8 ± .98) in comparison to control, insignificant in level of phosphorus and magnesium when compared with control group respectively ( p.value = 0.15 , 0.8 .) . there is significant decrease in the mean level of zinc and increase in the mean level of copper in covid-19 patients when were compared to control group (p value = 0.000) ,. however there was strong correlation between sodium (r=-.753, p= .000) , potassium (r= -.736, p=.000) , zinc (r= -.819, p= .000) and copper (r= .700, p= .000) with severity of disease. conclusions: covid-19 infection cause hypernatremia, hypokalemia, and hypocalcaemia. low zinc and high copper levels, the level of parameters is correlated with the severity of the disease. keywords: covid -19, sodium, potassium, calcium, phosphate, magnesium, copper zinc mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 70 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe introduction: the term "coronavirus" means "halo" or "crown." coronaviruses are enveloped, positive-sense singlestranded rna viruses with a genome size range of 26 and 32 kbs (1,2). coronaviruses are zoonotic infections that originate in animals and can be transmitted directly from one person to another. the seafood market in wuhan, china, where covid-19 is said to have first appeared, was later closed down by chinese authorities (3). infection is primarily spread from person to person through respiratory droplets, close personal contact, like touching or shaking hands, and fecaloral routes are rarely used. therefore, it has been advised to place persons who have been exposed to infection under quarantine for 14 days (4,5). electrolytes are compounds that dissolve in body fluids and can conduct an electrical current. the extracellular fluid and intracellular fluid include these substances, therefore electrolytes are essential for regulating homeostasis (6). neurological symptoms of hyponatremia, one of the electrolyte diseases, are present. headaches, disorientation, confusion, and nausea are common patient complaints. when the serum sodium levels are higher than 145 mmol/l, hypernatremia manifests. tachypnea, trouble falling asleep, and agitation are all signs of hypernatremia (7). the virus's entry reduces ace2 and stops angiotensin ii from degrading, which leads to an increase in the production of aldosterone and potassium loss from urine (8,9). despite the rarity of reports of hypocalcemia during covid-19 infection, we should therefore pay greater attention to changes in calcium/phosphorus metabolism in covid-19 patients and closely monitor calcium levels, especially in those with a history of hypocalcemia, to prevent the condition from getting worse and to start the right treatment as soon as possible. (6,8,9). in the pathophysiology of covid-19, trace elements play a significant role. recent assessments have noted that amounts of zinc are necessary for both the innate and adaptive immune systems (10). for instance, low levels of zinc impair the activity of natural killer (nk)cells, which are essential for maintaining the immune response against viruses and tumors (11). zinc must be in balance with copper in order to neutralize any negative impacts that copper may have. additionally, copper is an essential trace element for both humans and pathogens (12). no matter the causative agent (virus, bacterium, or fungus), a steady rise in serum copper is a characteristic of infection (13–15). however, there is no data on copper levels in people who have covid-19 infection. one of the significant ions needed as a cofactor for the atp enzyme, which is involved in numerous crucial enzymatic activities, is magnesium. by controlling the active sites of particular kinases, mg2+ has also been shown to play a crucial immunological function in cd8+ t cell activation in infection [16]. understanding the potential connection between magnesium and pulmonary outcomes of covid-19 disease depends on the finding from a recent study that serum magnesium levels may have a protective impact against lung function loss in asthmachronic obstructive pulmonary disease [17]. material and methods study group a cross-sectional study was conducted during the period from december 2020 to april 2021 in khartoum state. sudanese patients with covid-19 and patients who were diagnosed with covid-19 during the study period were enrolled to participate in this study. the confirmation of covid-19 will be based on a ct scan and/or rt-pcr. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 71 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe the total study group was 100, 50 patients with covid-19 as a case study, and 50 healthy individuals were enrolled as a control group. criteria for inclusion and exclusion patients with any chronic disease that may have an impact on serum electrolytes calcium phosphate magnesium zinc and copper levels will be excluded. ethical considerations: the study was revised and ethically approved by the ethical and scientific committee of the faculty of medical laboratory sciences, university of alzaiem alazhari. samples were taken with verbal consent from patients or their relatives. data collection: a direct interview questionnaire was used to collect data. medical information was collected from the patient's file with the help of the treating physician. collection of specimens: venous blood samples were collected by using sterile, dry, plastic syringes and a tourniquet to make the veins more prominent. the puncture sites are cleaned with 70% ethanol and 5 ml of blood is collected in lithium heparin containers. the lithium heparin blood sample was centrifuged at 4000 rpm to obtain the plasma and then stored at (-4 c) until the analysis. measurement of biochemical parameters: the serum electrolytes sodium potassium is measured by easylyte analyzer ion selective electrode technology, the flow-through sodium electrode uses a selective membrane that is specially formulated to be sensitive to sodium ions, and the potassium electrode employs a similar design with the appropriate selective membrane material. each electrode's potential is measured in relation to a fixed and stable voltage set by the double-junction silver silver chloride reference electrode.an ion-selective electrode develops a voltage that varies with the concentration of the ion to which it responds. (18) the colorimetric method is used for measuring zinc and copper by a single reagent colorimetric test with dibromo-paesa). the assay principle consists of dissociating copper from ceruloplasmin and other coppercontaining proteins, by a denaturalizing agent in acidic conditions. free and the portion associated with copper will form the copper-3-5dibr-paesa complex. which is detected by absorbance at 580nm. (19). zinc forms a red chelate complex with 2-(5-bromo-2pyridylase)-5-(n-propyl-n-sulfopropylamino)-phenol in a single reagent calorimetric test with 5-bromo-paps. (20) calcium, phosphate, and magnesium blood levels were measured by the cobas 6000 fully automated analyzer (roche-germany). data examination the statistical analysis of the results was performed by using the statistical package for social sciences (spss) version 15.0 for windows version 10 using a t-test for testing difference significance and a pearson correlation test ( rvalue as the coefficient ). a p value of 0.05 was considered statistically significant. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 72 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe results this study described 50 adult patients (21–81 years old) who were hospitalized with covid-19 in an isolation center in sudan. the study aimed to determine the serum levels of sodium, potassium, calcium, phosphate, magnesium, copper, and zinc in covid-19 patients and compare the results with a control group. the covid-19 patients are classified into mild (n = 19), moderate (n = 9) and severe (n = 22) according to disease severity in figure (1). in the present study, the majority of covid-19 cases were males (52%), which demonstrated that the incidence of covid-19 is higher in males than in females. abnormal laboratory parameters were more frequently observed in confirmed covid19 patients, particularly in mild, moderate and severe or critical patients, as shown in tables ( 1,2) and figures (2,3,4,5). table (1) showed hyponatremia and hypokalemia that there was a significant decrease in the mean level of sodium, potassium, and calcium in covid-19 patients when compared with the control group (p-value = 0.000). insignificant differences were found in the levels of phosphorus and magnesium among covid-19 patients. there was no significant difference in the levels of phosphorus and magnesium when compared with the control group. this study showed that there was a significant decrease in the mean level of zinc and an increase in the mean level of copper in covid-19 patients when compared to the control group (p-value = 0.000), table 1. pearson correlation investigates the relationship between covid-19 disease stages and biochemical changes in plasma parameters in table (2) and figures (2, 3, 4,) and (5) . negative correlation between sodium levels and disease severity stages, r = -0.75, p =.000; negative correlation between serum potassium levels and disease stages, r = -0.74 , p =0.000. negative correlation between plasma zinc level and stages of the disease, r= -0.8 p. value =0.000, positive correlation between plasma copper and stages of covid-19 disease, r= 0.7, p. value =0.000, mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 73 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe table (1) comparison of biochemical parameters means and sd. among of the study groups test cases (covid19 patients) control (healthy) p value sodium (na mmol\l) 132 ±4.3 139±2.9 0.000 potassium (k mmol\l) 3.2±.40 4.3±.46 0.000 calcium (ca mg\dl) 7.8±.98 9.2±.60 0.000 phosphate (ph mg\dl) 4.5±2.2 3. 9±.024 0.15 magnesium (mg mg/dl ) 2.2 ±0.5 2.2±0.2 0.8 zinc ( zn µg/dl) 60±26.8 85±23.4 0.000 copper (cu µg/dl) 219 ±89 93 ±23 0.000 table (2) correlation between the stages of the disease and biochemical changes in the plasma parameters test correlation(r-+) p.value na mmol\l -.753** .000 k mmol\l -.736** .000 zn μg \dl -.819** .000 cu μg \dl +.700* .000 figure ( 1 ) distribution of stages of the disease in the case study mild 38 % moderate 18 % severe 44 % mild moderate severe mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 74 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe figure (2) correlation between plasma sodium (na) level and stages of covid 19 disease, r= -0.75 , p.value =.000 figure (3) correlation between plasma level of potassium (k) and stages of covid 19 disease, r= 0.74p.value =0.000 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 75 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe figure (4) correlation between plasma zinc (zn) level and stages of covid 19 disease, r= -0.8 p.value =0.000 figure (5) correlation between plasma copper (cu) and stages of covid 19 disease, r= 0.7 p.value =0.000 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 76 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe figure (6) correlation between serum calcium (ca) level and stages of covid 19 disease r= 0.02 and p.value = 0.8. discussion a new coronavirus known as covid-19 was discovered in wuhan, china, at the end of 2019. it caused havoc there, with an overall case-fatality rate (cfr) of 2.3% (4512 deaths among 68151 confirmed cases (21) found to spread from person to person like droplet infections (22) and was highly contagious, leading to a city lockdown to stop the spread of the illness (23) it began to spread over the world, and in march 2020 it reached sudan (24). covid-19 is a huge global health problem due to its high rate of transmission and its high morbidity and mortality rates. among the numerous pathophysiological effects associated with the virus, endocrine and metabolic disorders stand out. however, the particular consequences on the electrolytes, calcium, phosphorus, and trace elements metabolism system are still not fully understood., electrolyte and trace elements disturbances are commonly observed in patients with coronavirus disease 2019 (covid-19) and associated with outcomes in these patients. our study was designed to examine whether abnormal levels of electrolyte and trace elements are associated with mortality in covid-19 patients. serum levels of electrolytes essential and trace elements are necessary for the well-functioning and maintenance of the immune system during any infection. in this present study, we measured serum levels of electrolytes and trace elements and their association with the severity of covid-19 patients. the results indicate that these metal levels are altered in a severity-dependent manner. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 77 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe this study described adult patients who were hospitalized with covid-19 in an isolation center in sudan. in the present study, the majority of covid-19 cases were males (52%), which agrees with the study of team tncpere (25) which demonstrated that the incidence of covid-19 is higher in males than in females. this is due to dissimilar innate immunity, steroid hormones, and factors related to sex chromosomes. the findings of this study, there was a significantly lower mean sodium and potassium levels in covid-19 patients when compared to the control group , these results corroborated those of carvalho et al. (26) who found that hyponatremia and hypokalemia were different associations with covid-19 in comparison to controls. the enhanced production of antidiuretic hormone (adh) in response to volume depletion after gastrointestinal fluid losses is thought to be responsible for these outcomes , severe illnesses have been linked to hyponatremia, hypokalemia, and hypocalcemia [27]. some theories have developed, despite the fact that the pathophysiological mechanisms behind such alterations are still not completely known. sars-interaction of cov-2's with the ace2 receptor may result in decreased ace2 expression and increased angiotensin ii, which stimulates potassium excretion and causes hypokalemia [28]. additionally, diarrhea brought on by gastrointestinal dysfunction may be a cause in electrolyte imbalance (28). the kidneys and gi tract are key players in various processes that regulate fluid and electrolyte balance. because of this, damage to them usually throws off the balance of fluid and electrolytes [29]. electrolyte changes in patients, including sodium, potassium, chlorine, and calcium imbalances, are confirmed by similar studies of covid-19 [30, 31]. hyponatremia is one of the most frequent electrolyte abnormalities and is associated with a higher mortality risk in hospitalized patients [32]. patients with covid-19 who take ras-inhibiting medications experience decreased aldosterone production, which can result in fluid and electrolyte imbalances. the central nervous system (cns), the heart, the kidneys, and other gi tracts like the colon all express the mineralocorticoid receptor (mr), also known as the aldosterone receptor. changes in ion concentration occur as a result of mr activation ( such as sodium and potassium). these adjustments are required to keep the body's fluid and electrolyte equilibrium. in spite of this, mr is present in the large intestine [33–35]. fluid and electrolyte imbalances result from a disruption of the aldosterone pathway, which also affects the absorption and secretion of ions in the colon. electrolyte abnormalities, such as hyponatremia, hypokalemia, and hypochloremia, were more prevalent in covid-19 patients than in controls, according to a case study [36]. a covid-19 consequence called hypokalemia can increase acute respiratory distress syndrome (ards) and put patients at risk for cardiac damage [37]. in patients with acute covid-19, hypernatremia is rather prevalent. patients with hypernatremia have spent more time in intensive care and are at greater risk of passing away. as a result, in covid-19 patients, the level of ions, especially sodium and potassium, is an important signal [38]. according to this study, there was a significantly lower mean calcium level in covid-19 patients than in the control group , these findings supported by yang's (39) finding that covid-19 was independently related with hypocalcemia more so than the control group. increased neuromuscular irritability, which is characterized by mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 78 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe muscle spasms, tingling in the limbs, and perioral numbness, was found to be the most frequent side effect of hypocalcemia in a prior study. a rare complication of hypocalcemia is reversible cardiomyopathy [40]. the findings of the current study are similar with those of ramesh (41) who found that covid-19 was significantly associated with hypocalcemia more so than among controls. when compared to the control group in this investigation, covid-19 patients had normal levels of phosphate see table (1). disagree with previous studies findings that hypophosphatemia was more significantly linked with covid-19 than the control group (39, 41). nutritional phosphate intake, intracellular to extracellular phosphate transfer, renal glomerular function, and tubular phosphate reabsorption all affect serum phosphate levels. diets and environmental changes are likely to be to responsible for the discrepancy. other earlier studies discovered that the link between hypophosphatemia and poor outcomes was likely mediated by the risk factors for hypophosphatemia, which are excessive energy consumption and catabolism as well as inadequate nutritional intake. individuals with covid-19 frequently suffered from malnutrition, which has been linked to a poor outcome for these patients. (4247). additionally, the regular operation of immune cells may be impacted by cellular atp depletion, which may be indicated by the low serum phosphorus level, which could affect the immune system's capacity to defend against viral infection. (42-47). the current study shows the case study's normal serum magnesium level. low of magnesium makes endothelium cells more susceptible to oxidative stress and encourages endothelial dysfunction. low intracellular magnesium increases platelet-dependent thrombosis, and low serum magnesium is linked to increased thrombotic risk and slower fibrinolysis (48,49,50 ,51). additionally, magnesium decreases mortality in vivo trials of induced pulmonary thrombosis and has antithrombotic properties (52 ). all of these shows that diffuse intravascular coagulopathy is more likely in covid-19 individuals who are magnesium deficiency. rare clinical data available on the serum cu status of covid-19 patients. the severity of the condition was positively correlated with higher serum copper levels among covid-19 patients in this study table (1). similar findings from previous studies have also shown that copper increased concentrations, with small deviations only in comparison to the healthy control group [53]. additionally, a study conducted in wuhan, china, found that patients with more severe diseases had generally higher cu statuses, without finding a difference in full blood cu between survivors and non-survivors [54]. zinc is transiently transferred from the serum to the organs during infection and inflammation, resulting in momentarily low serum zinc levels, which return to normal as the inflammatory response decreases (55,56). when fighting infections, a normal zinc level is essential, by controlling the pro-inflammatory response, zinc signals have an anti-inflammatory effect during infection. (57) higher il-6 responses have been linked to zinc deficiency. when covid-19 causes severe lung injury, il-6 is essential. when compared to mild, moderate, and controls in this study, it was found that the severe stage had significantly lower serum zinc levels see figure (4). similar findings were reported by jothimani et al., who found that patients with decreased zinc levels had more serious problems and required longer hospitalizations in hospitals [29]. numerous other studies [58, 59] reported mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 79 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe reduced zinc levels in covid-19-infected women, including pregnant women. muhammad et al. [60] reported similar outcomes in the nigerian population. in several studies, zinc supplements were also initiated as part of the standard treatment to confirm the role of zinc in the progression of the disease; the groups who were not given any supplements had higher mortality than the population taking zinc supplements [61]. other findings for zinc and trace elements evaluated in severe covid-19 patients are similar with those from earlier studies. when compared to mild-to-moderate covid-19 infection, serum zn levels have been reported to be reduced [62]. skalny and others, 2021 (63) . additionally, it was found that as compared to controls, increasing covid-19 severity is linked to a large, steady decline in serum zinc levels as well as declines in serum calcium, iron, and selenium levels. however, there are higher levels of serum cu and, in particularly, the cu zn ratio [63]. additionally, according to the study, there is no obvious gender difference in the mean levels of sodium and potassium in covid-19 patients (p-value 0.05). this result is in contrast a study by vahidy et al. (64) who found that male patients hospitalized for covid-19 had a larger proportion of abnormal laboratory values than female patients. the short sample size and environmental changes can be used as an explanation for this difference. potassium and sodium have a high negative significant link (r = -.736, p =.000) according to the correlation study. this is similar to zhou et al . (65), which discovered a high correlation between the severity of the disease and decreasing blood levels of sodium and potassium. the correlation study revealed a weak relationship between calcium and phosphate (r = 0.02, p = 0.8 and r = -0.02, p=0.9, respectively). this is in contrast to yang's study, which found a significantly positive link between the severity of the disease and reduced blood levels of phosphate and calcium. acute complications caused on by the virus can include acute kidney damage (aki) and digestive issues for the patient. fluid and electrolyte abnormalities are one of the side effects of kidney and gi involvement in covid-19. the most prevalent of these conditions are hyponatremia, hypernatremia, hypokalemia, hypocalcemia, hypochloremia, hypervolemia, and hypovolemia. if untreated, these conditions can lead to a variety of complications for patients and even increase mortality (66). additionally, changes in fluid, electrolyte, and trace element levels can be a good indicator of disease progression , this is due to the risk of fluid, electrolyte, and trace element disturbance complications requires special attention from clinicians in order to manage patients' fluid and electrolyte status, in addition to trace element supplements. conclusion in conclusion, based on our results there was a significant decrease in serum levels of sodium, potassium, and calcium in covid-19 patients when compared with the control group. in addition, there was a significantly strong negative correlation between serum levels of sodium, potassium, calcium, and severity of patients of covid-19. no biochemical change in serum level of phosphate and magnesium among patients of covid-19. serum level of zinc decrease and serum copper levels increase when compared to mild, moderate and sever ill patients of covid-19.according to our findings, serum levels of calcium were slightly lower in covid-19 patients. acknowledgment mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 80 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe we would like to thank the biomedical scientist who collected samples during the period of research and the staff of the therapeutic hospital for patients of covid-19 in khartoum state(nursing, doctors, and medical laboratory specialists) for providing facilities for this work. references wang, l.-f.; shi, z.; zhang, s.; field, h.; daszak, p.; eaton, b.t. review of bats and sars. emerg. infect. dis.,2006 ; 12: 1834–1840. ashikujaman s. coronavirus: a mini-review. int. j. curr. res. med. sci.202; 6(1): 8-10. huang, c., wang, y., li, x., et al. clinical features of patients infected with 2019 novel coronavirus in wuhan, china. the lancet, (2020). 395(10223), pp.497-506. carlos wg, dela cruz cs, cao b, pasnick s, jamil s. novel wuhan (2019-ncov) coronavirus. am j respir crit care med. (2020) ; 201:p7–8. holshue, m., debolt, c., lindquist, s et al . first case of 2019 novel coronavirus in the united states. new england journal of medicine, 2020; 382(10), pp.929-936. terry j. the major electrolytes: sodium, potassium, and chloride. j intraven nurs. (2018) 17(5):240-7. pmid: 7965369. shrimanker i, bhattarai s. electrolytes. . in statpearls [internet]. treasure island (fl): statpearls publishing; 2021 jan–. pmid: (2020) 31082167. lippi g, south am, henry bm electrolyte imbalances in patients with severe coronavirus disease 2019 (covid19). ann clin biochem (2020) 57(3):262–265. 9..berni a, malandrino d, parenti g, maggi m, poggesi l, peri a hyponatremia, il-6, and sars-cov-2 (covid19). (2020). 10-rink l, gabriel p. zinc and the immune system. proc nutr soc. (2000) ; 59:541–52. doi: 10.1017/s0029665100000781 allen ji, perri rt, mcclain cj, kay ne. alterations in human natural killer cell activity and monocyte cytotoxicity induced by zinc deficiency. j lab clin med. (1983) 102:577–89. kardos j, héja l, simon á, jablonkai i, kovács r, jemnitz k . copper signaling: causes and consequences. ccs 2018 ;16(1):1–22 ilbäck n-g, frisk p, tallkvist j, gadhasson i-l, blomberg j, friman g . gastrointestinal uptake of trace elements are changed during a common human viral (coxsackievirus b3) infection in mice. j trace elem med biol 2008 ;22(2):120–130 cernat r, mihaescu t, vornicu m, vione d, olariu r, arsene c . serum trace metal and ceruloplasmin variability in individuals treated for pulmonary tuberculosis. int j tuberc lung dis 2011; 15(9):1239– 1245 besold an, culbertson em, culotta vc .the yin and yang of copper during infection. j biol inorg chem 2016; 21(2):137–144 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 81 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe kanellopoulou c, george ab, masutani e, cannons jl, ravell jc, yamamoto tn, smelkinsonmg, jiang pd, matsuda-lennikov m, reilley j . mg2+ regulation of kinase signaling and immune function. j exp med 2019; 216(8):1828–1842 ye m, li q, xiao l, zheng z . serum magnesium and fractional exhaled nitric oxide about the severity in asthma chronic obstructive pulmonary disease overlap. biol trace elem res.2020 https://doi.org/10.1007/s12011-020-02314-5 18-69-tietz, n.w. (ed) fundamentals of clinical chemistry,2008; 6th ed. p.836-871 19-sergey makarychev -mikhailov, alexey shvarev, eric bakker new trend in iron selective electrode, electrochemical sensor, biosensor and their applications 2008;71 -114 d j johnson, yy djuh, j bruton, hl williams, improved colorimetric determination of serum zinc clinical chemistry 1977; 23, 1321 1323 wu z, mcgoogan jm. characteristics of and important lessons from the coronavirus disease 2019 (covid19) outbreak in china: summary of a report of 72,314 cases from the chinese center for disease control and prevention. j am med assoc; (2020); 323(13): 1239-42. chan jfw, yuan s, kok kh, to kk, chu h, yang j. a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. lancet. (2020) ; 140-6736(20): 30154-59. phan lt, nguyen tv, luong qc, nguyen tv, nguyen ht, le hq, et al importation and human-to-human transmission of a novel coronavirus in vietnam. n engl j med 2020, 382(9): 87274. hct & unct. sudancoronaviruscovid-19 country preparedness and response plan [internet]. (2020) team tncpere. the epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (covid19) in china. chin j epidemiol. 20202(8),113-122. carvalho hugo de, marie caroline richard, tahar chouihed, nicolas goffinet and quentin le bastard et al. electrolyte imbalance in covid‑19 patients admitted to the emergency department: a case-control study. internal and emergency medicine.2021; 1-6. lippi g, south am, henry bm. annals express electrolyte imbalances in patients with severe coronavirus disease 2019(covid-19). ann clin biochem 2020 ; 57(3) : 262 – 265. . https://doi.org/10.1177/ 0004563220922255 28 . dong chen jr , xiaokuni li et al. hypokalemia and clinical implications in patients with coronavirus disease 2019 (covid19).who,( 18, 593 medrxiv) , 2020; p 1-10. medrxiv 2020. https://doi.org/10.1101/2020.02.27.20028530 29. a.h.chowdhuryandd.n.lobo, "fluidsandgastrointestinal function," current opinion in clinical nutrition and metabolic care, 2011; vol. 14, no. 5, pp. 469–476. 30.-c. huang, y. wang, x. li et al., “clinical features of patients infected with 2019 novel coronavirus in wuhan, china,” the lancet,2020; vol. 395, no. 10223, pp. 497–506. mailto:topacademicjournals@gmail.com https://doi.org/10.1007/s12011-020-02314-5 https://doi.org/10.1007/s12011-020-02314-5 https://doi.org/10.1177/ https://doi.org/10.1177/ american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 82 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe w. guan, z. ni, y. hu et al., “clinical characteristics of coronavirus disease 2019 in china,” the new england journal of medicine, 2020 ; vol. 382, no. 18, pp. 1708–1720 g. corona, c.giuliani, g. parenti, et al., "moderate hyponatremia is associated with increased risk of mortality: evidence from a meta-analysis, " plos one 2013; vol. 8, no. 12, p. e80451, 33-z. belden, j. a. deiuliis, m. dobre, and s. rajagopalan, “the role of the mineralocorticoid receptor in inflammation: focus on kidney and vasculature,” american journal of nephrology, 2017; vol. 46, no. 4, pp. 298–314. y.-s. fan, r. l. eddy, m. g. byers, et al., "the human mineral –corticoid,.receptor gene (mlr) islocatedonchromosome4at 4 biomed research international q31. 2," cytogenetic and genome research,1989; vol. 52, no. 1–2, pp. 83-84. p. j. fuller and m. j. young, "mechanisms of mineralocorticoid action, "hypertension, 2005; vol.46, no.6, pp. 1227–1235. h.de carvalho,m.c.richard,t.chouihedetal., "electrolyte imbalance in covid-19 patients admitted to the emergency department: a case-control study," internal and emergency medicine, 2021; vol. 23, pp. 1–6. 37.g. lippi, a. m. south, and b. m. henry, “electrolyte imbalances in patients with severe coronavirus disease 2019 (covid-19),” annals of clinical biochemistry, 2020; vol. 57, no. 3, pp. 262–265. m. a. zimmer, a. k. zink, c. w. weißer et al., “hypernatremia—a manifestation of covid-19: a case series,” a&a practice, 2020 ;vol. 14, no. 9, p. e01295. yongkangdong, li dong novel coronavirus epidemic prevention and control research project of shanxi province, grant/award numbers the research project of shanxi health commission . : 202003d31002/gz, 202003d31005/gz. e. bove-fenderson and m. mannstadt, “hypocalcemic disorders,” best practice & research. clinical endocrinology & metabolism,2018; vol. 32, no. 5, pp. 639–656. 16..pal r, ram s, zohmangaihi d biswas i, suri v, yaddanapudi ln, malhotra p, soni sl, puri gd, bhalla a and bhadada sk . high prevalence of hypocalcemia in non-severe covid-19 patients: a retrospective case-control study. front. med 2021; 7:590805. doi: 10.3389/fmed.2020.590805. li t, zhang y, gong c, et al. prevalence of malnutrition and analysis of related factors in elderly patients with covid-19 in wuhan, china. eur j clin nutr. 2020;74(6):871–875. doi:10.1038/s414300200642-3 di filippo l, de lorenzo r, d'amico m, et al. covid-19 is associated with clinically significant weight loss and risk of malnutrition, independent of hospitalization: a posthoc analysis of a prospective cohort study. clin nutr. 2021;40(4):2420–2426. doi:10.1016/j.clnu.2020.10.043 yu y, ye j, chen m, et al. malnutrition prolongs the hospitalization of patients with covid-19 infection: a clinical epidemiological analysis. j nutr health aging. 2021;25(3):369–373. doi:10.1007/ s12603-0201541-y mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 83 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe liu a, cong j, wang q, et al. risk of malnutrition is common in patients with coronavirus disease 2019 (covid19) in wuhan, china: a cross-sectional study. j nutr. 2021;151(6):1591–1596. wei c, liu y, li y, zhang y, zhong m, meng x. evaluation of the nutritional status in patients with covid-19. j clin biochem nutr. 2020;67(2):116–121. doi:10.3164/jcbn.20-91 zhou j, ma y, liu y, et al. a correlation analysis between the nutritional status and prognosis of covid 19 patients. j nutr health aging. 2021;25(1):84–93. doi:10.1007/s12603-020-1457-6 sobczak ais, phoenix fa, pitt sj, et al. reduced plasma magnesium levels in type-1 diabetes associate with prothrombotic changes in fibrin clotting and fibrinolysis. thrombosis and haemostasis. 2020; 120:243– 52. [pmc free article] [pubmed] [google scholar] gromova oa, torshin iy, kobalava zd, et al. deficit of magnesium and states of hypercoagulation: intellectual analysis of data obtained from a sample of patients aged 18–50 years from medical and preventive facilities in russia. kardiologiia. 2018; 58:22–35. [pubmed] [google scholar] çiçek g, açıkgoz sk, yayla ç, et al. magnesium as a predictor of acute stent thrombosis in patients with stsegment elevation myocardial infarction who underwent primary angioplasty. coron artery dis. 2016; 27:47–51. [pubmed] [google scholar] shechter m, merz cn, rude rk, et al. low intracellular magnesium levels promote platelet-dependent thrombosis in patients with coronary artery disease. american heart journal. 2000; 140:212–8. [pubmed] [google scholar] sheu jr, hsiao g, shen my, et al. antithrombotic effects of magnesium sulfate in vivo experiments. int j hematol. 2003; 77:414–9. [pubmed] [google scholar] anuk a.t., polat n., akdas s., erol s.a., tanacan a., biriken d., keskin h.l., tekin o.m., yazihan n., sahin d. the relation between trace element status (zinc, copper, magnesium) and clinical outcomes in covid19 infection during pregnancy. biol. trace elem. res. 2020:1–10. 54 . zeng h.l., yang q., yuan p., wang x., cheng l. associations of essential and toxic metals/metalloids in whole blood with both disease severity and mortality in patients with covid-19. faseb j. 2021;35:e21392. doi: 10.1096/fj.202002346rr. [pmc free article] [pubmed] [crossref] [google scholar] wessels i, maywald m, rink l. zinc as a gatekeeper of immune function. nutrients. (2017) ; 9:1286. doi: 10.3390/nu9121286 maywald m, wessels i, rink l. zinc signals and immunity. int j mol sci. (2017); 18:2222. doi: 10.3390/ijms18102222 57 . wessels i, cousins rj. zinc dyshomeostasis during polymicrobial sepsis in mice involves zinc transporter zip14 and can be overcome by zinc supplementation. am j physiol gastrointest liver physiol. (2015); 309:g768–78. doi: 10.1152/ajpgi.00179.2015 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 84 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe arrieta f, martinez-vaello v, bengoa n, et al . serum zinc and copper in people with covid-19 and zinc supplementation in parenteral nutrition. nutrition 2021; 91–92:111467. https:// doi. org/ 10. 1016/j. nut. 2021. 111467 anuk at, polat n, akdas s et al . the relation between trace element status (zinc, copper, magnesium) and clinical outcomes in covid-19 infection during pregnancy. biol trace elem res2021; 199:3608–3617. https:// doi. org/ 10. 1007/ s1201102002496-y muhammad y, kani ya, iliya s, et al (2021) deficiency of antioxidants and increased oxidative stress in covid19 patients: a cross-sectional comparative study in jigawa, northwestern nigeria. sage open med 9:2050312121991246. https:// doi. org/ 10. 1177/ 20503 12121 991246 carlucci pm, ahuja t, petrilli c, et al . zinc sulfate in combination with a zinc ionophore may improve outcomes in hospitalized covid-19 patients. j med microbiol 2020; 69:1228–1234. https:// doi. org/ 10. 1099/ jmm.0. 001250 ishida t . antiviral activities of cu2+ ions in viral prevention, replication, rna degradation, and for antiviral efficacies of the lytic virus, ros-mediated virus, copper chelation. world sci news 2018; 99:148–168 te velthuis ajw, van den worm she, sims ac et al (2010) zn (2+) inhibits coronavirus and arterivirus rna polymerase activity in vitro and zinc ionophores block the replication of these viruses in cell culture. plos pathog 6:e1001176. https:// doi. org/ 10. 1371/ journal. pp t. 10011 76 vahidy fs, pan ap, ahnstedt h, munshi y, choi ha, tirunehy, et alsex differences in susceptibility, severity, and outcomes of coronavirus disease 2019: plosone journal. pone 2021; 16(1): e0245556.https://doi.org/10.1371/journal. pone.0245556.(2021) zhang w, du rh, li b. correlation between hyponatremia and severity of coronavirus disease 2019. emerg microbes infect 2020; 9:386–9. mohammad pourfridoni, seyede mahsa abbasnia, fateme shafaei, javad razaviyan, and reza heidarisoureshjani, fluid and electrolyte disturbances in covid-19 and their complications hindawi biomed research international volume 2021,article id 6667047, 5 pages mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 22 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe the essential elements of a sport management internship michael johnson california university l.a usa abstract: sport management programs in the united states have grown in popularity and recognition in recent decades. however, in today's competitive sport industry, students need more than just classroom theory to succeed. internships provide students with the opportunity to apply their knowledge and skills in a real-world setting, giving them a valuable advantage in the job market. keywords: sport management, internship, practical experience, career preparation, competitive advantage, job market. introduction sport management programs in the united states continue to gain popularity, recognition, and credibility in the nearly four decades since the first master’s program at ohio university in 1966 (spahr & wiegand, 2012; stier, 1993). there are over 400 sport management programs at the undergraduate and graduate level recognized by the north american society for sport management in the united states (nassm, 2016).in the competitive work environment with fluctuating unemployment rates, people with experience and abilities are all vying for the same positions. it is important that graduating students have the opportunity to apply classroom theory to practical work experiences that will give them the advantage they need to start their careers. practicum or volunteer experiences are important, but in today’s competitive sport industry, they are not enough. students need to go beyond the traditional classroom experiences and explore the field of sport through an unfiltered lens of a suitably organized and implemented internship experience as part of their graduation requirements. internships, one from of experiential learning, play a prominent role in the academic curriculum of sport management programs. students in these programs are awarded varying degrees of academic credit for their participation in internships. the inclusion of internship requirements into the accreditation standards, and their placement within many sport management curriculums seem to be a strong endorsement of the educational importance of this form of learning. numerous sport management programs rely heavily on internships to teach the knowledge and skills, which are deemed valuable in the sport marketplace (chinomona & surujlal, 2012; foster & dollar, 2010; martin, 2012, martin & mathner 2012; williams, 2003). the value of an internship lies in the opportunities provided, such as a) networking with professionals; b) the ability to develop professional talents and behaviors; c) the opportunity to develop, refine and acquire specific skills; d) assistance as they prepare for an entry-level position; and e) a bridge to eliminate the gap between theory and practice (beggs & hurd, 2010).employers, as evidenced by the national association of colleges and employers (nace) 2014 job mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 23 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe outlook survey, deem this type of learning valuable. three out of four (75%) employers prefer to hire new graduates who have relevant work experience (nace, 2014). the importance of internships in sport management curricula is apparent, considering that 77% of sport management programs at the bachelor’s, master’s or doctoral level have this experiential learning requirement and it is the most common curricular component in sport management programs (dieffenback, murray & zakrajsek, 2011; schoepfer & dodds, 2011).in fact, some have argued that no single step in a sport management career path is as valuable as an internship (moorman, 2004). with the significant growth of academic programs offering degrees in sport management, the curricular structure of those programs lends itself to more scrutiny. continued focus needs to be given to the requirements and policies in which programs implement their experiential learning components of their internship curriculum. more specifically, how are undergraduate sport management programs providing the best experiential learning opportunities to its students? literature review experiential learning has an established history within higher education, specifically within the hard sciences and arts and within the more practitioners based academic programs. these learning opportunities, commonly referred to as cooperatives, internships, practicum, and service learning, all seek to support students in bridging the gap between academia and their chosen profession by developing professional competencies that may not come from the traditional classroom setting (kiser & partlow, 1999). there are many experiential learning theories; however, john dewey (1938) and david a. kolb (1984) set a standard for research in the area. both models rely heavily on learning through experience. dewey’s model focused on 4 phases of education: 1) social environment, 2) knowledge and content organization, 3) learning readiness and experience, and 4) learning outcomes. dewey believed that “all genuine education comes through experience” (p.25).kolb’s theory emphasizes, “generating an action theory from your own experiences, and then continually modifying it to improve your effectiveness” (p. 53). kolb’s model of experiential learning represents a four-stage learning sequence: concrete experience; reflective observation; abstract conceptualization; active experimentation. students move from one stage to the next after completing specific activities with the last allowing students to apply what they learned in the classroom to the field. moreover, surujlal and singh (2010) pointed out, the value of student experiential learning through internship has become widely recognized and accepted in both the public and private sector. given the extensive use of internships in sport management curricula, information regarding sport management internship requirements, as well as the faculty role in coordinating internships, is minimal (jowdy, mcdonald, & spence, 2004). despite the increasing popularity of sport management programs, little research has been conducted regarding the internship roles/requirements from the programs standpoint. early studies involving internships provided suggestions laying the groundwork as a template for future programs. as one of the first foundational studies, reviewing sport management internships, chouinard (1993), stated that based upon the opinions of working professionals in the field and researchers in sport management, there is a mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 24 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe clear indication of the importance of an internship course component in professional preparation programs. chouinard (1993) provided a rationale for the importance of internships within sport management, as well as providing insight into internship supervision. the study on meaningful insights into sport management internship provided a solid foundation for support of well-rounded internship opportunities for students. in addition, (chouinard, 1993) noted that professors and/or coordinators of sport management programs that incorporate an internship must be highly skilled to meet the needs of students and must act as change agents to further improve the quality of student internships. chouinard is not only supporting the importance of the overall internship experience for sport management students, he is also supporting an allinclusive assessment of internship programs. another early study suggested that the practicum and internship experience within sport management be a series of professionally related work experiences that move from general experience to a more specific focus as each student progresses through the curriculum (kelley, beitel, desensi, &blanton, 1994). in addition,(kelley et. al., 1994) suggested that internships account for approximately 15 percent of the total curriculum and be the culminating experience in an undergraduate program of study. the internship should be, at a minimum, a onesemester, full-time applied work experience directly focused toward each student’s professional sport management career goals (kelley et al., 1994). since then, several scholars have continued research in the area of internships and added valuable knowledge to the field. verner, keyser, and morrow (2001) reviewed experiential learning through field experience and observed a major component of internships that is oftentimes overlooked. verner et al. (2001) suggested that internships allow the university and sport management programs to gain exposure, also providing the opportunities to nurture contacts within the field, and expand teaching methods and curriculum by remaining aware of developments. as literature has suggested, there are positive effects of internships not only to the student, but to the sport management program as well. williams (2003) studied the factors that were relevant to providing students with a quality internship, specifically in sport. data obtained from 77 institutions with sport management programs at the graduate and undergraduate level suggested that a quality internship for students within sport is based on two important factors. they include student preparation followed by the development of strong relationships with the internship site (williams, 2003). this suggests that the quality of the internship experience is dependent on the sport management program, as well as the internship site. jones, brooks and mak (2008) noted that because of the substantial growth in sport management programs, universities have started to expand the scope of their curriculum from a teaching based model to a more holistic approach, which includes requiring more field experience. by moving to a more holistic approach concerning sport management, as jones et al. have suggested, it should challenge those individuals in pursuit of a sport management career to have a more in-depth knowledge of the field and a broader range of competences once they graduate. foster and dollar’s (2010) book, experiential learning in sport management: internship and beyond, provided an overview for students and faculty preparing for work based experiential learning, or internships, in the field of mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 25 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe sport management. foster and dollar (2010) both have extensive experience coordinating internship programs, and suggest the experiential learning process should be part of the complete course of study, and not just a standalone component. similar to dieffenback et al. (2011), and chouinard (1993), foster and dollar (2010) also support an inclusive internship learning environment, suggesting that the collaboration between the student and the organization and academic supervisors should enhance the internship experiences. both supervisors should act as a mentor to the student in achieving academic and initial career goals. in addition, foster and dollar (2010) suggested an experiential learning model that recommended a cooperative education process throughout the degree. the model involves integrating on campus classroom activities with volunteering, apprenticeship, pre practicum elective experiences and culminating in a capstone internship. dieffenback et al. (2011) and foster and dollar (2010) also support an inclusive internship learning environment, suggesting that the collaboration between the student and the organization and academic supervisors should enhance the internship experiences. academic and field supervisors should act as a mentor to the student in achieving both academic and initial career goals. most recently, deluca and braunstein-minkove (2016), and koo et. al.(2016) looked at the effects of internship on student preparedness and satisfaction. deluca and braunstein-minkove (2016) revealed that students found great value in the mandate to have an internship. in addition, the study found that students were lacking leadership skills based on site supervisors’ evaluations. koo et. al.(2016) measured the effects of internship satisfaction on the pursuit of employment in sport management and found that students were more likely to enter the field after graduation if they reported satisfaction in their internship. purpose of the study the extensive review of literature on internships provides a foundation for the incorporation of internships into the curriculum. however, it does not provide insight on trends occurring at universities related to internship policies and procedures. the purpose of this study is practical in nature, seeking to examine undergraduate sport management internship requirements and policies in the united states. to do this, three research questions were developed; 1) what are the characteristics of sport management internship programs? 2) what are the similarities and/or differences between program sizes?and,3) how are current internships administered and supervised? the increasing importance of experiential learning opportunities within higher education has led to three fundamental reasons for examining sport management internships. first, there is limited research specifically related to programmatic internship requirements and best practices. second, the job market in sport management is very competitive, and an internship experience can provide students with an advantage for entry into the job market. finally, internships provide potential employers with an opportunity to recruit and train students, as well as providing students a window of opportunity to prove them to an organization. previous analysis of sport management internships has evaluated the benefits of internships, student satisfaction, professional preparation, school to work transition, etc. (foster & dollar, 2010; kelley, beitel, desensi, & blanton, 1994; stratta, 2004; williams, 2003). by examining sport management internship requirements and procedures, academicians in the field of sport management can further evaluate their own internship programs mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 26 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe and examine standards that can identify elements that foster student learning and job placement, and have insights on how to structure their internship programs. specifically, this research can provide a framework for future and established sport management programs to help design and implement curriculum. methodology participants the authors identified 290 institutions in the united states offering undergraduate programs in sport management/administration using the north american society for sport management (nassm) website. schools on the undergraduate program list that did not have an internship requirement were eliminated from the data set. to determine if the program offered an internship, the authors completed a detailed search of each school’s curriculum via the programs website. two hundred and nine schools met the criteria and the survey was emailed to the internship coordinator listed on each programs website. fourteen emails were undeliverable; therefore 195 surveys were sent to potential participants. seventy-two surveys were completed which accounted for a 36% return rate. instrumentation after conducting a comprehensive review of the literature, the researchers concluded that a survey was needed in order to gain knowledge on the requirements and procedures of undergraduate sport management internship programs. therefore, a multiple choice style questionnaire was created to shed light on these topics. the survey contained four sections: demographics; internship description; internship assessment and evaluation; and administration and workload. under demographics, researchers gathered information on the size of school and sport management program, whether the school was public or private, accreditation status, and number of faculty/staff teaching in sport management. the internship description consisted of formulated questions relative to the number of credit and contact hours required, if there was a field experience or required gpa before internship, grading options, timing of internships and internship site locations. under assessment and evaluation, researchers gathered information on course requirements (written logs, project, supervisor evaluations, etc.), the number of site visits and personal contacts faculty had with students, and if students were employed following graduation. lastly, the final section of the survey looked at the number of interns assigned to faculty supervisors and the release time provided to accomplish their responsibilities. the initial survey was given to a panel of reviewers in the field for analysis. two reviewers were full-time faculty serving as internship coordinators and one reviewer was a full-time faculty member that had served as an internship coordinator for 12 years but was no longer in that position. reviewers were informed of the purpose of the study and asked to comment on the survey design, content, question formation and length. based on the feedback, suggestions were taken into consideration and changes were implemented. the final survey consisted of 32 questions and took approximately 10 minutes to complete. procedures the research followed the tailored design method (tdm) for online questionnaire distribution (dillman, smyth, & christian, 2009). the tdm is considered the standard for conducting electronic surveys in the social sciences and can lead to increased response rates as well as elimination of common sources of error in survey research. an mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 27 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe email list of internship coordinators for undergraduate sport management programs with an internship requirement was developed for the project. following tdm protocol, the research team sent an advance notice email to internship coordinators at each of the participating sport management programs describing the need for, and purpose of the survey. included within the initial email, was an electronic cover letter along with a link to the online questionnaire. after three weeks, researchers sent a follow-up email thanking internship coordinators who had already responded and requesting a response from those who had not. two weeks after that, the researchers sent another thank you email and a final reminder to all remaining potential participants with an announcement of the survey’s final closing date. access to the survey was available for eight weeks giving ample time for participants to take part in the research study. survey monkey was utilized to design the survey and collect data while spss version 20 was utilized to analyze the results. results demographics more than fifty percent of programs that responded to the study came from private institutions (55.56%), with 44.44% of the respondents from public institutions. sport management programs with less than 100 students were the largest response rate at 36.11%, followed by 100 – 200 (31.94%) and more than 400 students at 31.94%. the majority of programs had two full time faculties at 27.78%, followed by more than 5 with 20.83%. programs with three full time faculties had a 19.44% response rate, followed by 5 full time faculties with 13.98%. many sport management programs rely on part time/adjunct faculty. programs with 1-part time/adjunct faculty had the highest response rate at 28.57%, followed by 2 with 25.40%. only 13.33% of the programs were cosma accredited while 86.67% had no formal accreditation. thirty percent of the programs have been in existence for 5 – 10 years, 25% have been in existence for over 20 years, 23.61% have been around for 11 – 15 years, and approximately8.33% of programs have only been around for less than 5 years. in addition, the researchers also wanted to portion out programs based on size for better application of the results. table 1 illustrates program requirements based on small (<100 students), medium (101-200 students) and large (>201 students) sport management programs. internship characteristics internship requirements vary between all programs. for example, 40% of the programs require students to register for greater than 9 credit hours for their internship, which equates to 200-300 contact hours. additionally, over half (55%) of all programs require students to complete field/work experience prior to internship, and 80% of the programs require a minimum gpa before students are eligible for internship. when results were broken down by program size, some similarities and differences between programs appeared. for example, with regard to credit hours, smaller programs (<100) and larger programs (>201) seem to agree on internship credit hours. both sized programs offer more credit hours for internship compared to medium programs. sixty percent of medium size programs (101-200) require prior field experience, more so than both small and larger size programs. also, smaller programs (<100) seem to require limited or no gpa requirement mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 28 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe for internship eligibility, compared to medium (101-200) and larger (>201) programs, which had higher gpa requirements (see table 1). internship assessment and evaluation all programs that responded do provide grades for internship, however, how that gradeis awarded is different. sixty-six percent of respondents provide a letter grade for internship and only 33% give a pass/fail grade. based on program size, medium programs (101-200) are more inclined to offer a letter grade compared to the other sized programs. ninety-six percent of all programs require some form of written logs. of those respondents who required written logs, the frequency of those logs vary with 55% of the programs requiring weekly logs, 10.61% requiring bimonthly logs, and 13.64% requiring a monthly log during internship. twenty percent of the respondents answered “other,” which included variations of bi-weekly reports and reports only at mid-term and finals. requiring special projects during an internship was customary, with 64.17% of all respondents requiring a project from students while on internship. thirty-five percent did not require a project during internship. site supervisor evaluations received overwhelming support as a requirement with (91%) of respondents requiring supervisor evaluations of interns. for those that required supervisor evaluations of internship, the frequency of those evaluations differed. most respondents required at least two evaluations (62.69%) during the semester, while some respondents only required one evaluation (23.88%) during internship. fifty percent of the respondents complete at least one in person site visit during the semester, whereas 35.29% do not complete a single site visit. internship supervisors stay in contact with students during internship with 62% percent making at least 1 – 3 personal contacts to students during the semester, and 22.08% making at least 4 – 6 contacts. administration and supervision there were many differences in how programs administered and supervised the internship. over half of all programs that responded have one full time internship coordinator that supervises all sport management internships (49.30%), which is consistent across all sized programs. in some cases, a select few faculty members were involved in supervision (26.76%). fourteen percent of the respondents stated that every faculty in sport management is involved in internship supervision. finally, 9.86% of the respondents did not have a clear designation of anyone who was responsible for supervising internships. in addition, an overwhelming majority of programs (86.84%) have the responsibility of securing internships on the student. all sized programs were very consistent requiring students to locate their own internship. however, when broken down by size, programs of 100 students or less actually placed their students for internship (24%) at the highest rate. intercollegiate sports (40.30%) seem to be the most frequented internship opportunity for students followed closely by professional sports (37.31%). because of the difference in program size, as well as the variation in when students can complete internship requirements, there are many inconsistencies in the amount of students supervised for internship in an academic year. twenty-one percent of respondents supervise either 11 – 20 students or 21 – 30 students a year for internship. fourteen percent of the respondents average 31 – 40 students a year, with 9.72% of respondents averaging 41 – 50 and over 80 students a year. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 29 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe not surprisingly, there were variations between all three sized programs. small (<100) and medium (101-200) sized programs are similar in the number of students interning each year, with the large (>201) program averaging the highest number of student’s yearly (see table 2). administrative workload with regards to internship supervision in the fall and spring varied among respondents. thirty-eight percent of respondents stated that all interns, no matter how many, are equivalent to one academic course, 16.92% responded that 10 or fewer are equivalent to one academic course. finally, 30.77% of respondents stated that interns are considered overload to their workload. in regards to summer supervision of internship, 32% of respondents stated that all interns, no matter how many under their supervision, are equivalent to one academic course, followed by 16.92% reporting that 10 or fewer are equivalent to one academic course. over one third (35.38%) of respondents stated that interns are considered overload to their workload during the summer semester. discussion the purpose of this research was to examine undergraduate sport management internship requirements and policies in the united states. more specifically, the goal of this study was to provide a comprehensive overview of the current internship practices of sport management programs offering internships as part of their undergraduate curriculum. the research was designed to encompass all programs (accredited, non-accredited, large, medium, & small), and the results revealed some unique characteristics. in general, the findings suggest that program requirements and procedures relating to internship curriculum vary significantly. research suggests that schools take very different approaches to the requirements and administration of their internship program. fleming and ferkins (2005) had similar findings looking at cooperative education in sport management across four countries and eight institutions. the structure, placement, supervision and hours required were all different at each institution. this may be due to a variety of factors, including but not limited to the number of students in a program, the number of full-time faculty or staff, program resources, faculty workload, and the amount of internship requirements. based on the findings of this study, sport management internship programs present the following profile: • they require11-12 credit hours which equates to 200-300 contact hours. • the internship is taken in the senior year (one semester). • there is a requirement of a prior field experience. • students are responsible for securing their own internship sites. • students are assigned a letter grade rather than being assessed on a pass/fail basis at the completion. • students are required to create weekly written reports and a special project. • supervisors are asked to submit two evaluations regarding student performance. • internship coordinators make one in person visit and have 1-3 personal contacts with students during the semester long experience. • in most instances, one internship coordinator is assigned to all student interns and is responsible for overseeing 11-30 students which equates to a workload of one academic course during each semester. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 30 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe do note that the characteristics are somewhat different when taking into account the size of the sport management program as reported in the results. the findings of the current study raise additional questions with respect to sport management internships requirements on a global scale. while exploring this topic, the researchers also reviewed international academic sport management associations (wasm, easm, smaanz, etc.) in regards to international internship procedures and requirements. international programs also vary in their internship requirements offering internships as elective credits, whereas sport management programs in the u.s. require internships as part of graduation requirements. for example, sotiriadou (2011) revealed that only 65% of sport management programs in australia and new zealand have at least one sport management practicum integrated into their program. most were typically an elective subject rather than compulsory and subject to 80 – 120 hours of practical voluntary experience. in south africa, surujlal and singh (2010) found that many students were lacking the needed skills to enter the workforce and suggest that internship be included as a compulsory component of the curriculum. while the global studies did not reference concerns due to program growth and issues with internship administration, the findings from the current study suggest that as programs in the u.s. grow to larger numbers of students, administrators are challenged with the demands of internship oversight. personal site visits take a tremendous amount of time and money and may not be feasible for some sport management programs, not just internship supervisors. institutions with a limited number of faculties also face the issue of overload. even programs that do not have high teaching workloads still have faculty who are stretched extremely thin. as the findings show, only 27% of the programs have two full-time faculties, which could provide difficulty in the supervision of large internship programs. almost 32% responded that they have between 101-200 majors. this means more part time and adjunct instructors are needed to teach core classes and possibly oversee student interns. nearly half of all programs surveyed have a full time internship coordinator that supervises all sport management internships. this type of structure paves the way for a close relationship with each student and can lend to needed feedback. in addition, since the internship must meet the needs of sport management organizations, it is beneficial to establish relationships with these entities. with this partnership, universities can meet the needs of students, students can acquire professional skills, and sport organizations can provide extended interviews to potential employees. however, the model of internship supervision in many institutions deserves scrutiny, as it appears that many faculty at a high percentage of these colleges appear to have a relatively small amount of release time to be able to provide quality mentoring and supervision. this dearth of time provided to faculty is probably a contributing factor regarding why students must research and secure their own internships. one of the most intriguing results was that the number of credit hours and total contact hours was so diverse from university to university. a question that arises with this diversity in number of required hours is, are students adequately prepared for entry-level positions by requiring fewer hours in the internship experience? when examining similar fields, the council on accreditation of parks, recreation, tourism and related professions (coaprt), which is the accrediting organization for parks and recreation/tourism programs, requires a comprehensive internship of not less than 400 clock hours and no fewer than 10 weeks (coaprt, 2014). mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 31 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe similar to sport management, and parks and recreation/tourism programs, physical education programs also provide valuable internship experiences for students. student teaching has been considered one of the most important aspects of professional preparation for soon to be teachers (hynes-dusel, 1999). according to hynesdusel, (1999), most students felt the university did not teach the reality of the classroom and they were not adequately prepared for teaching so student teaching was crucial for future success. the results of this study revealed that programs have specific times allocated to allow students to complete their internships, with over half, requiring field/work experience before students can complete an internship. some sport organizations are looking for graduates who possess the most in depth and/or diverse experiences. infusing experiential learning throughout the curriculum can benefit students by reinforcing the connection between theory and practice, which ultimately could make them more marketable when entering the workforce. an example of this infusion would be to have interns return to campus periodically to meet with their internship coordinator and/or peers, or require a post-internship meeting to assist in promoting deeper reflection of their internship experiences. this is difficult to do when the internship is the last component in a degree, but it is another important learning element in the internship process. this study also generates questions that can be investigated in future research: are students better equipped for jobs if they take part in internship programs that require more contact hours? if so, how many contact hours are ideal? should programs include a field experience component before students take part in an internship? what are the benefits? during their academic studies, when is the ideal time for students to complete an internship? what is the best approach to student supervision and how many contact/visits should the internship supervisor have with the student and professional in the field to ensure a positive experience? what assessments are the most relative for student learning during an internship (supervisor evaluations, log reports, etc.)?administratively, how many interns should a faculty supervise in a semester to ensure quality and excellence? as professionals in the field, we must take a proactive approach to answer these questions. because of the growth in sport management programs inside and outside of the united states, and the increase in qualified sport management graduates filling valuable sport management positions, the importance and understanding of the current sport management internship model is important. since the completion of the study, there is over 85 new sport management programs listed on the nassm website (nassm, 2016). the study shows a similar trend as 38% of the programs who responded to the survey were less than ten years old. in order to effectively and efficiently coordinate sport management internship programs, a basic understanding of what current sport management programs are implementing is necessary to better educate current students within a comprehensive sport management curriculum. hopefully, this study will serve as a vehicle to encourage academicians in the field of sport management to further evaluate their own internship programs and examine policies that can delineate specific criteria and requirements that benefit student learning and job placement. in addition, it can serve as a tool for new and future sport management programs. internship coordinators now have a snapshot of what other programs are requiring of their students. with this knowledge, they can plan and evaluate what internship requirements and processes will work best for their school and student population. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 32 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe within the field, students are oftentimes seen as extensions of the institution. by having an organized and efficient internship programs, it allows both students and internship sites the opportunity to be a part of a significant learning opportunity. a well-planned internship program can allow all students the opportunity to complete an off-campus internship that develops the student both personally and professionally, while creating new relationships between the program and the field. in addition, the importance of a well-organized and coordinated internship program will be important for the success of the student and the sport management program. in the future, with the assistance of cosma, sport management programs will have some standard guidelines that can be followed to ensure that students are getting the most of their experiences. conclusion the internship is an important component in the personal and professional development of students earning a degree in sport management. understanding the current requirements and policies of sport management programs within the united states can assist in creating a “best practices” opportunity for programs looking to create and implement internship programs, or assist programs who are looking to revamp their current program. ultimately, this insight should assist in providing the best experiences for students. the current study suggests that sport management internship requirements and procedures vary between universities in the united states. the findings of this study paint a unique and evolving picture of the current state of sport management internship curriculum. future research on sport management internship requirements and procedures can help provide a framework, through which sport management students can undertake meaningful, career shaping experiences through quality internships. references beggs, b., & hurd, a. r. (2010). internships bring the classroom to life. parks & recreation, 45(2), 31-33. chinomona, r. & surujlal, j. (2012). the influence of student internship work experience on their selfimprovement and professionalism in sport management. african journal for physical, health education, recreation and dance (ajpherd), 18,4(2), 885-899. chouinard, n. (1993). some insights on meaningful internships in sport management: a cooperative education approach. journal of sport management, 7, 95-100. coaprt (2015). council on accreditation of parks, recreation, tourism and related professions. learning outcomes, standards and assessment. retrieved from http://www.cosmaweb.org/list-of-accreditedprograms.html http://www.nrpa.org/uploadedfiles/nrpa.org/professional_development/a ccreditation/coaprt/2013%20coaprt%20standards_04-24-14.pdf dewey, j. (1938). experience and education. new york: macmillan publishing. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 33 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe dieffenback, k. d., murray, m., & zakrajsek, r. (2011). the coach education internship experience: an exploratory study. international journal of coaching science, 5(1), 3-25. dillman, d., smyth, j., & christian, l. (2009). internet, mail, and mixed-mode surveys: the tailored design method (3rd ed.). hoboken, nj: john wiley & sons, inc. deluca, j. r. & braunstein-minkove, j. (2016). an evaluation of sport management student preparedness: recommendations for adapting curriculum to meet industry needs. sport management education journal, 10, 1-12. fleming, j. & ferkins, l. (2005). cooperative education in sport: building our knowledge base. journal of hospitality, leisure, sport, and tourism education, 4(1), 42-47. foster, s.b., & dollar, j.e. (2010). experiential learning in sport management: internshipsand beyond. morgantown, wv: fitness information technology. hynes-dusel, j. (1999). cooperating teachers’ perceptions about the student teaching experience. physical educator, 4, 186-196. jones, d.f., brooks, d., &mak, j. (2008). examining sport management programs in the united states. sport management review, 11, 77-91. jowdy, e., mcdonald, m., & spence, k. (2004). an integral approach to sport management internships. european sport management quarterly, 4, 215-233. koo, g. i., diacin, m. j., khojasteh, j., & dixon, a. w. (2016). effects of internship satisfactionon the pursuit of employment in sport management. sport management education journal, 10, 2942. kelley, d.r., beitel, p.a., desensi, j.t., & blanton, m.d. (1994). undergraduate and graduatesport management curricular models: a perspective. journal of sport management, 8, 93-101. kiser, j., &partlow, c. (1999). experiential learning in hospitality education: an exploratorystudy. journal of hospitality and tourism management, 11(23), 70-74. martin, c. (2012). sport management graduate and undergraduate students’ perceptions of career expectations in sport management. sport management education journal, 6(1), 21-31. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 34 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe mathner, r. & martin, c. (2012). sport management graduate and undergraduate students’ perceptions of career expectations in sport management. sport management education journal, 6(1), 21-31. moorman, a. (2004). legal issues and supervised internship relationship: who is responsible for what? journal of physical education, recreation, and dance, 75(2), 19-35. nace (2014). national association of colleges and employers. the job outlook for the class of 2014. retrieved from http://www.naceweb.org/uploadedfiles/pages/mynace/grab_and_go/stu dents/job-outlook-2014student-version.pdf nassm (2016). north american society for sport management. sport management programs: united states. retrieved from http://www.nassm.com/infoabout/sportmgmtprograms/united_states schoepfer, k. l., & dodds, m. (2011). internships in sport management curriculum: should legal implications of experiential learning result in the elimination of the sport management internship? marquette law review, 21(1), 183-201. spahr, k. & wiegand, s. (2012). library collections for the support of academic sport management programs. journal of business and finance librarianship, 17(3), 220-241. sotiriadou, p. (2011). improving the practicum experience in sport management: a case study. european sport management quarterly, 11(5), 525-546. stier, w.f. (1993). alternative career paths in physical education: sport management. eric digest, 1-6. stratta, t. m. p. (2004). the needs and concerns of students during the sport management internship experience. journal of physical education, recreation, and dance, 75(2), 25 – 34. surujlal, j. & singh, c. (2010). internship as a mechanism for professional preparation of sport management personnel: an empirical study of students’ perceptions. south african journal for research in sport, physical education and recreation, 32(2), 117-130. verner, m.e., keyser, b.b., & morrow, m.j. (2001). experiential learning through field experiences: internships and practica. in b.l. parkhouse (ed.), the management of sport: its foundations and application (3rd ed., pp. 30-53). new york: mcgraw hill. williams, j. (2003). sport management internship administration: challenges and chances for collaboration. nace journal, winter (2), 28 – 32 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 53 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe reducing inappropriate antibiotic prescribing for upper respiratory infections with leaflets peter james brown california state university, bakersfield abstract: antibiotics are often prescribed for upper respiratory infections (uris) in the united states, despite the fact that most uris are caused by viruses and do not require antibiotics. this inappropriate prescribing contributes to the development of antibiotic-resistant bacteria, which can lead to more serious infections and even death. antibiotics can also cause side effects, such as nausea, diarrhea, and rash. the unnecessary use of antibiotics also increases healthcare costs. keywords: antibiotics, upper respiratory infections, antibiotic resistance, side effects, healthcare costs problem: antibiotics are inappropriately prescribed for upper respiratory infections (uris) throughout the united states, leading to complications like antibiotic-resistant pathogens, increased morbidity and mortality, adverse drug events, and increased healthcare costs (lee et al., 2017; meeker et al., 2016). upper respiratory infections are one of the most common conditions that primary care providers see in their practice (meeker et al., 2016). current evidence does not support the use of antibiotics for uris because most infections are caused by viruses, are self-limiting, and rarely lead to serious complications (lee et al., 2017). as a result of overprescribing antibiotics, pathogens are becoming increasingly resistant to existing antibiotics, which leads to increased morbidity and mortality worldwide (gonzales et al., 2013). according to the centers for disease control and prevention (cdc), each year in the united states over two million people become infected with antibioticresistant pathogens and as a result at least 23,000 people die (cdc, 2013). the use of antibiotics can have undesired consequences from side effects, adverse reactions, and complications. antibiotics can cause side effects like nausea, diarrhea, rash, itching, photosensitivity, and abdominal discomfort. moreover, antibiotics can lead to serious complications like acute kidney injury, hepatitis, anaphylaxis and secondary infections like clostridium difficile diarrhea (cdc, 2013). the health care costs of antibiotics to treat uris are significant in the united states. meeker et al. (2014) explains that in the united states alone, 41.2 million prescriptions for antibiotics aimed at treating uris are prescribed annually. this results in a cost of $1.1 billion dollars (meeker et al., 2014). according to the cdc (2013), one in five emergency department visits are a direct result of an adverse drug event from prescribed antibiotics. in children antibiotics are the most common cause of emergency department visits resulting from adverse drug effects (cdc, 2013). unnecessary use of antibiotics increases the healthcare cost from the initial purchase of the antibiotic, but also the emergency department visit associated with possible side effects (cdc, 2013). there is a psychological and sociocultural variable that influences the use of antibiotics in treatment of uris, and that is the desire to receive antibiotics by patients (coxeter, mar, & hoffmann, 2017). according to coxeter, mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 54 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe mar, and hoffmann (2017), many patients overestimate the benefits and underestimate the harms of using antibiotics. this thought process by the public leads to increased demand and desire for antibiotics, regardless of whether or not they are indicated. furthermore, patients often have inadequate knowledge and misconceptions about antibiotic use for uris (coxeter, mar, & hoffmann, 2017). for example, most patients believe that antibiotics are beneficial in treating common respiratory infections, including the ability to cure viral infections, and shorten the duration of uris (yu et al., 2014). patients’ misconception about antibiotics are a strong factor in the overuse of antibiotics, because when they visit their primary care provider they expect to receive antibiotics regardless of whether or not they are indicated (gonzales et al., 2013; o'sullivan, harvey, glasziou, & mccullough, 2016). primary interventions to reduce inappropriate use of antibiotics to treat uris include yearly influenza vaccinations, pneumococcal vaccinations, proper hand hygiene, avoidance of people who are ill and overcrowded places, and furthermore engaging in healthy activities such as getting adequate sleep, smoking cessation, eating a healthy diet and exercising regularly (wedro, 2018). secondary interventions include the use of point-of-care diagnostic tests like c-reactive protein testing, rapid strep testing, and rapid influenza testing to determine the cause of illness, and better determine what antibiotics, if any, are indicated (tonkin-crine et al., 2017). other secondary interventions are aimed at relieving associated symptoms (e.g., fever, cough, muscle pains, malaise). these interventions include analgesics, antihistamine/decongestant combinations, dextromethorphan, intranasal ipratropium bromide, saline nasal lavage, expectorants, zinc sulfate lozenges, and herbal products (sexton, mcclain, hirsch, aronson, & melin, 2018). tertiary interventions would be to avoid the use of antibiotics altogether, as this may lead to unforeseen complications in both the patient and general population (sexton et al., 2018). for example, antibiotics can cause adverse effects (e.g., anaphylaxis, kidney damage, c. difficile infection) to the patient, but they can also lead to increases in antibiotic-resistant organisms that can affect populations at a larger scale (gonzales et al., 2013; cdc, 2013). literature review the theoretical framework that clinicians can apply to reduce inappropriate antibiotic prescriptions for uris is that of kurt lewin’s change model theory. the change model theory is made up of three-stages called the unfreezing stage, change stage, and refreezing stage (shirey, 2013). the unfreezing stage can be applied to primary care providers and patients as the stage where they are preparing to let go of a previously accepted idea or expectation (i.e., using antibiotics for the treatment of uris). this stage is necessary in order to challenge the beliefs, attitudes, expectations and behaviors that are seen with the use of antibiotics for uris (manchester et al., 2014). the change stage is where the actual transition of practice takes place (i.e., information about antibiotics and uris is given to the patient). this transition is supported by evidence-based research, knowledge, behaviors and attitudes aimed at following the new processes (wojciechowski, murphy, pearsall, & french, 2016). the last stage, refreezing, is where the new process (i.e., antibiotics will not be used to treat uris) becomes the new practice, and efforts are made to keep the new behavior from regressing to what it used to be. this will require mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 55 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe thorough patient education to address cultural and personal beliefs; and also changes in policies, practices and habits of providers caring for those patients (manchester et al., 2014; shirey, 2013). lewin’s change model theory also has three factors that affect the direction in which change will occur: driving forces, restraining forces, and equilibrium (wojciechowski et al., 2016). driving forces are positive forces that push in the direction that will cause change to happen (manchester et al., 2014). an example of a driving force would be the information leaflet given to patients who are presenting with symptoms of uris. the information leaflet would act as a force pushing in the direction of the desired change (i.e., reduction in the use of antibiotics). restraining forces on the other hand, are forces that push in the direction against driving forces in order to keep change from taking place and maintain the status quo, or equilibrium (wojciechowski et al., 2016; manchester et al., 2014). an example of this would be the misconceptions that patients have about the use of antibiotics in treatment of uris. it is their misconception that prevents change from taking place. equilibrium occurs when the driving forces push against the restraining forces, and as a result, no change occurs (wojciechowski et al., 2016). as mentioned before, the unnecessary use of antibiotics to treat upper respiratory infections leads to consequences like increased drug-resistance, increased health care costs, and increased incidences of adverse effects (o’sullivan, harvey, glasziou, & mccullough, 2016; lee et al., 2017). uncomplicated uris result in 25 million visits to primary care providers across the united states each year (zoorob, sidani, fremont, &kihlberg, 2013). in a large outpatient study of more than 52,000 cases of uris, it was found that over 65% ofpatients received antibiotics, and although indicated in some cases, antibiotics are still vastly overused(zoorob et al., 2013). one reason antibiotics are overprescribed is because patients desire, and in some cases, expect to receive antibiotics from their providers, regardless of whether or not they are indicated (gonzales et al., 2013; o’sullivan et al., 2016). an evidence-based review of numerous research studies aimed at reducing antibiotic prescriptions for upper respiratory infections was conducted using pubmed, google scholar, and various online resources (e.g., cdc, uptodate). from these resources, five studies were found to show that printed information given to patients presenting with upper respiratory infections would result in reduced prescription rates for antibiotics (lee et al., 2017; wei et al., 2017; gonzales et al., 2013; agnew, taaffe, darker, o'shea, & clarke,2013; meeker et al., 2014). the use of printed information would come in various forms, including leaflets, brochures, pamphlets, and a poster-size education/commitment letter (lee et al., 2017; wei et al., 2017; gonzales et al., 2013; agnew et al.,2013; meeker et al., 2014). this evidence-based review is aimed at evaluating the use of printed information for patients, and will address the following research question: will providing information leaflets to adult patients with upper respiratory infections reduce the use of antibiotics? lee et al. (2017) designed a patient-targeted educational pamphlet on the causes of uris and the role of antibiotics, with a goal of reducing antibiotic prescriptions. the educational pamphlet was based on information from the health promotion board of singapore, the cdc of the united states, and consultations from several primary care and infectious disease providers, and public health experts (lee et al., 2017). lee et al. (2017) used mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 56 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe a randomized control trial in patients over 21 years in age, presenting with uri symptoms for seven days or less, who presented to the primary care clinics in singapore (lee et al., 2017). out of 457 patients who participated in the study, lee et al. (2017) found that the educational pamphlet significantly reduced antibiotic prescriptions for uris in a small indian ethnic subgroup. the rest of the participants had no significant decreases in prescription rates, but did increase the patients’ understanding of uris, why antibiotics are not necessary for uri, and side effects of antibiotics (lee et al., 2017). wei et al. (2017) used a two-part intervention, pragmatic cluster-randomized trial aimed at reducing inappropriate antibiotic prescriptions for uris in pediatric patients seeking care in primary care hospitals in china. the first intervention was aimed at educating and training providers on the guidelines of treating uris, appropriate prescribing, and also monthly peer-review meetings (wei et al., 2017). the second intervention was aimed at the parents of pediatric patients. parents were given paper leaflets about antibiotics and uris, and at the same time, there was an educational video playing on a loop in the waiting rooms of the primary care hospitals (wei et al., 2017). wei et al. (2017) saw a decrease in antibiotic prescription rates from 80% to 40% among participants in the intervention group. wei et al. (2017) concluded that interventions aimed at both providers and patients were highly effective at reducing the prescribing rate of antibiotics for upper respiratory tract infections. gonzales et al. (2013) conducted a three-arm, cluster-randomized trial aimed at reducing antibiotics for acute bronchitis. the three-arms were divided into a control group (no education was provided), a printed interventions group in which educational brochures from the cdc were given to patients at triage and posters displaying the clinical algorithm for treatment of acute bronchitis were posted in every exam room (gonzales et al., 2013). the computerized group used the electronic medical record to alert the nursing staff when a chief complaint of cough was entered, prompting the nurse to give an educational brochure from the cdc to the patient and also alert the provider, via the electronic medical record, to use a specific algorithm with specific documentation, relevant history, and physical exam elements (gonzales et al., 2013). gonzales et al. (2013) saw decreases in prescribed antibiotics in both the printed interventions group (80% down to 68.3%), and the computerized intervention group (74% down to 60.7%). gonzales et al. (2013) conclude that educational brochures can help reduce antibiotic prescription rates for upper respiratory infections. agnew et al. (2013) used an intervention trial study design with 115 patients from the dublin, ireland area presenting to their primary care provider with complaints of acute respiratory tract infections. the purpose of the study was to determine if delayed prescriptions and an information leaflet on antibiotics would reduce the rate of antibiotic use (agnew et al., 2013). the intervention group was given a delayed prescription for antibiotics and also an information leaflet. the information leaflet contained written details explaining the role of antibiotics in respiratory tract infections, indications for use, and potential side effects (agnew et al., 2013). agnew et al. (2013) called patients over the phone 10 to 14 days after their consultation, and as a result found that only 43% of the intervention group said they used the antibiotics they were given, concluded that the use of an additional information leaflet is highly effective at reducing the use of antibiotics for respiratory tract infections. meeker et al. (2014) conducted a randomized clinical trial with 954 adults presenting with acute respiratory infections in outpatient clinics located in los angeles, california. participants were 18 years and older, diagnosed mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 57 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe with a uri for which antibiotics might or might not have been appropriate. the intervention included the use of a poster-size (18 x 24 inch) commitment letter explaining why antibiotics were not appropriate in many cases; these would be posted in examination rooms (meeker et al., 2014). the clinicians who were included in the intervention group would have their photograph and signature added to the commitment letter (meeker et al., 2014).the rate of antibiotic prescriptions for the intervention group (n=449) decreased from 43.5% to 33.7%, and meeker et al. (2014) concluded that there was a significant reduction in antibiotic prescriptions for uris for patients treated by clinicians who signed and posted a commitment letter in their examination rooms. the commitment letter was written at an eighth-grade reading level in both english and spanish, and included information about antibiotics, use of antibiotics, side effects of antibiotics, increased drug-resistance due to antibiotics, and how it is important to “only use an antibiotic when it is necessary to treat your illness” (meeker et at., 2014, p. 427). discussion and application according to the cdc, initial treatment of upper respiratory infections consists of watchful waiting for patients who can easily follow up if their condition worsens (cdc.gov, 2017). other interventions are aimed at symptomatic relief with the use of decongestants, antipyretics, non-steroidal anti-inflammatory drugs (nsaids), and cough suppressants (cdc.gov, 2017). the use of antibiotics as initial or secondary interventions is not recommended for uncomplicated upper respiratory infections (cdc.gov, 2017). according to the infectious disease society of america (idsa), the use of antibiotics is indicated when one or more of three criteria are met by the patient: (a) persistent symptoms lasting greater than 10 days; (b) onset of severe symptoms, or signs of high fever (≥39°c [102°f]) and purulent nasal discharge, or facial pain lasting for at least 3–4 consecutive days; or (c) onset of worsening symptoms like new onset of fever, headache, or increase in nasal discharge following a typical uri that lasted five to six days and was initially improving (chow et al., 2012). both the cdc and the idsa advise against the use of antibiotics for uncomplicated uris, furthermore, the evidence-based research of five studies support this recommendation and attempt to curve the inappropriate use of antibiotics for uris using various printed mediums (cdc.gov, 2017; chow et al., 2012; lee et al., 2017; wei et al., 2017; gonzales et al., 2013; agnew et al., 2013; meeker et al., 2014). all five of the studies employed the use of printed information to educate patients about uris, antibiotics, side effects of antibiotics, and the inappropriate use of antibiotics for treatment of uris (lee et al., 2017; wei et al., 2017; gonzales et al., 2013; agnew et al.,2013; meeker et al., 2014). meeker et al. (2014) had one difference from all of the others in that the written information was posted in the exam room, and could not be taken home with the patient. all other of the studies provided patients with leaflets, brochures, or pamphlets that could be taken home (lee et al., 2017; wei et al., 2017; gonzales et al., 2013; agnew et al.,2013). wei et al. (2017) also included an educational video playing on a loop in the waiting rooms, whereas none of the other studies included a video medium. two studies, wei et al. (2017) and gonzales et al. (2013) also included education and training about antibiotics and uris to participating clinicians. three studies, lee et al. (2017), agnew et al. (2013) and meeker et al. (2014), included only adults in their sample selection, wei et al. (2017) only included children in their sample selection, and gonzales et al. (2013) included a combination of adolescents (>13 years old) and mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 58 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe adults in their sample selection. the overall conclusion of all five studies was that providing printed information to patients with uris was effective at reducing the rate of inappropriate antibiotic prescriptions (lee et al., 2017; wei et al., 2017; gonzales et al., 2013; agnew et al.,2013; meeker et al., 2014). providing education to patients about the use of antibiotics and uris is the first stage of lewin’s change model theory, unfreezing (manchester et al., 2014). this is supported by the idea that printed information given to patients will prepare them to let go their previously accepted ideas, or misconceptions, about using antibiotics to treat uris (manchester et al., 2014; lee et al., 2017). the unfreezing stage is further embodied by the use of guidelines and data showing the consequences of current antibiotic use (e.g., increased drug-resistance, adverse effects, and costs) (wojciechowski et al., 2016; o'sullivan et al., 2016). the change stage is where the education, implementation and presenting of the idea that antibiotics should not be used to treat uris takes place. this stage includes the use of evidence-based research to support the idea of not using antibiotics for treatment of uris, all the while fostering the new process (wojciechowski et al., 2016). meeker et al. (2014) found that clinicians were more influenced by interpersonal factors (i.e., their photograph and signature added to a commitment letter about antibiotics) than they were by pay-for-performance incentives. lewin’s change stage would attribute this phenomenon to providers’ engagement as stakeholders and role models with the new process (meeker et al., 2014; wojciechowski et al., 2016). the last stage of lewin’s change model theory, refreezing, is where the patients are encouraged and motivated by the resources they are given to accept the idea that antibiotics should not be used for treatment of uris, with examples like the risks vs benefits of antibiotics, the selflimiting etiology of uris, and the need to decrease antibiotic-resistance (manchester et al., 2014; wojciechowski et al., 2016). implications for practice are aimed at reducing antibiotic prescriptions for uris. the use of printed information, like leaflets, are aimed at educating patients about the pathogenesis of uris, lack of evidence showing that antibiotics are useful in treating uris, side effects, complications, and cost of unnecessary utilization of antibiotics (lee et al., 2017; wei et al., 2017; gonzales et al., 2013; agnew et al., 2013; meeker et al., 2014). clinicians can use printed information (e.g., pamphlets, leaflets, brochures) to educate patients about antibiotics and uris, which in turn will help reduce patient desire for antibiotics and decrease inappropriate use of antibiotics (lee et al., 2017; wei et al., 2017; gonzales et al., 2013; agnew et al.,2013; meeker et al., 2014). printed information in the form of leaflets has been found to be very useful in educating patients, especially for acute conditions where the patients are misinformed or lack knowledge (sustersic, gauchet, foote, & bosson, 2017). sustersic et al. (2017) conducted a systemic review of 986 articles and found that printed information leaflets improved patients’ knowledge, satisfaction, adherence to treatment for acute conditions, and also improved patients’ behaviors for chronic diseases. information leaflets are inexpensive and easily prepared interventions that can help reduce overall health care costs in the primary care setting (sustersic et al., 2017). clinicians can write, develop and implement information leaflets, in both english and spanish, to help educate their patients, curve desires for antibiotics, and inappropriate antibiotic use (lee et al., 2017; wei et al., 2017; gonzales et al., 2013; agnew et al.,2013; meeker et al., 2014). mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 59 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe the healthcare system in the united states can be described as a hybrid system of various payers, including private, business, and government, operating simultaneously and interactively (department for professional employees [dpe], 2016). there are multiple levels that exist within the government-funded healthcare system, among them are local, state and federal. at the federal level, we have medicare; at the state level, we have medicaid (i.e., medi-cal in california). within the united states healthcare system, there are various pay models. one example is the fee-for-service model which reimburses clinicians a set amount for each of the services they perform, regardless of patient health outcomes (healthcare.gov, n.d.). another model is the pay-for-performance model in which providers have financial incentives based on improving patient health outcomes (bardach et al., 2013). a new model from the centers for medicare and medicaid services (cms) is the capitated model, in which a provider, or group of providers, receive a monthly fixed amount of money to provide comprehensive care (i.e., outpatient, inpatient, preventative services, diagnostic and treatment services) to each patient assigned to them (cms, 2017). in capitated models there is a pool of money that is collected and held until the end of the year. if the overall healthcare costs of the patients are low, financial rewards are given to the providers, whereas if the overall healthcare costs are high, the financial rewards for providers are minimal (cms, 2017). the use of capitated models can influence clinicians’ decisions on care. on one hand, clinicians are asked to provide quality care, but on the other hand they are asked to manage that care while being cost-effective. this dilemma may cause clinicians to prescribe antibiotics when they are not indicated (i.e., for treatment of a uri) in order to keep their patient’s health from getting worse, which could lead to a hospitalization. for example, if a patient with a uri was seen by a provider and was not prescribed antibiotics, there is a small possibility that they could develop pneumonia and require hospitalization (gonzales et al., 2013). a clinician, incentivized by the capitated model, may be more inclined to prescribe antibiotics in order to prevent the expensive and costly hospitalization of a more serious infection. the capitated reimbursement environment may lead providers to err on the side of caution and prescribe unnecessary antibiotics for uris. since the implementation of the affordable care act (aca) in 2014, there has been an increasing trend in healthcare to deliver customer-centered care aimed at increasing patient satisfaction (detsky & shaul, 2013). the aca includes a provision that will redistribute up to 1% of medicare reimbursements from the hospitals with the lowest patient satisfaction scores to hospitals with the highest patient satisfaction scores (detsky & shaul, 2013).this environment of patient satisfaction and customer-centered care, has led providers to chase financial incentives derived from institutional pressures, reimbursement schemes, discretionary care (i.e., medical interventions that have no proven benefit), and the desire to avoid bad ratings from customers (detsky & shaul, 2013). clinicians will find themselves in a conflicting healthcare environment, where on one hand they are asked to improve patient satisfaction, but on the other hand they must deliver quality care. this dilemma further aggravates the issue of prescribing antibiotics for uris when patient satisfaction is such a strong variable. if a patient is not given a prescription to treat their upper respiratory infection, they may be more inclined to give the provider a low satisfaction score. conversely, providers may be more willing to give their patients a prescription of mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 60 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe antibiotics for uris if there is an opportunity to receive a higher satisfaction score, as this may lead to more financial compensation. the use of printed information has shown promising results at both educating patients and reducing prescriptions for inappropriate antibiotics for uris (lee et al., 2017; wei et al., 2017; gonzales et al., 2013; agnew et al.,2013; meeker et al., 2014). there are many variables that need to be addressed in regards to this issue. among them are patients, providers, institutions, policies, and payers. the need for further research aimed at multiple parties (i.e., patients, providers, and organizations) would be beneficial to address the issue from different angles. also, the use of information leaflets may be considered archaic when compared to the present day smart phones and digital applications. the use of smart phones, digital applications, emails, and text messages to deliver the same information found on leaflets may be beneficial to a younger and more technologically savvy population, furthermore suggesting the need for additional studies to verify the efficacy of these digital interventions. intervention recommended for clinicians clinicians can use printed information leaflets to educate patients on uris, antibiotics, indications for antibiotics, and complications that can arise from antibiotics. the information leaflets for this intervention would be written at an eight-grade reading level, and would contain information from various resources aimed at providing guidelines for clinicians (e.g., cdc, national institutes of health, and idsa). the information leaflet would be written in both english and spanish, as this will help capture a larger population of patients. the leaflet would have detailed information about the causes of uris, disease progress, and symptomatic management. it would also have descriptions of how antibiotics function, their side effects, possible complications that may arise, and how they are not indicated for uris because they are often times caused by viruses. all of this information will be written in a way that patients can easily read, understand and discuss with their providers. clinicians will be asked to help clarify any misconceptions, explain the information, and answer any questions patients may have about the information found on the leaflet. the leaflet can be given to patients at various points of contact throughout their visit in the primary care setting. the triage staff can provide the leaflet if the patient presents with a chief complaint of cough or cold-like symptoms. the leaflets can also be placed in easily accessible areas of the waiting room and examination rooms, to encourage patients to take one freely. lastly, the clinician can also hand a leaflet to the patient and discuss its content throughout the consultation. the strengths of the information leaflets would have to be that it is easy to read and understand, precise and straight to the point, and readily available to anyone. another benefit is the low-cost of printing copies, and the unnecessary purchase of new equipment (e.g., computers, tablets, smart phone applications). some of the weaknesses found in leaflets are that in a digital age, paper mediums are often overlooked. they are also discarded after being read and are seldom kept for reference. also, patients who are illiterate would not be able to read and comprehend the information provided in the leaflet. lastly, the discussion and explanation of the leaflet between the provider and the patient is paramount to the efficacy and outcome it aims to achieve. clinicians can use the leaflet to educate and curve patients’ desires for antibiotics, which in turn will help reduce inappropriate antibiotics for upper respiratory infections. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 61 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe references agnew, j., taaffe, m., darker, c., o'shea, b., & clarke, j. (2013). delayed prescribing of antibiotics for respiratory tract infections: use of information leaflets. irish medical journal, 106(8), 243-244. bardach, n. s., wang, j. j., de leon, s. f., shih, s. c., boscardin, w. j., goldman, l. e., & dudley, r. a. (2013). effect of pay-for-performance incentives on quality of care in small practices with electronic health records: a randomized trial. the journal of the american medical association, 310(10), 1051–1059. http://doi.org/10.1001/jama.2013.277353 centers for disease control and prevention (cdc). (2017). antibiotic prescribing and use in doctor’s offices. retrieved from https://www.cdc.gov/antibiotic-use/community/for-patients/common-illnesses/colds.html centers for disease control and prevention (cdc). (2013). antibiotic resistance threats in the united states, 2013. retrieved from https://www.cdc.gov/drugresistance/threat-report-2013/index.html centers for medicare & medicaid services (cms). (2017). capitated model. retrieved from https://www.cms.gov/medicare-medicaid-coordination/medicare-and-medicaidcoordination/medicaremedicaid-coordinationoffice/financialalignmentinitiative/capitatedmodel.html chow, a. w., benninger, m. s., brook, i.,brozek, j. l., goldstein, e. j. c., hicks, l. a., pankey, g. a., seleznick, m.,volturo, g., wald, e. r., & file, t. m. (2012). idsa clinical practice guideline for acute bacterial rhinosinusitis in children and adults. clinical infectious diseases, 54(8) e72–e112. https://doi.org/10.1093/cid/cis370 coxeter, p. d., mar, c. d., & hoffmann, t. c. (2017). parents’ expectations and experiences of antibiotics for acute respiratory infections in primary care. annals of family medicine, 15(2), 149–154. http://doi.org/10.1370/afm.2040 detsky, j.&shaul, r. z. (2013). incentives to increase patient satisfaction: are we doing more harm than good? canadian medical association journal, 185(14), 1199–1200. https://doi.org/10.1503/cmaj.130366 department for professional employees (dpe). (2016). the u.s. health care system: an international perspective. retrieved from http://dpeaflcio.org/programspublications/issue-fact-sheets/the-u-s-healthcare-systeman-international-perspective/ gonzales, r., anderer, t., mcculloch, c. e., maselli, j. h., bloom, f. j., graf, t. r., stahl, m., yefko, m., molecavage, j., &metlay, j. p. (2013). a cluster-randomized trial of decision support strategies for mailto:topacademicjournals@gmail.com http://doi.org/10.1001/jama.2013.277353 https://www.cdc.gov/antibiotic-use/community/for-patients/common-illnesses/colds.html https://www.cdc.gov/drugresistance/threat-report-2013/index.html https://www.cms.gov/medicare-medicaid-coordination/medicare-and-medicaid-coordination/medicare-medicaid-coordinationoffice/financialalignmentinitiative/capitatedmodel.html https://www.cms.gov/medicare-medicaid-coordination/medicare-and-medicaid-coordination/medicare-medicaid-coordinationoffice/financialalignmentinitiative/capitatedmodel.html https://www.cms.gov/medicare-medicaid-coordination/medicare-and-medicaid-coordination/medicare-medicaid-coordinationoffice/financialalignmentinitiative/capitatedmodel.html https://doi.org/10.1093/cid/cis370 https://doi.org/10.1093/cid/cis370 http://dpeaflcio.org/programs-%09publications/issue-fact-sheets/the-u-s-health-care-system-an-international-perspective/ http://dpeaflcio.org/programs-%09publications/issue-fact-sheets/the-u-s-health-care-system-an-international-perspective/ http://dpeaflcio.org/programs-%09publications/issue-fact-sheets/the-u-s-health-care-system-an-international-perspective/ american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 62 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe reducing antibiotic use for acute bronchitis. journal of the american medical association internal medicine, 173(4), 267–273. http://doi.org/10.1001/jamainternmed.2013.1589 healthcare.gov. (n.d.). fee for service. retrieved from https://www.healthcare.gov/glossary/fee-for-service/ kernfamilyhealthcare.com. (n.d.). kern family health care – the friendly face of kern health systems. retrieved from http://www.kernfamilyhealthcare.com/ lee, m. h. m., pan, d. s. t., huang, j. h., chen, m. i. c., chong, j. w. c., goh, e. h., jiang, l., leo, y. s., lee, t. h., wong, c. s., loh, v. w. k., lim, f. s., poh, a. z., tham, t. y., wong, w. m., & yu, y. (2017). results from a patient-based health education intervention in reducing antibiotic use for acute upper respiratory tract infections in the private sector primary care setting in singapore. antimicrobial agents and chemotherapy, 61(5), e02257–16. doi: 10.1128/aac.02257-16 manchester, j., gray-miceli, d. l., metcalf, j. a., paolini, c. a., napier, a. h., coogle, c. l., & owens, m. g. (2014). facilitating lewin’s change model with collaborative education in promoting evidence based practices of health professionals. evaluation and program planning, 47, 82-90. https://doi.org/10.1016/j.evalprogplan.2014.08.007 meeker, d., knight, t. k., friedberg, m. w., linder, j. a., goldstein, n. j., fox, c. r., rothfeld, a., diaz, g., & doctor, j. n. (2014). nudging guideline-concordant antibiotic prescribing: a randomized clinical trial. journal of the american medical association internal medicine, 174(3), 425–431. http://doi.org/10.1001/jamainternmed.2013.14191 meeker, d., linder, j.a., fox, c.r., friedberg, m.w., persell, s.d., goldstein, n.j., knight, t.k., hay, j.w., & doctor, j.n. (2016). effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices: a randomized clinical trial. journal of the american medical association.315 (6):562–570. doi:10.1001/jama.2016.0275 o'sullivan, j.w., harvey, r.t., glasziou, p.p., &mccullough, a. (2016). written information for patients (or parents of child patients) to reduce the use of antibiotics for acute upper respiratory tract infections in primary care. cochrane database of systematic reviews, (11).doi:10.1002/14651858.cd011360.pub2. sexton, d. j., mcclain, m. t., hirsh, m. s., aronson, m. d., &melin, j. a. (2018). the common cold in adults: treatment and prevention. retrieved from https://www.uptodate.com/contents/the-common-cold-inadults-treatmentand prevention?search=upper%20respiratory%20tract%20infection&source=search_result&s electedtitle=2~150&usage_type=default&display_rank=2#h3247441674 mailto:topacademicjournals@gmail.com http://doi.org/10.1001/jamainternmed.2013.1589 https://www.healthcare.gov/glossary/fee-for-service/ http://www.kernfamilyhealthcare.com/ https://doi.org/10.1016/j.evalprogplan.2014.08.007 http://doi.org/10.1001/jamainternmed.2013.14191 https://www.uptodate.com/contents/the-common-cold-in-adults-treatment-and-%09prevention?search=upper%20respiratory%20tract%20infection&source=search_result&s%20electedtitle=2~150&usage_type=default&display_rank=2#h3247441674 https://www.uptodate.com/contents/the-common-cold-in-adults-treatment-and-%09prevention?search=upper%20respiratory%20tract%20infection&source=search_result&s%20electedtitle=2~150&usage_type=default&display_rank=2#h3247441674 https://www.uptodate.com/contents/the-common-cold-in-adults-treatment-and-%09prevention?search=upper%20respiratory%20tract%20infection&source=search_result&s%20electedtitle=2~150&usage_type=default&display_rank=2#h3247441674 https://www.uptodate.com/contents/the-common-cold-in-adults-treatment-and-%09prevention?search=upper%20respiratory%20tract%20infection&source=search_result&s%20electedtitle=2~150&usage_type=default&display_rank=2#h3247441674 https://www.uptodate.com/contents/the-common-cold-in-adults-treatment-and-%09prevention?search=upper%20respiratory%20tract%20infection&source=search_result&s%20electedtitle=2~150&usage_type=default&display_rank=2#h3247441674 american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 63 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe shirey, m. r. (2013). lewin’s theory of planned change as a strategic resource. journal of nursing administration, 44(2), 69-72. doi: 10.1097/nna.0b013e31827f20a9. sustersic, m., gauchet, a., foote, a., &bosson, j. (2017). how best to use and evaluate patient information leaflets given during a consultation: a systematic review of literature reviews. health expectations: an international journal of public participation in health care and health policy, 20(4), 531–542. http://doi.org/10.1111/hex.12487 tonkin-crine, s. k. g., tan, p. s., van hecke, o., wang, k., roberts, n. w., mccullough, a., hansen, m. p., butler, c. c., & del mar, c. b. (2017). clinician-targeted interventions to influence antibiotic prescribing behaviour for acute respiratory infections in primary care: an overview of systematic reviews. cochrane database of systematic reviews (9). doi:10.1002/14651858.cd012252.pub2 wedro, b. (2018). upper respiratory infection. retrieved from https://www.emedicinehealth.com/upper_respiratory_infection/article_em.htm#upper_respiratory_infect io n_facts wei, z., zhang, z., walley, d.h., hicks, j. p., zeng, j., deng, s., zhou, y., yin, j., newell, j. n., sun, q., zou, g., guo, y., upshur, r. e. g., & lin, m. (2017). effect of a training and educational intervention for physicians and caregivers on antibiotic prescribing for upper respiratory tract infections in children at primary care facilities in rural china: a cluster-randomised controlled trial. the lancet global health, 5(12), e1258– e1267.https://doi.org/10.1016/s2214-109x(17)30383-2 wojciechowski, e., murphy, p., pearsall, t., french, e. (2016). a case review: integrating lewin’stheory with lean’s system approach for change. the online journal of issues in nursing,21(2). doi:10.3912/ojin.vol21no02man04 yu, m., zhao, g., stålsby lundborg, c., zhu, y., zhao, q., & xu, b. (2014). knowledge, attitudes, and practices of parents in rural china on the use of antibiotics in children: across-sectional study. bmc infectious diseases, 14, 112. http://doi.org/10.1186/1471-2334-14-112 zoorob, r., sidani, m. a., fremont, r. d., & kihlberg, c. (2013). antibiotic use in acute upper respiratory tract infections. american family physician, 86(9):817-822. mailto:topacademicjournals@gmail.com https://www.emedicinehealth.com/upper_respiratory_infection/article_em.htm#upper_respiratory_infection_facts https://www.emedicinehealth.com/upper_respiratory_infection/article_em.htm#upper_respiratory_infection_facts https://www.emedicinehealth.com/upper_respiratory_infection/article_em.htm#upper_respiratory_infection_facts american journal of medical and physical education vol.7, issue 1; january-febuary 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 7 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe the gendered experiences of female gamers 1thomas (benjamin) bopp, sarah (jane) jones2, michael (david) smith,3 1assistant professor, department of human nutrition and hospitality management, university of alabama. associate professor, southern new hampshire university.2&3 abstract esports is a rapidly growing industry with a global audience of over 470 million people. however, the industry is still male-dominated, with only 5% of professional gamers being women. this paper reviews the literature on gender in esports and discusses the factors that contribute to this gender imbalance. the paper also calls for more research and scholarly efforts to create a more inclusive esports space for women and other marginalized gamers. keywords: esports, gender, women in esports, marginalized gamers, inclusion, research introduction electronic sport (esport) is a subdomain of video-gaming that denotes competitive play ranging from professional teams to individual amateurs, typically through organized gaming events or tournaments, hosted both inperson and in an interactive online environment (chan et al., 2022; darvin et al., 2020; gough, 2021a; scholz, 2019). despite the emerging state of the industry, the accessibility of esports (e.g., advances in technology, multiple gaming platforms on which to play and/or spectate, reduced geographical hindrances) is enabling its exponential growth (cranmer et al., 2021). in 2021, the global esports market was estimated at $1.28 billion, with an audience size of 474 million fans (statista, 2021). as the popularity, widespread consumption, and media coverage of esports continue to increase, the industry has garnered comparisons to the growth and attention received by more traditional sport (funk, et al., 2018). however, unlike traditional sport, the enforcement and administration of rules and competition is not carried out through a central governing body, but rather, game manufacturers and tournament organizers (jenny et al., 2017). the decentralized regulation of the industry makes it a fertile space to serve as a means for social and cultural advancement (reitman et al., 2020), while concurrently reproducing gendered norms and hierarchies (cote, 2020; rogstad, 2021). it is estimated that 35% of esports enthusiasts are women, but only 5% play professionally, where they earn 0.05% of wages paid to male players (cagnè-lebel, 2022; hilbert, 2019; newzoo, 2022); thereby contributing to a gaming ecosystem in which females continue to be minoritized and marginalized (gough, 2021b; darvin et al, 2020; hindman & walker, 2020). research on gender-based differences has been ongoing and revealed discrepancies in genre and game preference, as well as gameplay intentions and consumption (jang et al., 2021). moreover, the practical implications of such factors on how one identifies (e.g., gamer, gender, race) must be considered if research into the nuanced spaces of the gaming ecosystem is to positively influence the experiences and engagement of women and other marginalized gamers. thus, as esports continue to mature and permeate traditional sport spaces and organizations, scholarly efforts (e.g., education, research) are needed to aid practitioners in the successful navigation of the industry’s growth and development toward a more inclusive (e)sport space (cunningham et al., 2018; funk et al., 2018; heere, 2018). research efforts stemming from the field of sociology tend to focus on gender and identity creation and maintenance in gaming communities, as well as how said communities can challenge and deconstruct gendered discourse, stereotypes, attitudes, depictions, and treatment (bryce & rutter, 2005; condis, 2015; cote, 2020; reitman et al., 2020; ruberg et al., 2019; ruvalcaba et al., 2018; taylor, 2009). for instance, research has mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 1; january-febuary 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 8 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe examined performativity of gender and gender identity (zolides, 2015), hegemonic masculine barriers (rogstad, 2021), #gamergate and geek masculinity (braithwaite, 2016), tournament earning gaps (siutila & havaste, 2019), sexual and gender harassment coping strategies (cote, 2017), and a toxic culture that perpetuates gender biases and inequalities, as well as discrimination and hostility toward women (darvin et al., 2020; kim, 2017; madden et al, 2021). social and legal concerns over cyberbullying, a lack of diversity, and gender discrimination pose a substantial threat to the industry (foley & lardner, 2022) and need to be addressed in a practical and applicable manner. gender inequalities pervade many contexts in the gaming ecosystem and scholarly research can help to identify and locate areas of concern, as well as possible curative interventions (cote, 2020; ruberg et al., 2019). to this end, the purpose of this project is to better understand and identify when, where, and how gendered toxicity might influence the gaming experiences of women. 1. literature review despite being recognized as a male-dominated space, akin to many traditional sports, women have always engaged with games in the electronic, digital, and online ecosystem of esport (bryce & rutter, 2003; rogstad, 2021), having contributed to the advancement of esport as casual gamers, active streamers, tournament competitors, event attendees, and partaking in gambling activities (gainsbury et al., 2017). the notion that women are not interested in gaming and esports, representing a small minority of participants, is challenged when reviewing polls which have regularly reported that at least 41% (us participants) and 45% (eu participants) of video game players are female (entertainment software association, 2020; interactive software federation of europe, 2020). moreover, female gamers represent nearly a third of all players of vastly popular esport games such as call of duty (36%), fortnite (34%), and super smash bros (31%; statista, 2021). despite these levels of involvement, overall female participation is lacking, particularly as professional and semi-professional players. efforts have been made to garner more female interest and engagement; however, female-only tournaments and leagues are perceived as low-level contests that may serve to disenfranchise female gamers by restricting them to online play and with smaller earnings (siutila & havaste, 2019). such disparities have led researchers to argue that women exist in this space but are deterred from playing or treated as “invisible” by their male counterparts (bryce & rutter, 2005). even when visibility is achieved, female gamers are likely to be labeled as “oddballs,” “anomalies,” or “intruders” (hjorth et al., 2009). moreover, women participants are often trolled or challenged through gendered discourse to prove their masculinity and/or legitimacy as a gamer; and subsequently typecast as a “sexy sidekick”, “casual”, or “fake geek girl” (condis, 2015). it is also common for women gamers to be downgraded to supportive roles found in traditional sports such as cheerleaders, providing encouragement and financial support for their sons’ or partners’ teams, or ‘booth babes’ tasked with marketing gaming products to the male audience. female players must constantly prove themselves as there is a perception that flirting and/or delegating tasks to others is a use of sexuality, not skill; and it is the player’s sexuality that is considered their source of power (mejeur & cote, 2021). for example, ‘halo hoes’ has been used to denigrate the rare female competitor(s) in early esports tournaments, insinuating they play simply to distract other male competitors and draw their attention (taylor et al., 2009). similarly, ruberg et al. (2019) found terms such as “titty streamer” not only suggest women draw attention and viewers through their looks and embodied sexualization but devalue their efforts and place. these examples demonstrate the ever-present misogynistic and gendered discourse that maintains a toxic and masculine gaming culture that posits, both explicitly and implicitly, acceptable levels of femininity and is hostile to women gamers outside said prescriptions (ruberg et al., 2019; ruvalcaba et al., 2018). several works have examined women’s experiences participating in esport and concluded that the online communities and gaming industry are unwelcoming to women, and troubled with gender stereotypes, sexism, and harassment (condis, 2015; darvin, et al.,2020; nakandala, et al., 2017; ruotsalainen & friman, 2018; ruvalcaba, et al., 2018; schelfhout, et al., 2021; siutila & havaste, 2019). it is no surprise then, that gaming culture tends to be referenced mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 1; january-febuary 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 9 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe more by women as a barrier to participating rather than the type of game (yee, 2008). the (mis)perception that women’s skills are not equal or comparable to men illustrates dialogue found at competitive events that tend to be present with misogynistic, or at least, regressive beliefs about women (schelfhout et al., 2021; taylor, 2012). despite and because of this, advocates for an inclusive esport environment repeatedly present spaces for female engagement and opportunities to challenge societal gender roles and theories of masculinity and femininity (bryce & rutter, 2005). research by mejeur and cote (2021) explores gamer identity and discusses that it is not simply male, but also consists of different forms of masculinity that either supports or diverges from the “mythical norm”. esports integrate the idea of traditional athletic masculinity with geek masculinity, consequently “transforming and enforcing hegemonic masculinity in the context of geek gamer culture” (ruotsalainen, & friman, 2018, p. 3). this geek gamer culture typecasts white, masculine, and heterosexual males as “gamers”; and anyone who does not fit this profile is considered an outsider and likely to experience animosity and harassment (cote, 2020). for instance, even female gamers who experience success in this space are suggested to have earned their accomplishments due only to assistance from more skilled, male players (mejeur & cote, 2021). grindstaff and west (2011) suggest that men’s control in the facilitation and delivery of esport contributes to a hegemonic (geek) masculine culture, manifesting a toxic environment for women that normalizes them as representatives of their gender, rather than as gamers (ruotsalainen & friman, 2018). darvin et al. (2020) applied the theoretical tenets of hegemonic masculinity finding that because of “strong male cultural norms and ideologies, it may be difficult for male esports participants to conceptualize the experience of an underrepresented group, such as their female counterparts” (p. 43). based on the male-dominated structure of esport environments and the similarities associated with processes of hegemony for traditional sport, esports settings need to continue to examine participant experiences (cote, 2020; ruvalcaba et al., 2018). it is important to examine the gendered experiences and marginalization of gaming participants, inclusive of the extant toxicity experienced, the spaces in which they exist, when they occur, and at what level of play. thus, the purpose of our study is to better understand and identify when, where, and how gender influences the gaming experiences of women. more specifically, we seek to explore the potential relationships between amount of time, time of day, and day of week played, as well as game genre and level of play, and women gaming experiences. 2. methods 3.1 participants and procedure participants for this irb-approved project were students of an introduction to esport class; 18 of whom agreed to document their online gaming experiences over a four-week period for a class project. the age range of the students was 18-30 years old, and the gender breakdown was 15 male and 3 female students. with the intent of learning more about the treatment of women in online gaming, the male participants used female-identifying gamer tags, while the female students used their personal accounts or created a fictitious id. to determine the validity of the gendered gaming ids, a consensus check was run. accordingly, eight of the ids were unanimously perceived as female, one unanimously male, five achieved at least 85% agreement as female, and the remaining four ranged between 15-50% female. participants were instructed to select and play a title of their choice on their preferred gaming platform. the games selected by the participants included desert storm, fifa, fortnite, league of legends, madden, overwatch, rocket league, and super smash brothers. participants were asked simply to play the game and directed not to speak or engage (i.e., communicate) with anyone. prior to data collection, students were trained on how to best record and organize their notes. accordingly, during the four-week period, participants kept a record of how many games/matches and hours they played, their rank, the time(s) of day during which they participated, and if/when any form of interaction, comment, or behavior occurred. after each gaming session, participants saved their chatlogs and made notes of their experiences. at the conclusion of the four weeks, mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 1; january-febuary 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 10 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe all chatlogs, notes, and additional data were collected, transcribed, and uploaded into a microsoft excel spreadsheet. 3.2 analysis given the exploratory inclination of this project, the data collected from participants were analyzed through an inductive content analysis (elo & kyngäs, 2008). in the preparation phase, each of the 18 participants anonymized and submitted their personal chatlogs, observations, and documented experiences (e.g., comment, interaction, behavior, etc. from other gamers), each of which was unitized for analysis by the lead investigator (campbell et al., 2013). each unit of analysis was then collated and distributed to the students in the class, akin to a book of transcripts. over several class periods and reviews of the transcripts, the lead investigator and student participants codified units of data though descriptive coding (saldaña, 2013). categories were then created to effectively group codes that exemplify the full gamut of each participants’ experiences (elo & kyngäs, 2008). a negotiated coding approach was undertaken to help strengthen reliability of the project; during which the verification of the coding scheme and results of categorization, discrepancies and differences of opinion were discussed until consensus was reached (garrison et al., 2006; thomas, 2006). during this process, the investigators used three techniques described by patton (2002) to increase trustworthiness and credibility. first, the data were kept in an electronic database (microsoft excel), offering an audit trail for external reviews of the results at any given time. second, all student participants and the lead investigator coded the data, during which they came together to discuss the suitability of the established codes and categories via a negotiated coding process (garrison et al., 2006). this enhances credibility to the discoveries as the data have been examined by more than one individual and any confusion of context could be explained by the participant themselves. the final step in the analysis was to assign a numerical code to the observed experiences, in accordance with their relevant category, and to establish quantifiable demographics of the occurrences. 3. results after charting and documenting their online gaming experiences over a four-week period, the 18 participants tallied 410 hours of gameplay, documenting a total of 575 occurrences, interactions, and comments. these coded and categorized occurrences revealed twelve different types of experiences witnessed by the “female” gaming participants: toxic behavior, sexist behavior, positive sporting behavior, friend request, rude behavior, threatening behavior, banter, instructional, sexual harassment, flirting, playful, and none. none denotes that a participant did not experience any occurrence or interaction during their online engagement. toxic behavior was reported most often (44.7%), followed by sexist behavior (19.1%), and positive sporting behavior (10.3%). see table 1 for additional results and examples of occurrences that were experienced by the participants. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 1; january-febuary 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 11 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe table i. categories of participant experiences categories frequency percent examples toxic behavior 257 44.7% was told i weigh 265 pounds; immediately belittled by "gay guys who hate women"; messaged by member of another guild, harrasing me for killing their guildmate; also questioned by guild for bringing up an issue with a female, saying it was "girl drama", not a l; fucking trash needs to be banned from ranked; ff (forfeit); "maybe if you stop trying to demo all the time you could hit the ball"; need me to penetrate you girl?; you're cancer sexist behavior 110 19.1% "got you boo"; "rez me baby"; whats up girl can i get yo number; is your boyfriend palying?; "uh oh we have an egirl"; you suck bitch; bro you aint fooling anyone; 8=====d; how long is your hair; hello mami positive sporting behavior 59 10.3% nice 1; what a baller; youre a solid player; nice steal; can i give you a tip im not trying to be rude?; good sportsmanship; great pass; you a champ?; gg; get "fuuuuuuucked"; i can not do that impressive; wow your good friend request 51 8.9% yoooo add me; friend request rude behavior 48 8.3% treadmills help with the weight...js; try jogging; way; u look slikk fat tbh; what wrong big mama; what up fatty; lmao i couldn’t fit in your size with a fat suit on hahahaha; omg ur a femist; #saduglywomen; ugly threatening behavior 38 6.6% you gotta loosen up with that shotgun; kill yourself; the french will do one thing will you rape in the public square;i stand bigger than yoru abusive dad, just saying(:; fist fight me like a man; hand to hand combat is more fun banter 6 1.1% get balled; stop cutting me off; hahaha i suck; reeeeee? ?!@?@? instructional 2 0.3% stop camping fucker; when rotating make sure you check to back post first :) sexual harassment 2 0.3% how many stds you got? you should save your saliva for submission; might be in love; adorable and play video games; french kiss sur ton vagin; join the party big mama please#biggirlsneedlovetoo; hi sexy; flirting 1 0.2% teammate keeps passing to me, even when not the best option. playful 1 0.2% "will you marry me?"; total 575 100% mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 1; january-febuary 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 12 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe the genre of video games were considered in the analysis. participants playing massively multiplayer online role-playing games (mmorpg) were reported to experience the most occurrences (82.6%), followed by sport simulations (12.3%). each of the other gaming genres, multiplayer online battle arena (moba), first person shooter (fps), action adventure, and battle royale, accounted for less than 2% of the total number of occurrences. most occurrences were reported by elite players (76.8%) during the pm hours (83%) of fridays (23.7%) during the four-week evaluation period. see table 2 for additional details. table ii. who, where, and when of comment occurrences game genre frequency percent mmorpg (desert storm) 475 82.6% sport simulation (fifa, madden, rocket league) 71 12.3% action adventure (fortnite) 10 1.7% first person shooter (overwatch) 10 1.7% other (super smash brothers) 8 1.4% moba (league of legends) 1 0.2% 575 time of day am 72 12.5% pm 503 87.5% 575 level of play casual 89 15.5% competitive 9 1.5% elite 477 83% 575 day of the week monday 61 10.6% tuesday 53 9.2% wednesday 103 17.9% thursday 79 13.7% friday 136 23.7% saturday 84 14.6% sunday 59 10.2% 575 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 1; january-febuary 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 13 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe hours played <= 2 19 4.6% 3 – 4 104 25.4% 5 – 6 42 10.2% 7 – 8 17 4.2% 9 – 10 92 22.4% 11 – 12 5 1.2% 13 – 14 85 20.8% => 15 46 11.2% total 410 100 4. discussion and implications overall, our analysis revealed toxic and sexist rhetoric toward women gamers to be most prevalent in the online environment when playing mmorpgs during the latter half of the week into the weekend, as well as in the evening and nighttime hours. the findings provide further insight into the influence of gender, particularly for female gamers, at all levels of play; demonstrating that it is not just the elite levels of esport where gendered toxicity is experienced, but also among casual, and to a lesser extent competitive, gaming. perhaps current participants and gamer tags expressing femininity dissipate on the competitive scene as they do not fit the normative, masculine profile embraced in the online gaming environment and at mainstream esport events and tournaments. traditional sport segregates men and women on the claims of biological differences that result in males having more muscle, strength, aggression, and power; thereby situating females into supplemental roles, such as cheerleaders and swimsuit models, that we witness being replicated in the esport industry (taylor et al., 2009). the results from the current project do little to dissuade this argument when considering the toxic, sexist, rude, threatening behaviors, sexual harassment, and flirting experienced by our participants. yet, given that the esport industry is experiencing increases in female engagement and fandom (andrews & crawford, 2021), it would behoove esport industry leaders to alleviate and/or minimize the aggressive predispositions, antagonistic activities, images of violence, hypermasculine culture, and highly competitive ethos that denigrate females in many gaming and online environments. despite the presence of regulations and codes of conduct, gendered harassment endures (friman & ruotsalainen, 2022). a practical implication of our findings is that we provide a cursory overview to the times and days of the week during which the bulk of toxicity occurs, so that esport and online gaming administrators, as well as game designers, can focus their attention outside of gaming tournaments and events to quell negative discourse and behaviors toward women participants. similarly, our findings support that women gamers contend with a gendered social hierarchy at all levels of play (casual, competitive, and elite). our participants experienced more negative behaviors at the elite level of play, which could be the result of dedicating more time in the online environment to hone their skills and refine their craft. however, we offer that this finding could result from a vague demarcation between competitive and elite gamers. not much can be learned from this finding as currently (and independently) explained. however, much in the way that jang and byon’s (2020) reorganization of gaming genres created three new and meaningful esport market segments that allow for each’s unique consumers to be better served, so too could a delineation between the needs and motivations of distinct levels of play (e.g., amateur, novice, professional, elite). while we recognize mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 1; january-febuary 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 14 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe a ranking system exists at the elite levels of competition, we suggest future research consider the merit and distinguishable characteristics of play at varying levels of gaming proficiency. more importantly, that we found gender harassment existent at levels of play ranging from casual to elite might reveal how toxic meritocracy (paul, 2018) paradoxically manifests hegemonic masculinity while concurrently elucidating why women gamers might be willing or expected to endure such demeaning and belligerent discourse. we argue that women gamers have the lived experiences, insight, and credibility to best challenge the phenomenon, yet might find themselves in the precarious position of having to reinforce normative toxicity or adopt negative behaviors to gain the cultural and social capital for the opportunity to do so. almost a fifth (17%) of the toxic experiences were incurred by gamers playing below an elite level. though previous research demonstrates the difficulties in deconstructing the current esport ecosystem of toxicity, masculinity, and meritocracy (friman & ruotsalainen, 2022; paul, 2018; schelfhout, et al., 2021), our findings suggest there might be a substantial opportunity for new and lessexperienced players to help critically address, reconstruct, and develop a more inclusive gaming community (boudreau, 2022). our results point to the logical conclusion that gamers who play more are subject to more negative discourse and behavior. considering these results in context of the masculine normative gaming space, the existence of inappropriate comments and interactions can be explained by the very stereotypes themselves. stereotypes are beliefs about groups of people, that when inaccurate, can produce prejudicial and discriminatory attitudes and behaviors (siutila & havaste, 2019). thus, females seeking to develop an inclusive space for gamers can be further hindered by stereotype threat. that is, the performance and expectations of female esport participants can suffer from negative stereotypes that add pressure and inhibiting their ability to play better than their peers (ruvalcaba et al., 2018). likewise, ruotsalainen and friman (2018) found that gamers avoided being known or identified as a female gamer because of the added criticism they would receive related to their looks and abilities. efforts have been made to garner more female interest and engagement; however, female-only tournaments and leagues are perceived as low-level contests that may serve to disenfranchise female gamers by restricting them to online play and with smaller earnings (siutila & havaste, 2019). yet, even at the upper echelon of elite competition, women gamers have experienced toxic masculinity, bullying, and sexism from peers, teammates, and spectators (schelfhout et al., 2021). our findings suggest that the experiences within and influenced by different game types and genres should continue to be explored. the primacy of game study research focuses on hardcore over casual games and has done so to the detriment of advancing the field of game studies (chess & paul, 2019). while the genre categories utilized in our project hardly do justice to the diversity of available styles and genres of gameplay, our results suggest that further work must be done in the analysis of how various games and genres contribute to, reconstruct, and reinforce dominant logics and narratives in the current games studies field (coavoux et al., 2017). to our knowledge, the bulk of scholarly efforts and gameplay center on mmorpg, moba, and fps. through our work, we find that a good deal of toxicity may also occur in sport simulations, and suggest it be taken serious as a space in which gendered discourse and harassment are examined and monitored. curating and making available more demographic data on the makeup and experiences of participants in particular games, leagues, and events could illuminate all to the severity of the issue and lead to more education and resources to promote gender equality, as well as identify and alleviate gendered barriers. with this project, we contribute to this end by providing details of the toxic attitudes and behaviors experienced by “female” participants, as well as, in what games, level of play, and time of day such negative interactions occur. for instance, having a better sense of when and in which games negative gender tropes are most likely to occur, will allow games, leagues, and events to be more proactive with quelling such incidents through the increased presence of moderators during troubled timeframes and/or games. additionally, disclaimers, warnings, and resources could be made more readily available and prominent during these times. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 1; january-febuary 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 15 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 5. conclusion recent research in games studies has called for a more nuanced and wide-ranging understanding of the esport ecosystem and gaming community (boudreau, 2022; chess & paul, 2019). the results of our exploratory project validate such petitions by providing more insight into the current esport literature aimed at advancing a more inclusive online environment. more specifically, our work sheds light on when and where toxicity takes place in gaming and furthers knowledge on how it manifests. as a nascent field in the sport space, having a better sense of the types of harassment and degree to which and when they occur will help esport leaders and administrators better identify and influence policy to mitigate or prevent it from occurring. overall, the results can help establish additional measures to create safe and inclusive environments for women gamers and marginalized esport players. by understanding and identifying the types of negative behaviors, comments, experiences, and barriers women gamers face, esport leaders and participants can use their influence and assert themselves to seek inclusion, challenge current structures and environments, and push toward a less toxic and masculine space. 6. limitations as with any research, there are limitations that future research could address. the first is the gender identity of the participants, as well as their gaming tags. despite using several legitimate female gaming tags and running a consensus check, we cannot ensure that all usernames and tags were perceived as female. additionally, of the student participants in this work, only three (17%) identified as female. thus, the bulk of the self-reported incidents by participants may be influenced by the male perspectives and biases. future studies should be sure to include more voices of female gamers. given the accompanying social issues surrounding the pc/console divide (peterson, 2018), that participants were able to utilize their preferred gaming platform could also be seen as a limitation. though outside the scope of this project, some of our participants reported negative experiences outside the context of gameplay and in other spaces in which they consume esport. thus, we also recommend future research explore other esport platforms and mediums, such as discord, reddit, twitch.tv., twitter, and other social media outlets. having access to and data from these diverse sources will afford researchers to better triangulate the commonalities of negative behaviors women gamers experience and may provide additional details and examples of praise, criticism, and harassment (ruvalcaba et al., 2018). additionally, the current project utilized participants from a college esport class, and while they are a representative sample of esport participants, future studies should aim to use a diversity of esport participants and more female esport participants. the use of additional participants will provide more opportunities for statistical analyses between categories such as level of play, game genres, types of negative behaviors experienced, and the originating source (i.e., discord, during gameplay, etc.). references andrews, s. k., & crawford, c. m. (2021). barriers, issues and similarities among women in esports and similar mixed gender sports: ascertaining common ground. in s. andrews & c. crawford (eds.), pathways and opportunities into the business of esports (pp. 25–46). hershey, pa.: igi global. boudreau, k. (2022). beyond deviance: toxic gaming culture and the potential for positive change. critical studies in media communication, 1-10. https://doi.org/10.1080/15295036.2022.2080848 braithwaite, a. (2016). it’s about ethics in games journalism? gamergaters and geek masculinity. social media + society, 2(4), 1-10. https://doi.org/10.1177/2056305116672484 bryce, j., & rutter, j. (2003). the gendering of computer gaming: experience and space. in s. fleming & i. jones (eds.), leisure cultures: investigations in sport, media and technology (pp 3-22). bolton, england: leisure studies association. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 1; january-febuary 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 16 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe bryce, j., & rutter, j. (2005). killing like a girl: gendered gaming and girl gamers’ visibility. in j. raessens & j. goldstein (eds.), handbook of computer game studies (pp. 310-310). cambridge, ma: mit press. cagnè-lebel, b. (2022, january 14). the “femme effect”implementing coed teams & tournaments in the esports industry. femme gaming. https://femmegaming.gg/the-femme-effect-implementing-coed-teamstournamentsin-the-esports-industry/ campbell, j. l., quincy, c., osserman, j., & pedersen, o. k. (2013). coding in-depth semistructured interviews: problems of unitization and intercoder reliability and agreement. sociological methods and research, 42(3), 294320. https://doi.org/10.1177/0049124113500475 chan, g. huo, y., kelly, s., leung, j., tisdale, c., & gullo, m. (2022). the impact of esports and online video gaming on lifestyle behaviours in youth: a systematic review. computers in human behavior, 126(106974), 1-16. https://doi.org/10.1016/j.chb.2021.106974 chess, s., & paul, c. a. (2019). the end of casual: long live casual. games and culture, 14(2), 107-118. https://doi.org/10.1177/1555412018786652 coavoux, s., boutet, m., & zabban, v. (2017). what we know about games. a scientometric approach to games studies in the 2000s. games and culture, 12(6), 563-584. https://doi.org/10.1177/1555412016676661 condis, m. a. (2015). the politics of gamers: identity and masculinity in the age of digital media (publication no. 3737628) [doctoral dissertation, university of illinois at urbana-champaign]. proquest dissertations and theses global. cote, a. c. (2017). “i can defend myself”: women’s strategies for coping with harassment while gaming online. games and culture, 12 (2), 136-155. https://doi.org/10.1177/1555412015587603 cote, a. c. (2020). casual resistance: a longitudinal case study of video gaming’s gendered construction and related audience perceptions. journal of communication, 70, 819-841. cranmer, e. e., han, d. d., gisbergen, m., & jung, t. (2021). esports matrix: structuring the esports research agenda. computers in human behavior, 117(106671), 1-13. https://doi.org/10.1016/j.chb.2020.106671 cunningham, g. b., fairley, s., ferkins, l., kerwin, s., lock, d., shaw, s., & wicker, p. (2018). esport: construct specifications and implications for sport management. sport management review, 21(1), 1-6. https://doi.org/10.1016/j.smr.2017.11.002 darvin, l., vooris, r., & mahoney, t. (2020). the playing experiences of esport participants: an analysis of treatment discrimination and hostility in esport environments. journal of athlete development and experience, 2(1), article 3. https://doi.org/10.25035/jade.02.01.03. elo, s., & kyngäs, h. (2008). the qualitative content analysis process. journal of advanced nursing 62(1), 107– 115. https://doi.org/10.1111/j.1365-2648.2007.04569.x mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 1; january-febuary 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 17 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe entertainment software association. (2020). 2020 essential facts about the computer and video game industry. https://www.theesa.com/wp-content/uploads/2020/07/final-edited-2020-esa_essential_facts.pdf. foley & lardner llp. (2022). esports survey report: fourth annual esports survey. https://www.foley.com/en/insights/publications/2022/01/fourth-annualesports-survey-report friman, u., & ruotsalainen, m. (2022). gender and toxic meritocracy in competitive overwatch: case “ellie”. in ruotsalainen, m., törhönen, m., & karhulahti, v. (eds.), modes of esports engagement in overwatch (pp. 135-154). palgrave macmillan. https://doi.org/10.1007/978-3-030-82767-0 funk, d. c., pizzo, a. d., & baker, b. j. (2018). esport management: embracing esport education and research opportunities. sport management review, 21(1), 7–13. doi:10.1016/ j.smr.2017.07.008. gainsbury, s., abarbanel, b., & blaszczynski, a. (2017). game on: comparison of demographic profiles, consumption behaviors, and gambling site selection criteria of esports and sports bettors. gaming law review, 21(8). doi:10.1089/ glr2.2017.21813. garrison, d. r., clevelan-innes, m., koole, m., & kappelman, j. (2006). revisiting methodological issues in transcript analysis: negotiated coding and reliability. the internet and higher education, 9(1), 1-8. https://doi.org/10.1016/j.iheduc.2005.11.001 gough, c. (2021a, october 21). esports market – statistics and facts. statista. https://www.statista.com/topics/3121/esports-market/#dossierkeyfigures gough, c. (2021b, september 28). share of female esports fans worldwide in 2019, by country. statista. https://www.statista.com/statistics/1109959/global-female-esports-audience/ grindstaff, l., & west, e. (2011). hegemonic masculinity on the sidelines of sport. sociology compass, 5, 859881. heere, b. (2018). embracing the sportification of society: defining e-sports through a polymorphic view on sport. sport management review, 21(1), 21-24. https://doi.org/10.1016/j.smr.2017.07.002 hilbert, j. (2019, 9 april). gaming & gender: how inclusive are esports? the sports integrity initiative. https://www.sportsintegrityinitiative.com/gaming-gender-how-inclusive-are-esports/ hindman, l. c., & walker, n. a. (2020). sexism in professional sports: how women managers experience and survive sport organizational culture. journal of sport management, 34, 64-76. https://doi.org/10.1123/jsm.2018-0331 hjorth, l., na, b., & huhh, j. (2009). games of gender: a case study on females who play games in seoul, south korea. in l. hjorth & d. chan (eds.), gaming cultures and place in asia-pacific (pp. 273–288). new york: routledge. interactive software federation of europe. (2020). isfe key facts 2020. https://www.isfe.eu/isfe-key-facts/. mailto:topacademicjournals@gmail.com https://www.theesa.com/wp-content/uploads/2020/07/final-edited-2020-esa_essential_facts.pdf https://doi.org/10.1016/j.smr.2017.07.002 https://doi.org/10.1016/j.smr.2017.07.002 https://www.isfe.eu/isfe-key-facts/ american journal of medical and physical education vol.7, issue 1; january-febuary 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 18 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe jang, w., & byon, k. k. (2020). antecedents of esports gameplay intention: genre as a moderator. computers in human behavior, 109(106336), 1-12. https://doi.org/10.1016/j.chb.2020.106336 jang, w., byon, k. k., williams, a., & pedersen, p. m. (2021). augmenting the formation of esports gameplay intention: interaction effects of genre and gender. sport, business and management: an international journal, 11(5), 620-646. https://doi.org/10.1108/sbm-04-2021-0049 jenny, s. e., manning, r. d., keiper, m. c., & olrich, t. w. (2017). virtual (ly) athletes: where esports fit within the definition of “sport”. quest, 69(1), 1-18. https://doi.org/10.1080/00336297.2016.1144517 kim, s. j. (2017). gender inequality in esports participation: examining league of legends (master’s thesis). university of texas, austin. retrieved from https://repositories.lib. utexas.edu/bitstream/handle/2152/62914/kim-thesis2017.pdf?sequence¼1. madden, d., liu, y., yu, h., sonbudak, m. f., troiano, g. m., & harteveld, c. (2021). “why are you playing games? you are a girl!”: exploring gender biases in esports [proceedings]. 2021 chi conference on human factors in computing systems, yokohama, japan. https://doi.org/10.1145/3411764.3445248 mejeur, c., & cote, a. (2021). who gets to be in the guild? race, gender and intersecting stereotypes in gaming cultures. loading, 14(24), 70–89. https://doi.org/10.7202/1084839ar nakandala, s., ciampaglia, g., su, n., & ahn, y. y. (2017, may). gendered conversation in a social gamestreaming platform. in proceedings of the international aaai conference on web and social media, 11(1), 162-171. newzoo (2022). global esports and live streaming market report. https://newzoo.com/products/reports/globalesportslive-streaming-market-report patton, m. q. (2002). qualitative research and evaluation methods (3rd ed.). sage publications. paul, c. a. (2018). the toxic meritocracy of video games: why gaming culture is the worst. university of minnesota press. peterson, l. (2018). why aren’t more black kids going pro in esports?. the undefeated. retrieved from https://theundefeated.com/features/why-arent-more-black-kids-going-proin-esports/. reitman, j. g., anderson-coto, m. j., wu, m., lee, j. s., & steinkuehler, c. (2020). esports research: a literature review. games and culture, 15(1), 32-50. https://doi.org/10.1177/1555412019840892 rogstad, e. t. (2021). gender in esports research: a literature review. european journal for sport and society, 1-19. https://doi.org/10.1080/16138171.2021.1930941 mailto:topacademicjournals@gmail.com https://doi.org/10.7202/1084839ar https://doi.org/10.7202/1084839ar https://doi.org/10.1080/16138171.2021.1930941 https://doi.org/10.1080/16138171.2021.1930941 american journal of medical and physical education vol.7, issue 1; january-febuary 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 19 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe ruberg, b., cullen, a., & brewster, k. (2019). nothing but a “titty streamer”: legitimacy, labor, and the debate over women’s breasts in video game live streaming. studies in media communication, 35 (6), 466-481. doi: 10.1080/15295036.2019.1658886. ruotsalainen, m., & friman, u. (2018). “there are no women and they all play mercy”: understanding and explaining (the lack of) women’s presence in esports and competitive gaming. proceedings of nordic digra. ruvalcaba, o., shulze, j., kim, a., berzenski, s. r., & otten, m. p. (2018). women’s experiences in esports: gendered differences in peer and spectator feedback during competitive video game play. journal of sport and social issues, 42, 295-311. saldaña, j. (2013). the coding manual for qualitative researchers (2nd ed.). sage publications. schelfhout, s., bowers, m., & hao, a. (2021). balancing gender identity and gamer identity: gender issues faced by wang ‘baize’ xinyu at the 2017 hearthstone summer championship. games and culture, 16, 22-41. doi: 10.1177/1555412019866348. scholz, t. (2019). esports is business: management in the world of competitive gaming. basel, switzerland: springer international publishing. siutila, m., & havaste, e. (2019). a pure meritocracy blind to identity: exploring the online responses to allfemale esports teams in reddit. transactions of the digital games research association, 4(3), 43-74. statista (2021). statista dossier on the esports market worldwide and in the u.s. https://www.statista.com/study/34163/esports-market-worldwide-statista-dossier/ taylor, n. (2009). power play: digital gaming goes pro (doctoral thesis). york university. retrieved from http://www.collectionscanada.gc.ca/obj/thesescanada/vol2/002/nr64963. pdf. taylor, n., jenson, j., & de castell, s. (2009). cheerleaders/booth babes/halo hoes: programming, gender and jobs for the boys. digital creativity, 20, 239–252. doi:10.1080/ 14626260903290323. taylor, t. l. (2012). raising the stakes: e-sports and the professionalization of computer gaming. cambridge, ma: mit press. thomas, d. r. (2006). a general inductive approach for analyzing qualitative evaluation data. american journal of evaluation, 27(2), 237–246. https://doi.org/10.1177/1098214005283748 yee, n. (2008). maps of digital desires: exploring the topography of gender and play in online games. in y. b. kafai, c. heeter, j. denner, & j. y. sun (eds.), beyond barbie and mortal kombat: new perspectives on gender and gaming (83–96). cambridge, ma: mit press. zolides, a. (2015). lipstick bullets: labour and gender in professional gamer self-branding. persona studies, 1, 42–53. doi:10.21153/ps2015vol1no2art467. mailto:topacademicjournals@gmail.com https://doi.org/10.1177/1098214005283748 https://doi.org/10.1177/1098214005283748 american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 18 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmp the role of extracurricular sport and physical activity in the leisure lifestyles of young people in welsh secondary schools sarah jane williams cardiff school of sport, cardiff metropolitan university, cyncoed campus, cardiff, uk. cf23 6xd abstract: youth cultures and lifestyles are reflected in the transition from childhood to adulthood. they are part of an ‘idioculture’ that represents beliefs, values, symbols and activities that young people share by engaging in cultural practices such as music, dance, fashion and ‘hanging about’. in contemporary western societies, young people’s lifestyles and behaviours are often centred around the opportunity to assert independence, relationships, instability of interests, playing computer games, watching tv and the opportunity to be physically active. sport and physical activity are amongst the popular sites of expression for young people in their leisure time, and are perceived as important for establishing social and moral skills for young people and promoting personal and social responsibility. keywords: youth cultures, lifestyles, idioculture, leisure time, sport, physical activity, social responsibility introduction youth cultures and lifestyles are reflected in the transition from childhood to adulthood. they are part of an ‘idioculture’ (wilson & white, 2001) that represents beliefs, values, symbols and activities that young people share by engaging in cultural practices such as music, dance, fashion and ‘hanging about’ (frith, 1984). in contemporary western societies young people’s lifestyles and behaviours are often centred around the opportunity to assert independence, relationships, instability of interests, playing computer games, watching tv and the opportunity to be physically active (green, 2002). in this sense leisure time provides young people with an opportunity for independence, responsibility and autonomy from parental influence (roberts, 1996).sport and physical activity are amongst the popular sites of expression for young people in their leisure time. they are perceived as important for establishing social and moral skills for young people and promoting personal and social responsibility (bailey, 2005). as with other aspects of their lives, young people’s participation in sport and physical activity is complex (parker & don, 2013). hitherto there have been relatively few large scale qualitative studies using young people-centred methods to develop a nuanced understanding of their leisure lifestyles and participation in extracurricular sport and physical activity. the purpose of this paperis therefore to present the findings from a large-scale empirical programme of research based in secondary schools in wales. its aim was to explore young people’s participation and nonparticipation in extracurricular sport and physical activity, and their relationship to leisure lifestyles. importantly, the research placed young people at the heart of analysis (macphail&kinchin, 2004).the focus of the research was a pan-wales initiative that targeted extracurricular sport and physical activity in all secondary schools known as the ‘5x60’ initiative its aim was to raise physical activity levels to meet the welsh government’s target of young people engaging in sport and physical activity for one hour (60 minutes), five times a week. introduced as a pilot in 2004, (bolton et al 2007), its main objective was to locate a sports development officer (sdo) to stimulate and provide additional extracurricular sport and physical activity opportunities, especially mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 19 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmp targeting those currently not involved in school sport, school team sport and / or physical education (sports council for wales, 2006). following this introduction, the paper has four substantive sections. the background and context presents a multidisciplinary overview of themes linked to the sociology of leisure, informed in particular by the work of ken roberts (1996, 1997, 2004), as well as paediatric exercise psychology and ken fox’s (1988) conceptual underpinning on engagement in physical activity. the procedures used for data capture are briefly presented before a consideration of the key findings. the results are synthesised around presenting and understanding of the young people’s leisure lifestyles, and their characteristics which display considerable heterogeneity. there are also important findings for the programme delivery, namely, the image of the programme, the range of activities and role of the sdo. finally, an explanatory framework based on these finding is presented together with a discussion that considers some implications for policy makers involved in youth programmes. 2. background and context “young people” can be distinguished as a maturational group between childhood and adulthood; and ‘youth describes aspects of people’s social position which are an effect of their biological age but not completely determined by it” (frith, 1984, 2). quite often then the transition from childhood to adulthood is viewed as the development of the immature child to the independent employable adult. however, to mark clear differentiation between ‘youngpeople’, ‘children’ and ‘adults’ can be difficult for two main reasons. first, the reference to ‘the immature child and the independent employable adult’ fails to identify the sociocultural constraints of youth as a distinct stage in the life-course (bynner, 2001). second, frith (1984, 2) argues that “if the end of youth is marked by our taking on an adult role – marriage and children, work and a career, our own household – then people stop being young at a great variety of ages”. since the mid-1990s sociological research has referred to the ‘new condition of youth’ (roberts, 1996). there has been a tendency towards prolonging life-stages as the typical ages at which individuals cross adult thresholds (such as marriage) have risen, and major life events have ceased to be as closely linked to specific ages as in the past. young people’s futures have become more uncertain and their biographies more individualised – partly due to the sheer pace of economic and social change, the variety of courses in postcompulsory education, training schemes, temporary and part-time jobs, and periods of unemployment (arnett, 2006). an important aspect of this individualization is the young person’s ability to choose what to do and when to do it (roberts, 1996). young people are often preoccupied with identity problems of ‘who am i?’ and in an attempt to find individual lifestyle preferences they experiment with different leisure activities and social roles (zeijl, du bois raymond &dtepoel, 2001). often, adolescents’ focal concerns, such as, relationships with sexual partners, peers and parents produce identity conflicts (hendry &kloep, 2010). roberts (1997) has also argued that leisure is less equipped to support identity formation but is more likely to act as fun. the identities young people create for themselves disintegrate almost as quickly as they were constructed; that is to say, ‘leisure pursuits affect how young (and older) people feel about themselves and add fine detail to their social identities but do not tell them or others who they basically are’ (roberts, 1997, p.14). yet it is also true that some young people do create their leisure identity and idioculture based upon their shared beliefs and experiences of sport and physical activity (wilson & white, 2001). almost twenty years ago roberts (1996) noted the shift away from spending leisure time in organised and supervised settings toward spending time with groups of friends in unsupervised situations (roberts, 1996).a corollary of that trend is a decline in participation in organised youth clubs and diminished commitment to sports clubs. indeed, general trends of participation show an increased diversification of physically active leisure opportunities and a move away from traditional team games towards more informal, recreational, lifestyles and mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 20 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmp adult-like activities such as, aerobics, swimming and weight training (smith, green,& thurston, 2009). there are a number of key influences on young people’s socialisation into, and participation in sport and physical activity. they include gender (e.g.,biddle, coalter, o’donovan, macbeth, nevill & whitehead2005), previous experience (e.g., kjønnisken, anderssen & wold,2009), social processes (e.g., sandford, armour, & warmington, 2006), friends (e.g., green, 2002), family (e.g., kirk, carlson, o’connor, burke, davis & glover,1997) and social class (e.g., green, smith, roberts, 2005). together theyhighlight some of the complexity of young people’s sport and physical activity participation but also help explain aspects of young people’s lives more generally. alongside these there are, as wouters (2007) explains, on-going processes of informalisation, democratisation and sociability, which are concerned directly with relationships between adults and children. to elaborate, the general pattern is for changes to, and relaxation of the rigid codes of behaviour and in the dominant mode of social conduct for young people. there is a marked increase in sensitivity and flexibility for young people, and a lessening of inequality linked tochanges in the power relations between the parent and the child (wouters, 2007). set against this backdrop of social change in the lives of young people, policy makers have attempted to understand (and hence promote) young people’s participation in sport and physical activity (smith et al., 2009). recent evidence has demonstrated that quality of adult-youth relationships is important in contributing towards positive outcomes from initiatives and programmes targeted at young people (armour, sandford&duncombe, 2013; sandford, duncombe& armour, 2008).moreover, social processes have been identified as the key to behaviour change rather than specific activities in which young people are engaged (bailey, 2005), and are likely therefore to play a crucial role in explaining young people’s participation in sport and physical activity. in the late 1980s landmark conceptual work made explicit the importance of a childcentred approach and emphasized the need for a psychological perspective that considered the child’s perception of their sport and physical activity experience (fox, 1988). a ‘broad brush’ typology was advanced that highlighted psychological dispositions towards sport and physical activity amongst young people. the categories were: approachers – individuals who perceive sport and physical activity as uplifting, see some kind of reward in sport and / or exercise, and independently seek out physical experiences (fox, 1988). neutrals – ‘those who have no strong feelings or convictions about sport and / or physical activity, and activity patterns’ (fox, 1988, p.35). this group’s sport and physical activity participation is likely to be sporadic and responsive to the social setting. given the right circumstances (for instance, being invited by friends to an activity), they might be persuaded to participate. avoiders – individuals who perceive sport and physical activity negatively and stressful. they tend to perceive themselves as uncoordinated and incompetent and are unlikely to choose to participate (without substantial persuasion). this group is the least likely to receive the benefits of physical activity, but is in most need of them (fox, 1988). this conceptual point of departure has also been deployed in policy development, for example in sports england’s (n.d.) categorisation of ‘always’, ‘sometimes’ and ‘never’ participants. it also acts as a platform for the present study. specifically, the ‘avoiders’ and ‘neutrals were those young people who were more difficult to engage in sport, physical activity and physical education, and were of primary concern to this research. since it was thought that participation in sport and physical activity for these groups of young people was likely to be sporadic or non-existent, it was necessary to gain an understanding of their leisure lifestyles in general, and not just their leisure-sport preferences (green, 2002). 3. a note on method following ethical approval from the university, an accumulated twelve month period of case study research was undertaken in two sequential phases. the first phase was an exploratory study where 18 weeks was spent in six mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 21 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmp secondary schools selected from across wales to take account of different socio-economic areas, geography and language (incorporating welsh and english speaking schools).the purpose of the first phase was to explore young people’s experiences of, and attitudes towards participation in extracurricular sport and physical activity.young people were self-defined by gender and also whether they declared themselves as a participant of ‘5x60’ or a nonparticipant of ‘5x60.’focus groups (n=71)were undertaken that included 413 pupils drawn from 18 separate classes in years 7, 8 and 9 (11-14 years old).the research was supplemented by 24 stakeholder interviews (officers, teachers, heads and local authority officials) and observations. in the second phase two schools from the original six were selected for more intensive ethnographic fieldwork that built on initial findings from phase one from years 7-10 (11-15 year olds).a further eight weeks were spent at both valley high and rhyd y fro in order to develop existing relationships with the young people to provide better of understanding of their ‘world’ (christensen & james, 2000), and how sport and physical activity is reflected in their leisure lifestyles. seven information-rich case studies were developed with individuals who were less likely to participate and thus ‘hard to reach’. the principal investigator (pi) was a qualified physical education secondary teacher fluent in english and welsh. adopting the role of teacher-researcher (peeke, 1984) during supply cover lessons. during these sessions the pi developed some classroom-based activities (see bryant et al., 2015) as a means of exploring issues and developing a rapport with the young people themselves. from a total of 488 young people in both schools, 436 were involved in the data capture, and a total of 33 focus groups were conducted which involved 152 pupils. all classroom activities were subject to content analysis and all focus groups and semi-structured interviews were transcribed and thematically analysed. pseudonyms have been used throughout and interviews conducted through the medium of welsh have been translated and are italicized. 4. findings the most striking feature of the research was the heterogeneity of the young people which showed the overall picture to be complex and sensitive to important external influences including gender, socio-economic background, school context, peers and family (eime, 2013). the opportunity to spend a prolonged period of time with the young people resulted in a four-fold typology of leisure lifestyles being established into which most young people, most of the time, could be clearly located. the typological categorization provided a deeper and more nuanced appreciation of how extracurricular sport and physical activity formed part of young people’s leisure lifestyles. based on phase two’s research findings, the defined categories were ‘sporty’ (n=106), ‘arty’ (n=34), ‘sporty and arty’ (n=15) and ‘leisure’ (n=241). evidence from the focus groups and leisure lifestyle activities confirmed that those in the ‘sporty’ category were highly motivated, competitive and active participants of the community club and school teams including young people like james, “i love all types of sports and physical activity, i am very busy with rugby, football and cricket in school teams and outside clubs. i also enjoy activities like surfing, swimming and golf.’”typically, this group were all classified as fox’s (1988) approaches to sport and therefore most forms of physical activity and / or competition acted as a participation trigger for this group. in this sense the young people could be compared to sport england’s (nd) ‘always participants’ of sport and physical activity. the ‘arty’ category included young people like siwan who perceived their participation in activities like music and drama to be most important:“i do the sketch-show, choir and folk dancing in school and in the evening i go to a ‘performing school’ and we do a bit of everything like drama and singing”. a relatively small but important group comprised young people who were both ‘arty’ and ‘sporty’ – like dai, “i am a member of the local swimming and running club …i also perform with stage show and what i love is meeting new people, famous mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 22 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmp people and performing on the stage.”broadly, this group included young people who were neutrals and avoiders as well as some approachers (fox, 1988). the largest and most interesting single group was the ‘leisure’ category which included some approachers but also many neutrals and avoiders of sport and physical activity. the leisure category was extremely heterogenous, with a range of young people and activities characterised by physicality and sociability which took place at the home, youth club/centre, or on the streets reflecting trends and fashions in young people’s leisure lifestyles (green, 2002).popular activities included facebook, going out with friends, (non-competitive) swimming and shopping. although all young people were typically involved in these types of activities, for those in this category the activities were their main and sometimes only form of leisure engagement. the findings from the classroom activities and focus groups revealed some interesting dimensions in relation to the ‘5x60’ initiative. in contrast to other related research that examined this impact (bolton et al., 2008) the data showed more girls participating than boys in three out of the four categories. only in the ‘sporty’ category showed more boys than girls were involved in the ‘5x60’ programme. put simply ‘5x60’ provided new opportunities for sporty boys who were interested in mountain biking, basketball, 5 a-side football and water polo while sporty girls appeared to enjoy touch rugby / tag rugby, not typically available during traditional pe lessons. as the largest and most diverse group, the ‘leisure’ category also included considerably more females than males. for this category the look of ‘5x60’ was particularly important as was the role of the ‘5x60’ sdo in establishing a distinct approach that aimed to be different to the school’s norms and set the programme apart. for rhys, a ‘5x60’ sdo, the fact that the pe staff did not know the names of the pupils taking part indicated that ‘…you know you have targeted the right people.’ the need to be a friend not a teacher was pivotal to its success and highlighted the role of in formalisation and democratisation in establishing a successful relationship (smith et al., 2009). the ‘5x60’ dancers and members of the aikido and fencing clubs included young people from the leisure category that did no other physical activity. by listening to their stories it was clear that some avoiders were resistant to changes in their daily patterns either voluntarily or involuntarily. but others were receptive if the ‘offer’ appeared attractive and it suited them. for these neutrals the ‘5x60’ intervention was particularly important and had the potential to demonstrate how young people may be prepared to shift their patterns of behaviour and incorporate sport and physical activity into their leisure lifestyles. groups of image conscious girls were particularly attracted to dance related activities and some more street boys were drawn to basketball, break dancing and surfing. inter-form and inter-house dodgeball and basketball tournaments were also popular. more important than the activities themselves, however, was the need to create the right kind of environment for the young people. in this regard the role of the ‘5x60’ sdo was pivotal for getting to know the young people and developing an attractive programme that would be appealing to nontraditional, non-sporty types. a synopsis of seven individual examples of young people resistant to physical activity but were enticed by the ‘5x60’ offer is presented in table 1 (also see leyshon et al., 2012). table 1: synopsis of individual examples case study summary of case study evidence mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 23 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmp tommy, 16 year old male an overweight pupil who was disengaged in school life and never brought his pe kit to lessons. tommy was a well known character in the school staff room, he’d been on the verge of being suspended for his unruly and inappropriate classroom behaviour.as a result of his active involvement in ‘5x60’ mountain biking, aikido and fencing club he demonstrated more confidence and a change in attitude towards sport and physical activity. his increased confidence was reflected in his motivation for pe and school multi-gym participation. moreover his participation also resulted in his family’s socialisation into sport and physical activity. ‘5x60’ dance leaders, female 1416 years old disengaged pupils in school who had made the link from their curriculum dance leaders course to become leaders of dance clubs such as the primary school dance club. the dance leaders’ course offered at the school was a vehicle for female pupils (14-16 year olds) who had become disengaged from pe to become involved again in physical activity. georgina and jo – were difficult characters in detention quite a lot as a result of going through the dance leaders role they became more pleasant young adults. they also developed respect and empathy with teachers when leading.claire – disliked school but dance leaders was used as an avenue to engage her with school. billy & sammy 14 year old male young both billy and sammy were in the foundation (bottom) set in school, they found it difficult to concentrate and disliked any school work that involved writing. sammy was dyslexic and had a previous history of being disruptive. the most important aspect of school life was their pe lessons and their leaders & ‘5x60’ participants involvement with ‘5x60’.importantly, the boys were responsible for lending sport equipment to pupils (in the zone 2) and active members of ‘5x60’ clubs. both boys enjoyed a chat and social contact with the ‘5x60’ officer, and for billy this was probably his main reason for participation. the boys proudly wore their ‘5x60’ hooded t-shirts and reported an improvement in their selfesteem as a result of their role. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 24 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmp the male ‘fencers’ steffan 13 yrs old lloyd & ben – 15 year olds thirteen year-old steffan was an active member of ‘5x60’ fencing, aikido, football and gymnastics. steffan was also the recipient of the ‘mr.5x60 award’ for attending the most number of ‘5x60’ clubs. he also tried his best at the traditional school sport teams but never quite made it into the teams. however, as a result of his fencing experience he joined the community fencing club and then successfully went on to represent wales.fifteen year-olds lloyd & ben were active members of ‘5x60’fencing and successfully made the link to the community fencing club. making this link required a big commitment from the boys and their parents who lived a forty minute drive away from the club.both did no other form of physical activity. ben liked rugby but didn’t think he was good enough so started the ‘5x60’ fencing club to impress his pe teacher. lloyd was dyspraxic, had no interest in sport but joined the fencing club as he was interested in the historical link with fencing. ‘5x60’ female touch rugby club, 11-18 year olds a successful ‘5x60’ female club with a range of sporty and non-sporty members. the club took place after school on a friday and had up to 45 members. an emphasis on fun in a competitive environment, including, opportunity to participate in the regional touch rugby tournament and a national tournament contributed towards the success of the club. the sixth form male leaders played an important role in the success of the club, they were very popular and were able to relate the young people. the females perceived the sixth formers as role models and friends around school. female ‘5x60’ street dancers, 12-13 years old non-sporty pupils who were active members of the ‘5x60’ street dance but did no other form of sport and physical activity. the dance coach, was a female in her early twenties and was very popular with the girls. the group relished the opportunity to perform in dance festivals and concerts. such opportunities were very positive experiences for the girls and have them an opportunity to build or regain their confidence. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 25 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmp bethany 12 year old female a pupil with ‘asperger’s’ syndrome referred to as a developmental disorder, usually of childhood characteristics, by impairment of social interactions and repetitive behaviour patterns (reference). moving from primary to secondary school was a big ordeal for bethany. she was inactive at home, had a negative previous (primary) experience of sport and physical activity, was unable to do after school activity clubs as she had to get a taxi home. as a result of her involvement with the interform lunch time basketball tournament at the start of the year she gained confidence to join the ‘5x60’ touch rugby club and represented the school in the la tag rugby tournament. these seven examples provided in table 1 acknowledge the role that the ‘5x60’ sdo had in motivating them to participate. the sdo was often central in terms of talking to, negotiating with and getting to know the young people, which in turn helped develop an understanding of the pupils and their context (smith et al., 2009). the importance of the social aspect and process of building purposeful adult-youth relationships has been noted by sandfordet al., (2008), and this appeared to apply especially to the neutrals and avoiders some of whom were considered ‘hard-to-reach.’ this point was illustrated in tommy’s case study when one teacher commented, “rhys, the ‘5x60’ sdo, has been great with tommy, he has given him the time and attention that he has been looking for”. similarly, the dance leaders course proved to be a vehicle and trigger for disengaged females who previously did not participate in pe lessons to return to physical activity. amy, referred to enjoying dance leaders and like most others on the course was attracted to it because it fitted well with her lifestyle priorities such as fashion, make-up, msn, facebook and boys. indeed, many females participating inthe dance leaders thought that this activity preferable to other possibilities. amy explained: we enjoy pe more because of dance leaders we really want to do it. last year i didn’t even take part and would have a note because we did hockey and swimming. now it is really good as you get to listen to your own music and fetch your ipod in, and make your own dance that suits you best. we are also excited to teach dance in the primary school. in addition to participating in physical activity and gaining a leadership qualification, there were many other benefits and incentives provided by the dance leaders course. as a disengaged pupil, the dance leaders course was used by valley high as an incentive for claire: before i didn’t like school so i stopped coming. the welfare officer and my father came into school for a meeting and they agreed that if i would came to school for two days a week for the dance leaders course, english, maths and science. i feel better for doing dance leaders and coming to school just two days a week. significantly for the sustainability of the ‘5x60’ initiative, claire successfully gained her qualification and then, with her friends, went on to deliver dance at the ‘5x60’ club and primary school. georgina felt that she had blossomed as a result of her participation in the course: i’m much more confident now … before i didn’t use to have any respect for the teacher but doing dance leaders helped me develop respect for people. when leading you see things from a teacher’s point of view.i used to be a mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 26 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmp bit naughty, but now before i start ignoring teachers i think what i felt like teaching in front of the class and i didn’t like it. these examples illustrate some of the benefits of this particular ‘5x60’ activity, namely, improved behaviour and attendance (sandfordet al., 2008), improved self-confidence and esteem, the development ofbelonging and acceptance (donnelly &coakley, 2002), and an increased respect towards others. other ‘5x60’ activities revealed a wide range of benefits to the participants. for some, there was the opportunity to assert independence, the informal drop-in nature of clubs, the latest fashions, opportunity for choice and hanging out with friends (smith et al., 2009), which all appealed to some from the leisure category. the young people relished the element of choice and ownership provided by the exciting and different activities like street dance, fencing, gorge walking, surfing, roller hockey dodgeball, cheerleading and climbing, describing these activities positively using words such as ‘awesome’, ‘wicked’ and ‘safe’ – meaning that they were enjoyable and exciting. tommy explained: ‘gorge walking’ i didn’t know what it was first ... oh my gosh, it was amazing you walk up and over stones, up rivers and jump off waterfalls. some people were screaming i didn’t … but doing it definitely gave me an adrenaline rush and more confidence in myself and with water. he went on to elaborate on an additional benefit that arose from his participation in ‘5x60’ – his family’s engagement in sport and physical activity and the importance of that shared experience: so now (after going to ‘5x60’ club) i’ve had daddy to do it (cycling) as well ... before i didn’t socialise with daddy, but now we socialise more together on the bikes. at home the attitude towards sports has changed a lot…we go out a lot more, we have been out cycling, and we cycle down the pub on a bike.activity triggers were closely linked to lifestyles; similarly to the dance leaders, the street dance ‘5x60’ activity fitted well with the young females lifestyles. the young people’s participation in some clubs was also influenced by the media – tv programmes, magazines and dvds. ben, a 13 year-old fencer, was clear: “i went fencing because i watched it during the olympics and thought it was cool and i liked the idea of swords”. for some young people activity triggers were linked to personal interests and or hobbies that were not necessarily related to sport. lloyd disliked rugby but was attracted to fencing: “with fencing if it is linked to history or something then for me that is interesting.” touch rugby was a different / new sport for some females and as a result acted as a trigger for participation. however, the success of female touch-rugby at rhyd y fro could also be attributed to other factors, especially the structure of the club, the sixth-form leaders and the competitive opportunities provided by the club.three touch-rugby sessions (12-13 year olds, 14-15 year olds and 16-17year olds) were held simultaneously, the 12-13 and 14-15 year olds female sessions were taken by the male sixth-formers and the female 16-17 year olds was taken by the ‘5x60’ sdo. the benefits of this structure were three-fold. first, having all ages present was advantageous for motivation; second, the older sixth-form females enjoyed having the male ‘5x60’ sdo leading; and third, as sandfordet al. (2008) discovered in their own study, that successful leaders encouraged the younger pupils to participate by providingan opportunity for skill development as well as a social aspect to the club. as bolton et al. (2007) indicated in their analysis of the ‘pilot’ for the ‘5x60’ initiative, a competitive infrastructure was a desirable characteristic of the provision and the opportunity to participate in regionaland national tournamentsalso contributed to the success of the ‘touch rugby club. 5. discussion and implications the research presented in this paper has examined the leisure lifestyles of young people andbased on their perceptions and perspective; it has explored their attitudestowards extracurricular sport and physical activity. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 27 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmp the research design involved extensive qualitative research (interviews, focus groups and observations) over a prolonged period of time, cumulatively amounting to twelve months fieldwork. in summary, the findings revealed the heterogeneity of young people and that for many, their interest in physical activity and sport needed to be viewed as part of a wider approach to leisure lifestyles generally. based on theseresearch findings, figure 1(see below) offers an explanatory framework that addresses the complex and inter-twined environment of policy and how its implementation, can influence young people’s leisure lifestyles. to be interpreted from left to right, it recognises the central role of young people and acknowledges the context specific environments that young people find themselves. to varying degrees all young people are influenced by three sets of factors, namely individual (which includes personal-psychological and family issues), local (which includes peers, neighbourhood, cultural and community issues) and societal (which includes structural socio-economic, demographic and political issues). each of these sets of factors is extremely complex in its own right and how they connect to each other and between each other will undoubtedly impact on the attitudes and behaviour of young people. after fox (1988), the analysis from the six participating schools revealed that while some young people are ‘approachers’ to physical activity and sport, many are either ‘neutral’ or indeed resistant, otherwise referred to as ‘avoiders.’ headline data from welsh government (2013) have revealed an insufficient participation in physical activity and sport resulting in too few ‘approachers’ and too many ‘neutrals ‘ and ‘avoiders’ only 35% of children were reported as undertaking an hour of physical activity a day, only 29% of adults were reported as doing physically activity on five days a week (welsh government, 2013). moreover, reports such as the welsh health survey increasingly acknowledge the increase in child obesity (welsh government, 2013)and its concomitant links to sedentary lifestyles (includes a poor diet, lack of exercise and too many hours watching tv and gaming).recognising that many young people are resistant to physical activity and sport, this issue has become relevant with successive governments becoming drawn in(houlihan, 2000. evidence has shown the long-term benefits of adopting healthy lifestyles when young (kjonniskenet al., 2009) and consequently the westminstergovernment and devolved governments of northern ireland, scotland and wales have introducedvarious policies to address these problems. in relation to the present research, figure 1 reflects recognition of these contextualising variables by welsh government in its national strategy which led to the policy that all children and young people must undertake 60 minutes of exercise every day (welsh assembly government, 2005). this led to the introduction of the ‘5x60’ initiative. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 28 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmp the complexity of young people’s lifestyles made any categorisation beyond fox’s threefold typology difficult. nonetheless, though spending a prolonged period with the young people and gathering data from classroom based research activities, four categories were used to define the lifestyles of young people (sporty, arty, sporty and arty and leisure orientated). this research was over-laid with a detailed analysis of the intervention itself that revealed there were three key elements to the ‘5x60’ initiative that could make a real differencelocally, in terms of its implementation on the ground. firstly, the image of the programme and how it is presented and communicated to young people is pivotal in creating an identity. participants in the present study frequently referred to its distinct characteristics and many relished the fact it was marketed and branded differently from other school programmes and initiatives. these factors are fundamental to the way the target audiences perceive the programme and its relevance to them. inevitably the use of social media will be a key driver in communicating directly with the target audiences and can enable bespoke messages and branding that will be attractive to different sub-groups of young people. secondly, there are the activities themselves – the type and range of activities (linked to the expressed and latent demands of young people) and their organisation (timing, quality of coaching and overall logistics) will impact on take-up. while the opportunity to participate in a new activity produced a renewed sense of responsibility and commitment for some, others wanted the more informal recreational set up,characterised by an ‘opt in, opt out’ arrangement as it suited their transient lifestyles. thirdly, the research revealed the difference that the ’5x60’ sdo could make. being in situ was considered very important both by pupils and school alike. this individual was uniquely placed to break down barriers and ‘get to know’ pupils, especially those that would not typically be associated with school sport. this was frequently commented on by the young people themselves who saw the ’5x60’ sdo as a mentor and coach, not someone in authority (see nesti, 2001).importantly and perhaps unbeknown to the young people themselves, was the performance of the sdo her/himself who was affected considerably by the support received from the local authority and the school itself (in terms of attitude to the programme, commitment, ethos, and staff buy-in). evidence from the present study suggests that if well established and managed properly, changes in participation patterns should be expected. figure 1 explains that there should be an increase in the percentage of young people participating and more significantly a change in attitude towards physical activity and sport including, for some, a pathway that bridges school activities to community clubs and beyond. however, this study also makes clear that although policy initiatives and interventions are necessary they are not in themselves sufficient to produce long-lasting and sustained changes in attitudes toward sport and physical activity among young people. thus the final aspect of figure 1 suggests that whilea successful programme can bring about in situ changes these cannot be guaranteed to affect what we have termed generational change. to achieve this requires long term sustained investment where a whole system approach is taken that includes school, club, and community and which puts young people themselves at the centre. withthe right balance it is possible to implement interventions that reflect young people’s heterogeneity and are grounded in the leisure lifestyles of young people themselves. in conclusion figure 1 should be tested further by considering some of the research and emerging themes explored in this paper. additionally, we suggest three further areas of research that were beyond the scope of this project but which would benefit from further investigation. firstly, if physical activity is to become a lifelong habit then there is a need to explore interventions alongside the role of transitions further, from primary to secondary and from secondary to further education, higher education mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 29 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmp and the work place. secondly, research that places the young people at the centre of programme design could be the basis of some action research studies. for volunteers and pupil ambassadors, the role of ‘co-creators’ could be crucial for the success of such projects. lastly, research that looks further at identity and youth sub-cultures, especially in terms of communication and the role social media could play would be valuable to sport managers. this research has revealed the importance of understanding the heterogenous nature of young people’s leisure lifestyles which in turn through the development of the ‘5x60’ initiative provided new opportunities to engage young people to participate. this should be developed further by analysing specific sub-groups that are more resistant to engaging in extracurricular sport and physical activity. references armour, k.,sandford, r.,&duncombe, r. (2013). positive youth development and physical activity / sport interventions: mechanisms leading to sustained impact, physical education and sport pedagogy, 18(3),256-281. arnett, j.j. (2006). emerging adulthood in europe: a response to bynner, journal of youth studies, 9 (1),111123. bailey, r. (2005). evaluating the relationships between physical education, sport and social inclusion, educational review, 57 (1),71-90. biddle, s., coalter, f., o’donovan, t., macbeth, j., nevill, m.,& whitehead, s. (2005).increasing demand for sport and physical activity by girls, edinburgh, sport scotland. bolton, n., fleming, s. & galdes, m. (2007).extra-curricular physical activity programmes for secondary schools: implications from a pilot scheme.managing leisure12, 74-88. bryant, a., bolton, n., fleming, s. (2015).this is awesome miss. it is safe. we don’t do this with any other teacher.classroom activities to listen to pupils’ voices, educationalfutures, 7(1), 56-75. bynner, j. (2001). british youth transitions in comparative perspective, journal of youth studies, 4 (1), 5-23. christensen, p. & james, a. (2000).research with children: perspectives and practices, london, falmer press. eime, r.m., harvey, j.t., craike, m.j., symons, m.c.,& payne, r.w. (2013).family support and ease of access link socio-economic status and sports club membership in adolescent girls: a mediation study, international journal behaviour nutrition physical activity. 10, 50. fox, k. (1988). the child's perspective in physical education part 5: the psychological dimension in physical education, british journal of physical education,19 (1), 34-38. frith, s. (1984).the sociology of youth, ormskirk, causeway press. green, k. (2002). lifelong participation, physical education and the work of ken roberts, sport, education and society,7 (2), 167-182. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 30 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmp green, k., smith, a. & roberts, k. (2005). young people and lifelong participation in sport and physical activity: a sociological perspective on contemporary physical education programmes in england and wales, leisure studies, 24 (1), 27-43. hendry, l. b. &kloep, m. (2010). ‘how universal is emerging adulthood’ an empirical example’, journal of youth studies,13 (2). houlihan, b. (2000).sporting excellence, schools and sports development: the politics of crowded policy spaces, european physical education review, 6 (2), 171-193. kirk, d. carlson, t., o’connor, a., burke, p., davis, k.,& glover, s. (1997). the economic impact on families of children’s participation in junior sport, australian journal of science and medicine in sport,29(2), 2733. kjønnisken, l., anderssen, n. & wold, b. (2009). organized youth sport as a predictor of physical activity in adulthood, scandinavian journal of medicine and science in sport,19(5),646-654. leyshon, a., bolton, n.& fleming, s. (2012). the ‘5x60’initiative: illustrative case studies 2007-2009, cardiff, sport wales. macphail, a.&. kinchin, g. (2004). the use of drawings as an evaluative tool: students’ experiences of sport education, physical education and sport pedagogy, 9 (1),87108. nesti, m. (2001). working in sports development. in k. hylton, p. bramham, d. jackson and m. nesti (eds.) sports development: policy, process and practice. london: routledge, pp. 195-213. parker, a. and don, v. (2013).youth sport, physical activity and play: policy, intervention and participation, london, routledge. peeke, g. (1984). teacher as researcher, educational research, 26 (1), 24-26. roberts, k. (1996). youth cultures and sport: the success of school and community sport provision in britain, european physical education review, 1(2), 105-115. roberts, k. (1997). same activities, different meanings: british youth cultures in the 1990s. leisure studies, 16 (1), 1-15. roberts, k. (2004).the leisure industries, palgrave, macmillan. sandford, r. a., armour, k.m.,&warmington, p g. (2006). re-engaging disaffected youth through physical activity programmes, british educational research journal, 32 (2), 251-271. sandford, r. a., duncombe, r., & armour, k. m. (2008). the role of physical activity/sport in tackling youth disaffection and anti-social behaviour, educational review, 60 (4), 419-435. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 31 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmp smith, a., green, k. & thurston, m. (2009). ‘activity choice’ and physical education in england and wales, sport, education and society, 14 (2),203-222. sport england (n.d.). sport england market segmentation, retrieved from http://www.sportengland.org/index/get_resources/research/se_market_segmentati on sport council for wales (2006).secondary school programme 5x60 first: council paper (ppa (06) 05 item 6), cardiff, sport council for wales. welsh assembly government (2005).climbing higher.the welsh assembly government, strategy for sport and physical activity, cardiff, welsh assembly government. welsh government (2013).bolton , cardiff, welsh government. wilson, b. & white, p. (2001). tolerance rules: identity resistance, and negotiation in an inner city recreation/drop-in centre: an ethnographic study, journal of sport and social issues, 25, 73-103. wouters, c. (2007) informlization: manners and emotions since 1980, london, sage publications. zeijl, e., du bois raymond, m.,&dtepoel, y. (2001) young adolescents’ leisure patterns, society and leisure, 24 (2), 379-402. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 85 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe covid cases comparison of different american states muhammad k. javed1, muhammad i. qadir2, anam javaid3 and dr. sumbal javaid4 1-2institute of molecular biology and biotechnology, baha uddin zakariya university, multan, pakistan 3women university multan, pakistan 4nishtar medical university and hospital, multan, pakistan abstract: the goal of this research is to check the average of covid-19 cases in different states of usa (united states of america) and to check the variation of covid-19 cases in different usa states. to check the variation or average of covid-19 reported cases and deaths in different states of usa, we took data from the world o meter and compare the covid-19 cases from march to may in usa states. descriptive analysis is used to conduct this research. the purpose of the study is to observe the total number of cases in our state. death ratio in the state with the total number of active cases in the state. the purpose is the identification of the first case, when it deducted with the first death of the person due to covid-19. there is total of 9.2 milion population in the the state of new jersey. in which for the month of march, total of 18,696 people were effected from covid-19. so a total of 0.002% ( 18696/9200000) were effected from the covid-19. the total of (267/9200000) = 0.0000290% of the total population death occur. in the march 2020, covid-19 also attacked on the other states of us. e.g. in the state of new york, there were total of 83,712 cases were reported and 1941 number of deaths occur in the state of new york. in illinois, 4th case were confirmed in march 2, 2020. in the end of march 2020, there were total of 5994 cases were reported. the number of deaths were 99 in that state. its means that among the total population of 13.1 million, total of 0.00045% population were effected from this disease. while 0.0000076% population died with this pandemic. similarly the total of confirmed cases with the deaths were observed. for the other states, total number of confirmed cases with the number of deaths were observed as in california, there were total of 8155 cases were reported in the end of march. there were 171 deaths occur. similarly in the state of massachusettes, there were 6,620 cases were appear in the end of march 2020. the total number of deaths were 89 until the end of march 2020. the comparisons with the other states were observed with the state of new jersey and the conclusion is made as that in some states, the cases were more than the new jersey and in some states, the cases were less than the new jersey. similarly for the number of deaths, same thing happens. over all in the us, the number of cases for the covid-19 increased exponentially. the ratio for the number of death also increased from this pandemic. keyword: virus, corona, threat, disease introduction the world did not forget the year 2020 just because of a virus known as corona virus disease 2019 or abbreviated as covid-19 [1]. this virus shutdown everything even the entire world almost [2]. this virus mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 86 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe attacks around 4.3 million folks around the globe and still increase cases exponentially [3]. this virus arose from wuhan, china. there are lots of negative effects of this virus. all the business shutdown just because of corona and it seems that 2020 is wasted due to covid-19 [4]. the economy of the world is badly destroyed just because of corona. this virus shows that we need to focus more on our scientists and provide them all the facilities to conduct research on different major topics [5]. this virus aware people about some of the major fields like virology, microbiology, and biotechnology and now people said that the biotechnology is the future of the world. with lots of negative effects of covid-19, there are also some positive affects like on environment, climate, and some major fields like biotechnology [6]. we can see that ozone layer start filling faster than ever in 2020 and can see the heavy decline in different types of pollution like air pollution, noise pollution etc. the most affected countries due to covid-19 includes usa (united states of america), italy, spain, germany, and china. in this research we compare the cases of corona from different states of usa [7]. objective • to check the average of covid-19 cases in different states of usa • to check the variation of covid-19 cases in different states of usa methodology data collection to check the variation or average of covid-19 reported cases and deaths in different states of usa, we took data from the world o meter and compare the covid-19 cases from march to may in usa states. statistical analysis descriptive analysis is used to conduct this research result and discussion the outcome of this research is listed in the following section: descriptive statistics and diagrams a)the number of cases in us are observed . the cases can be observed through figure 1. figure 1: confirmed cases in us from january 2020 to april 2020 from figure 1, the confirmed cases of covid-19 are observed. from the figure 1, it is clearly observed that from january 2020 untill april 2020, total confirmed cases in us are increased. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 87 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe the confirmed cases for the month of march is observed for the state new jersey. the total cases are observed in figure 2. figure 2: confirmed cases in new jersey for march 2020 from figure 2, it is observed that the total number of effected cases are increased exponentialy in the new jersey for the month of march 2020. from 4th march, there was one case while untill 31st march, there were 18696 cases were reported from the pendemic of covid-19. b)similarly, for the number of deaths, the cases were observed in the us from january 2020 to april 2020. the figure 3 is obtained for the purpose of observing number of deaths in us. figure 3: total deaths in us from january 2020 to april 2020 figure 3 state the total deaths in us from the start of january untill the end of april. it can be clearly observed that the ratio of death is increased in the us from covid-19. there are now 56245 number of deaths untill mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 88 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe the end of april. specifically in our state, total number of deaths are observed only in the month of march from this pendemic. figure 4 is obtained for this purpose. figure 4: total deaths in new jersey for march 2020 from figure 4, the total death ratio can be observed. the deaths are rapidly increasing in the month of march 2020. the discriptive statistics is observed for the all four cases. the mean and standard deviations are observed to see the variation in the cases and the deaths. the details are observed intable 1. mean s.d cases in us 177466.5 294211.7 deaths in us 8111.354 15597.69 cases in new jersey for march 3304.321 5432.102 deaths in new jersey in march 52.86364 75.64975 c) from the figure 1-figure 4, it is observed that how much faster the cases are increased for the pendemic and for deaths in us and in our state. from table 1, the variation can be observed for each situation. the variation in the overall us is more than the variation in our state. ots means that the overall variation in deaths and cases are more as compared to just our state. on the average, also the mean is greater for us as comapred to our state only. d) the advantages of presenting the data in charts is that only by seeing just one time, the pattern can be observed that whether there is an increase or decrease in that situation. on the other hand, disadvantage is that the whole exact figure cannot be observed or we cannot obseve that what happened exactly in the middle of that period. 3) a) for the probability count, the number of cases and the deaths are observed only in the month of march 2020. the exact digits can be observed in table 2. table 2. number of cases and deaths in march 2020 for some states of us states number of cases number of deaths mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 89 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe new jersey 18696 267 illinois 5994 99 california 8155 171 massachusetts 6620 89 texas 3266 41 florida 6741 85 total 49472 752 on the basis of table 2, it is observed that the number if cases in our state is more than other states in march.the probability of the number of cases is increasing in our state as compared to the other states. similarly, the number of deaths are increasing in our state as compared to the other states. the frequency of march shows that the cases are increasing day by day. also the number of deaths are increasing on daily basis in march. 4. the descriptive statistics for the new jersey in the month of march 2020 is found. the number of confimed cases with the total number of deaths were observed. the summary statistics for that can be defined in table 3. table 3: summary statistics of new jersey in march 2020 descriptive total cases total deaths mean 3304.321 52.86364 standard error 1026.571 16.12858 median 347 13.5 mode 4 1 standard deviation 5432.102 75.64975 sample variance 29507729 5722.885 kurtosis 2.194049 1.979609 skewness 1.788444 1.639772 range 18695 266 minimum 1 1 maximum 18696 267 for the rest of the state that has been used in comparison, discriptive analysis is carried out from table 4 table 7. table 4: summary statistics of illinois in march 2020 descriptive total cases total deaths mean 1250.392857 29.71428571 median 436.5 17.5 mode 1049 #n/a standard deviation 1714.965507 30.32497973 minimum 4 1 maximum 5994 99 table 5: summary statistics of massachusetts in march 2020 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 90 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe descriptive total cases total deaths mean 1192.931 28.33333333 median 218 20 mode 2 #n/a standard deviation 1912.309 26.91850777 minimum 2 1 maximum 6620 89 table 6: summary statistics of texas in march 2020 descriptive total cases total deaths mean 654.3077 15.53333 median 95 11 mode 5 5 standard deviation 1004.135 13.78854 minimum 5 1 maximum 3266 41 table 7: summary statistics of flourida in march 2020 descriptive total cases total deaths mean 1233.552 20.58333 median 216 10 mode 2 2 standard deviation 1898.746 24.45745 minimum 2 2 maximum 6741 85 a) from table 3-7, the descriptive analysis shows that the highest mean number of cases are observed for new jersy. while the lowest mean number of cases are observed for texas. the highest mean number of death is observed for new jersy and the lowest mean number of death was observed for texas. b) standard deviation tell us that how much variation is observed on the average. the more standard deviation means the more variation on daily number of cases. the less standard deviation mean that the less variation in number of cases or the number of deaths. e.g. the highest standard deviation was observed for new jersy for the number of cases observed. the lowest standard deviation was observed for texas. the highest standard deviation was observed for new jersy and the lowest is observed for texas in case of number of deaths. conclusion the purpose of the study is to observe the total number of cases in our state. death ratio in the state with the total number of active cases in the state. the purpose is the identification of the first case, when it deducted with the first death of the person due to covid-19. there is total of 9.2 milion population in the the state of new jersey. in which for the month of march, total of 18,696 people were effected from covid-19. so a total of 0.002% ( 18696/9200000) were effected from the covid-19. the total of (267/9200000) = 0.0000290% of the total population death occur. in the march 2020, covid-19 also attacked on the other mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 91 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe states of us. e.g. in the state of new york, there were total of 83,712 cases were reported and 1941 number of deaths occur in the state of new york. in illinois, 4th case were confirmed in march 2, 2020. in the end of march 2020, there were total of 5994 cases were reported. the number of deaths were 99 in that state. its means that among the total population of 13.1 million, total of 0.00045% population were effected from this disease. while 0.0000076% population died with this pendemic. similarly the total of confirmed cases with the deaths were observed. for the other states, total number of confirmed cases with the number of deaths were observed as in california, there were total of 8155 cases were reported in the end of march. there were 171 deaths occur. similarly in the state of massachusettes, there were 6,620 cases were appear in the end of march 2020. the total number of deaths were 89 untill the end of march 2020. the comparisons with the other states were observed with the state of new jersey and the conclusion is made as that in some states, the cases were more than the new jersey and in some states, the cases were less than the new jersey. similarly for the number of deaths, same thing happens. over all in the us, the number of cases for the covid-19 increased exponentially. the ratio for the number of death also increased from this pendemic. references tuite, a. r., ng, v., rees, e., & fisman, d. (2020). estimation of covid-19 outbreak size in italy. the lancet. infectious diseases, 20(5), 537. hisaka, a., yoshioka, h., hatakeyama, h., sato, h., onouchi, y., & anzai, n. (2020). global comparison of changes in the number of test-positive cases and deaths by coronavirus infection (covid-19) in the world. preprints. https://www.worldometers.info/coronavirus/ javaid, s., & javaid, m. k. j. d. a. (2020). survey on corona virus: a case study in pakistan. international journal of medical science in clinical research and review, 3(02,), 223227.cavanagh, d. (2007). bukht, n., & javed, m. k. (2020). banker’s awareness of corona virus. international journal of medical science in clinical research and review, 3(03,), 251-255. bukht, n., & javed, m. k. (2020). banker’s awareness of corona virus. international journal of medical science in clinical research and review, 3(03,), 251-255. dr. sumbal javaid3*m. k. j. b. (2020). covid-19 effect on poor. international journal of medical science in clinical research and review, 3(03 ,), page : 263-268. retrieved from http://www.ijmscrr.in/index.php/ijmscrr/article/view/84 dr.anam javaid3*m. k. j. j. (2020). corona virus awareness in pakistan: a case study. international journal of medical science in clinical research and review, 3(03 ,), page : 256-262. retrieved from http://www.ijmscrr.in/index.php/ijmscrr/article/view/83 mailto:topacademicjournals@gmail.com https://www.worldometers.info/coronavirus/ https://www.worldometers.info/coronavirus/ http://www.ijmscrr.in/index.php/ijmscrr/article/view/84 http://www.ijmscrr.in/index.php/ijmscrr/article/view/84 http://www.ijmscrr.in/index.php/ijmscrr/article/view/83 http://www.ijmscrr.in/index.php/ijmscrr/article/view/83 american journal of medical and physical education vol.6, issue 2; march-april 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 1 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe demographic disparities in quality physical education karen s. kulik, hannah m. brewer and jonathan s. baker university of california, los angeles abstract: physical activity is essential for children's health, but many do not get enough. schools are a key setting for physical activity, but there are challenges to implementing quality physical education programs. this paper reviews the factors that affect schools' ability to implement quality physical education programs, and discusses strategies for overcoming these challenges. keywords: physical activity, children's health, schools physical education, quality challenges strategies 1. introduction physical activity has been shown as an effective way to improve the weight status of children and adolescents (mcdaniel et al., 2014). participation in regular physical activity has also been shown to help control body weight, maintain healthy bones and reduce the risk for developing chronic diseases such as cardiovascular disease, hypertension, and diabetes mellitus (american heart association, 2013; luke et al., 2004; u.s. department of health and human services, 2010). the current public health recommendation is for children to participate in 60 minutes of daily physical activity (u.s. department of health and human services, 2008). schools have been identified as a key setting for children to engage in physical activity because children spend more time in school than any other place outside the home (quitério, 2012). although schools may not allow students the opportunity to accumulate all of the recommended minutes of physical activity, they do offer opportunities for children and adolescents to become active. within the school environment, physical education has been targeted as the most effective way to increase physical activity among students (story et al., 2006; us department of health and human services, 2010). for students to benefit from the increased amounts of physical activity, schools need to offer quality physical education programs that provide opportunities for students to meet the recommended daily amount of physical activity. to help schools develop quality physical education programs, the society of health and physical educators (shape), formerly known as the national association for sport and physical education (naspe), has developed a set of guidelines to provide schools with specific criteria to help increase opportunities for students to meet the recommended daily amount of 225 minutes per week of physical education. the guidelines include ensuring that the individuals delivering the physical education are qualified, and that there is appropriate safe space for physical education to be administered (national association for sport and physical education, 2011). although the benefits of physical activity are clear (us department of health and human services, 2010) and guidelines have been established to help schools deliver quality physical education, many children and mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 2; march-april 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 2 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe adolescents do not participate in regular physical activity.based on the results from the 2011 national youth risk behavior survey, only 28.7% of high school students meet the recommended level of physical activity (centers for disease control and prevention, 2012). moreover, the percentage of students participating in 60 minutes of daily physical activity decreases as they progresses across the 9th (30.8%), 10th (30.8%), 11th (27.3%) and 12th grades (25.1%). very few studies have examined the reasons for the lack of physical activity in school. a critical step in the design of quality physical education programs that deliver increased opportunities for physical activity,is understanding the factors that may affect the schools ability to implement such a program (barroso et al., 2005). a study conducted by barroso et al. (2005) described the barriers toa quality physical education curriculum as reported by elementary physical education specialists trained as part of the child and adolescent trial for cardiovascular health (catch)program. the data wasobtained from four consecutive annual surveys (20002004) that were collected from 157 teachers. the combined results from these surveys revealed that significant barriers exist to providing quality physical education. the teachers identified factors including inadequate indoor and/or outdoor facilities and insufficient numbers of physical education specialists were among the major obstacles (barroso et al., 2005). other reported barriers included low priority of physical education compared to other academic subjects and limited financial resources. there is research to suggest that the factors identified from this study may influence a schools ability to deliver quality physical education. to investigate the effect of location on physical activity, springer et al. (2009) conducted a study to examine the prevalence of physical activity and sedentary behaviors in a probability sample of students in 4th, 8th, and 11th grades by urban, suburban and rural locations. data was collected from the 2004-2005 school physical activity and nutrition (span) study. the results of the study revealed that urban 8th and 11th grade students reported the lowest prevalence of physical activity. students in suburban or rural schools were significantly more likely than urban students to report higher school-based team sport participation in 8th graders (p=0.001), higher vigorous physical activity (p=0.01) and strength training exercises (p=0.01) in 11th grade boys. attendance in physical education was also higher among urban 4th grade (p<0.01) and urban 11th grade (p=0.05) students. participation in sports teams (p=0.04) and other organized physical activity (p=0.04) was higher in urban 4th grade girls. participation in vigorous physical activity was higher in urban 8th grade boys (p=0.04) when compared to the other students. the results of this study suggest significant differences in participation in physical activity by location status (springer et al., 2009). similar to springer, butcher et al. (2008) conducted a study to assess the rates and correlates of adolescents’ compliance with guidelines for physical activity. the variables examined included: race/ethnicity, income level, geographic region, and parental education level. a phone survey was used to gather self-reported physical activity data from 1625 adolescents ages 14-17. the parents of each adolescent also participated in the phone survey to answer demographic questions. results of the survey revealed that compliance among adolescents who lived in a household with a higher household income (above $60,000) was significantly associated with compliance of the physical activity guidelines (p = 0.03), although there was not a significant relationship between compliance mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 2; march-april 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 3 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe and low or middle income. this suggests that a relationship may exist between socioeconomic status and participation in physical activity levels (butcher et al., 2008). in support the research of springer and butcher, jones et al. (2003) conducted a study to examine the effectof factors such as location, schools size and school type have on schools in the united states implementing health promoting policies, programs, and facilities. the data used for the study was collected from the school health policies and programs study 2000. the following variables were used to group the schools: school type (public, private, or catholic), urbanicity (urban, suburban, or rural), and school enrollment size. the results of this study revealed that public schools (vs. private and catholic schools), urban schools (vs. rural and suburban schools) and schools with larger enrollments (vs. smaller schools) had more health-promoting policies, programs and facilities in place. these results are significant because they suggest that students who attend these schools may have access to higher quality programs including physical education than students who attend schools with fewer resources. therefore, there is evidence to support factors such as school location, school size and socioeconomic status may influence physical activity levels among children. however, what is unclear is how these factors affect a schools ability to achieve shape’s recommendationsfor quality physical. this information may be valuable in understanding how to improve the quality of physical education and as a result, improvethe health benefits of children and adolescents associated with increased physical activitylevels. the primary focus of this studytherefore,was to determine whether a sample of high schools in southwestern pennsylvania, usa met the shape guidelines including instruction time for physical education, teacher qualifications and facilities available for physical education and to determine the factors that may influence their ability to meet these guidelines. further study aims were to (1) determine if school size influences a schools ability to meet the shape guidelines for instruction time for physical education, teacher qualifications and facilities, (2) determine if school location influences a schools ability to meet the shape guidelines and (3) determine if socioeconomic status influences a schools ability to meet the shape guidelines. 2. methods 2.1 sample there are 91 public high schools in southwestern pennsylvania. the physical education department chairperson or designated high school physical education teacher for each of the 91 schools was invited to participate in the study via an electronic letter that provided an overview of the study aims and directions on how to complete the electronic survey. the email addresses for the physical education department chairperson or designated high school physical education teacher were obtained directly from each school’s website. 2.2 survey validity and reliability the survey instrument was developed by the researcher based on an existing questionnaire used by shape to evaluate quality physical education programs. survey validity was reviewed by a panel of 12 experts in the field of physical education and curriculum design. the survey was distributed to this panel twice during the mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 2; march-april 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 4 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe development process and feedback from each review was incorporated to determine the final version of the survey. to examine the survey question clarity, general question format, and to provide data on reliability of the survey questions, a pilot study was conducted. the survey was sent to 18 randomly selected schools that were similar in demographics (i.e. school size, locale and ses status) to the schools in the target population. atest of internal consistency was conducted using cronbach’s alpha on the pilot study data. 2.3 statistics the data were analyzed using the statistical program spss 16.0. descriptive statistics were used to describe the study schools, respondents of the survey, instruction time provided by each school and the facilities available for physical education. a chi-square test of independence was calculated to determine if there was a significant difference in between schools that responded to the survey and schools that did not respond to the survey. to determine the study schools’ ability to meet the shape recommendations, a within-subjects repeated measures of analysis of variance (anova) was used. to determine the effect of demographic factors (school size, location and ses) on the study schools’ ability to meet the shape recommendations, repeated measures anova was used. a chi-square test of independence was used to compare the availability of specific type of facilities available for physical education and demographic factors. 3. results 3.1 reliability of the study survey instrument the survey instrument specific for this study was developed, and a pilot study was conducted to assess the reliability of this survey instrument. eighteen schools were selected at random to participate in this pilot study. fifteen of the 18 schools (83.3%) completed the survey. cronbach’s alpha was used to measure the internal consistency of the survey and this analysis revealed a score of .707. the test/retest correlation was .979. based on these results it was determined that the survey met acceptable criteria for reliability to proceed with the recruitment of additional schools for this study. 3.2 recruitment of schools the target population for this study included 91 public high schools from southwestern pennsylvania. initial outreach to these schools was to identify a physical education department chairperson or other designated physical education teacher to contact regarding participation in this study. contact information was obtained for 83 out of the 91 schools (91.2%). the invitation letter and electronic survey were sent to the physical education department chairperson or other designated physical education teacher at these 83 schools, with 39 schools partially or fully completing the survey, for a response of 46.98%. when considered based on the sample of 91 possible schools, the response was 42.9%. 3.3 school characteristics table 1 summarizes the demographic information including school size, locale and socioeconomic status (ses) of the schools that responded to the survey and the schools that did not respond to the survey. school size was determined based on the pennsylvania interscholastic athletic association (piaa) ranking system which is mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 2; march-april 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 5 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe established based on senior (12th grade) enrollment. rankings include a, aa, aaa, and aaaa with “a” representing schools with low enrollment and “aaaa” representing schools with high enrollment. school locale was determined based on the national center for educational statistics (nces) classification system to describe a school’s location in proximity to an urbanized area ranging from “large city” to “rural.” the ses status of each school was determined based on the number of students eligible for a free or reduced lunch and were classified as low, middle or high as reported by the pennsylvania department of education (pde). a chi-square test of independence was calculated to determine if there was a significant difference in school size, locale or ses status between respondents and non-respondents of the survey. no significant difference was found between respondents and non-respondents for school size (x2 (3) =5.99, p>.05), locale (x2 (5) =6.33, p>.05), or ses status (x2 (5) =3.55, p>.05). table 1: demographic information for the respondent schools and non-respondent schools respondent non-respondent (n=39) (n=52) frequency percent frequency percent school size by piaa class a aa 9 7 23 18 14 17 27 33 aaa 10 26 14 27 aaaa 13 33 7 13 school locale large city 3 8 7 14 urban fringe of a large city 24 61 34 65 urban fringe of a mid-size city 0 0 1 2 small town 0 0 1 2 rural, outside cbsaa 5 13 1 2 rural, inside cbsaa 7 18 8 15 ses status low (1-14.79%)b 15 39 11 21 middle (14.8-32.29%) b 11 28 16 31 high (32.3-100%) b 13 33 25 48 a = cbsa = core based statistical area b = indicates based on tertiles the percent of students within a school receiving a free and reduced price lunch. 3.4 achievement of the shaperecommendations 3.4.1instruction time. the instruction time for physical education within each of the study schools was collected for each grade level (10, 11, and 12). the number of days per week that physical education was offered in 10th, 11thand 12th grade was 2.8±1.4, 2.7±1.4, and 2.5±1.4 days per week per year, respectively. results of a withinsubjects repeated measures analysis of variance showed no difference between the number of physical education classes offered per week for the entire school year for grades 10, 11 and 12 (p=.135). the number of mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 2; march-april 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 6 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe minutes per week of physical education was offered in 10th, 11th and 12th grade was 104.9±54.3 min/wk, 100.1±55.1 min/wk, and 92.3±53.4 min/wk. a within-subjects repeated measures anova revealed no significant difference for minutes of physical education instruction per week between grades 10, 11 and 12 (p=0.23). 3.4.2 academic training of physical education teachers.data was collected from each school regarding the number of teachers with an undergraduate and/or graduate degree in physical education. the percent of schools reported having 5 or more teachers with an undergraduate degree in physical education was 34.3, whereas 28.6% of schools reported that none of their teachers have a graduate degree in physical education. the mean percentage of teachers within a school having an undergraduate degree in physical education was 96.9±14.6% and the mean percentage of teachers within each school with a graduate degree in physical education was 65.0±34.8%. 3.4.3 facilities available for physical education.schools reported information regarding the number and type of facilities available for physical education. the percent of schools reported having indoor spaces available for physical education was 100% and 94.3% of these schools reported that they also have outdoor grass spaces available for physical education. the majority of schools also reported having access to a track (71.4%), fitness center (68.8%), and outdoor concrete spaces (62.9%). the climbing wall (34.3%) and swimming pool (42.9%) were identified as the least available facilities for physical education. 3.5 demographic factors influencing achievement of the naspe recommendations 3.5.1 school size to determine the effect of school size on physical education instruction time, the categories of minutes per week that physical education was offered were recoded to 29 min/wk for the <30 minute category, the midpoints of the range were used for the 30-59, 60-89, 90-119, 120-149, and 150-179 minute categories, and 180 min/wk was used for the >180 minute category. a two-factor (grade x school size) repeated measures anova was performed and revealed no significant grade effect, school size effect, or grade x school size interaction effect for minutes of physical education offered. these data are shown in table 2. in addition to the parametric tests, nonparametric tests were also used. results of the kruskal-wallis h test revealed no significant difference between school size and physical education instruction time offered in10th grade (h (3) = .577, p=.902), 11th grade (h (3) = .245, p=.970), or 12th grade (h (3) = 3.464, p=.325). table 2. repeated measures analysis of variance (anova) to compare minutes of physical education per week by grade level between classifications of school size. school size categories p-values grade level a (n=9) aa (n=6) aaa (n=10 aaaa (n=12) grade school size grade x school size mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 2; march-april 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 7 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 10th grade 111.3±65.3 101.9±47.0 104.5±49.7 95.8±56.2 0.213 0.938 0.115 11th grade 97.8±62.7 101.9±47.0 106.1±55.7 95.8±59.7 12th grade 66.0±45.2 101.9±47.0 106.1±55.7 95.8±59.1 a one-way anova was computed to compare the differences in teacher qualifications as determined by the number of teachers with an undergraduate degree or graduate degree in physical education within each school and the percent of teachers with an undergraduate degree or graduate degree in physical education within each school and school size. as shown in table 3, a significant difference was found for the number of teachers with an undergraduate degree within each school (f (3, 31) =2.923, p=.049). post-hoc comparisons using the lsd test indicated that for the number of teachers with an undergraduate degree for piaa class a schools (3.8±1.1) was significantly lower when compared to piaa class aaaa schools (5.3±1.5). however, there was no significant difference between the percent of teachers with an undergraduate degree (f (3, 31) =.522, p=.671) between school size classifications. moreover, there was no significant differences found for the number of teachers with a graduate degree (f (3, 31) =.877, p=.464) or the percent of teachers with a graduate degree (f (3, 31) = .149, p=.929) between school size classifications. table 3. one way analysis of variance (anova) to compare physical education teacher qualifications within each school by classifications of school size. teacher qualifications school size categories a (n=9) aa (n=6) aaa (n=8) aaaa (n=12) f value p-value number of teachers with undergraduate degree percent of 3.8 ±1.1 a 4.0 ±1.1 4.8 ±1.0 5.3 ±1.5a 2.923 0.049 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 2; march-april 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 8 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe teachers with undergraduate degree 100.0±.0 95.8±10.2 100.0±.0 93.1±24.1 0.522 0.671 number of teachers graduate degree with 2.3 ±1.9 3.0 ±2.3 3.3 ±2.1 3.8±2.2 0.877 0.464 percent of teachers graduate degree with 58.2±28.7 66.7±36.8 67.1±38.5 68.1±39.1 0.149 0.929 note: values with the same superscript within each grade level are significantly different at p<0.05. to compare the number of facilities including the total number of facilities, number of indoor spaces, number of outdoor grass spaces and the number of outdoor concrete spaces available within each school to support physical education and school size, a one-way anova was computed. as shown in table 4, a significant difference was found for the number of available indoor spaces between schools based on piaa classification (f (3, 31) =3.519, p=.026). post-hoc comparisons using the tukey test indicated that for the number of available indoor spaces to support physical education within each school for piaa class a schools (1.8±0.8) was significantly lower than for piaa class aaaa schools (3.7±1.5). no significant difference was found for the total number of facilities (f (3, 31) = 1.286, p=.297), the number of available of outdoor grass spaces (f (3, 31) = .409, p=.748), or the number of outdoor concrete spaces (f (3, 31) = .1.359, p=.274). in addition to the total number of facilities available to support physical education, data was also collected to determine the specific types of facilities available within the study schools. the chi-square test of independence was used to compare the availability of facilities including a swimming pool, track, rock climbing wall and a fitness center within each school and school size. a significant relationship was found for the availability of a climbing wall by school size with a higher number of small schools having a climbing wall available for physical education (x2(3) = 8.185, p=.042). no significant relationship was found between school size and the availability of a swimming pool (x2(3) = 4.318, p=.229), the availability of a track (x2(3) = .700, p=.873), or the availability of a fitness center (x2(3) = 1.488, p=.685). table 4. one way analysis of variance (anova) to compare the facilities available to support physical education between classifications of school size. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 2; march-april 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 9 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe facilities school size categories a (n=9) aa (n=6) aaa (n=8) aaaa (n=12) f value p-value total facilities 7.6±2.1 9.8±4.8 9.4±3.4 10.7±4.0 1.286 0.297 indoor spaces 1.8±0.8a 3.5±2.1 3.8±1.7 3.7±1.5a 3.519 0.026 outdoor grass spaces 2.6±1.2 2.8±2.4 3.2±2.3 3.4±1.8 0.409 0.748 outdoor concrete spaces 0.9±0.8 0.8±0.8 0.6±0.7 1.4±1.2 1.359 0.274 note: values with the same superscript within each grade level are significantly different at p<0.05. 3.5.2school location to determine the effect of school location on physical education instruction time, a two-factor (grade x school size) repeated measures anova was performed and revealed no significant grade effect, school locale effect, or grade x school locale interaction effect for minutes of physical education offered. these data are shown in table 5. results of the non-parametric test, kruskal-wallis h test, revealed a non-significant difference between physical education instruction time and school locale. table 5. repeated measures analysis of variance (anova) to compare minutes of physical education per week by grade level between school locales. grade level school locale categories large city (n=3) urban fringe of a large city (n=22) rural outside cbsa (n=5) rural inside cbsa (n=7) pvalues grade school locale grade x school locale mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 2; march-april 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 10 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 10th grade 119.3±78.2 103.8±47.8 80.5±62.7 108.9±63.1 0.145 0.381 0.100 11th grade 119.3±78.2 104.5±52.2 56.3±32.7 108.9±63.1 12th grade 119.3±78.2 104.5±52.2 59.4±30.1 65.8±47.4 a one-way anova was computed to compare the differences in school locale and teacher qualifications within each school. as shown in table 6, a significant difference was found for the number of teachers with an undergraduate degree within each school (f (3, 31) =4.795, p=.007). post-hoc comparisons using the tukey test indicated that the number of teachers with an undergraduate degree for schools classified as “urban fringe of a large city” (5.1±1.0) was significantly higher than schools classified as “rural, outside cbsa” (3.2±0.4). no significant differences were found for the number of teachers with a graduate degree (f (3, 31) =.1.040, p=.389), the percent of teachers with an undergraduate degree (f (3, 31) = 1.377, p=.286), or the percent of teachers with a graduate degree (f (3, 31) = .658, p=.584) table 6. one way analysis of variance (anova) to compare teacher qualifications within each school by between school locales. school locale categories teacher large city urban rural rural qualifications (n=3) fringe of a outside inside f value p-value large city cbsa cbsa (n=22) (n=5) (n=7) number of teachers with undergraduate degree number of 4.0±0.0 5.1±1.0 a 3.2±0.5 a 3.8±1.9 4.795 0.007 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 2; march-april 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 11 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe teachers with graduate degree percent of 3.5±0.7 3.2±2.1 1.8±0.8 4.0±3.0 1.040 0.389 teachers with undergraduate degree percent of 100.0± 0.0 98.9±5.3 100.0± 0.0 86.1±34.0 1.377 0.268 teachers with 87.5±17.7 62.2± 36.7 55.0±20.1 76.4±41.0 0.658 0.584 graduate degree note: values with the same superscript within each grade level are significantly different at p<0.05. a one-way anova was computed to compare the number of facilities including the total number of facilities, number of indoor spaces, number of outdoor grass spaces and the number of outdoor concrete spaces available within each school to support physical education and school locale. as shown in table 7, no significant differences were found between school locale and the total number of facilities available within each school to support physical education (f (3, 31) = 1.146, p=.346), the number of indoor spaces available (f (3, 31) =1.199, p=.326), the number of outdoor grass spaces available (f (3, 31) = 1.361, p=.273), or the number of outdoor concrete spaces available (f (3, 31) = .459, p=.731). the chi-square test of independence was used to compare the availability of facilities including a swimming pool, track, rock climbing wall and a fitness center within each school and school locale. a significant relationship was found between school size and the availability of a climbing wall (x2(3) = 8.827, p=.032). no significant relationship was found between school size and the availability of a swimming pool (x2(3) = 1.294, p=.731), the availability of a track (x2(3) = 1.160, p=.763), or the availability of a fitness center (x2(3) = 1.099, p=.777). table 7. one way analysis of variance (anova) to compare the facilities available to support physical education between school locales. facilities school locale categories large city urban fringe of a large city rural outside cbsa rural inside cbsa f value p-value mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 2; march-april 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 12 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe total facilities 7.0±4.2 10.0±3.6 7.2±1.5 10.2±5.0 1.146 0.346 indoor spaces outdoor 3.0±1.4 3.5±1.7 2.0±1.0 3.0±2.1 1.199 0.326 grass spaces 1.0±1.4 3.2±1.9 2.4±1.1 3.7±2.1 1.361 0.273 outdoor concrete spaces 0.5±0.7 1.1±1.0 0.8±0.8 0.8±0.8 0.459 0.713 note: values with the same superscript within each grade level are significantly different at p<0.05. 3.5.3 socioeconomic status (ses) to determine the effect of ses on physical education instruction time, a two-factor (grade x school ses status) repeated measures anova was performed and revealed a non-significant grade effect, school ses status effect, and grade x school ses status interaction effect for minutes of physical education offered. these data are shown in table 8. results of the non-parametric test, kruskal-wallis h test, revealed a non-significant difference between physical education instruction time and school ses status. table 8. repeated measures analysis of variance (anova) to compare minutes of physical education per week by grade level between school ses status. school ses status pvalues lowest tertile (1% to <14.8%) (n=13) middle tertile (14.8% <32.3%) (n=11) to highest tertile (32.3% to 100%) (n=13) grade school ses status grade x locale school mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 2; march-april 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 13 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 81.3±44.7 96.3±47.3 130.0±58.5 0.248 0.089 0.698 76.7±45.2 103.2±53.6 120.7±60.1 76.7±45.2 89.5±51.3 110.3±60.7 a one-way anova was computed to compare the differences in teacher qualifications within each school and ses status. as shown in table 9, ses status of the school did not appear to affect the number of teachers with an undergraduate degree (f (2, 32) = .776, p=.469) or the number of teachers with a graduate degree (f (2, 32) = 2.065, p=.143),the percent of teachers with an undergraduate degree (f (2, 32) = 1.560, p=.226), or the percent of teachers with a graduate degree (f (2, 32) = .567, p=.573). table 9. one-way analysis of variance (anova) to compare teacher qualifications within each school by school ses status. teacher qualifications school ses status lowest tertile (1% to <14.8%) (n=13) middle tertile (14.8% <32.3%) (n=11) to highest tertile (32.3% to 100%) (n=13) f value pvalue number of teachers with undergraduate degree 4.8 ±1.6 4.6 ±1.4 4.2 ±1.0 0.776 0.469 number of teachers graduate degree with 3.9 ±2.2 3.4 ±2.6 2.3 ±1.1 2.065 0.143 percent of teachers with undergraduate degree 91.0±24.5 100.0±.00 100.0± 0.0 1.560 0.226 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 2; march-april 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 14 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe percent of teachers with graduate degree 72.4± 38.6 65.8±37.3 57.1± 29.3 0.567 0.573 note: values with the same superscript within each grade level are significantly different at p<0.05. a one-way anova was computed to compare the number of facilities including the total number of facilities, number of indoor spaces, number of outdoor grass spaces and the number of outdoor concrete spaces available within each school to support physical education and school ses status. as shown in table 10, no significant differences were found between school ses status and the total number of facilities available within each school to support physical education (f (2, 32) = .303, p=.741), the number of indoor spaces available (f (2, 32) =2.248, p=.122), the number of outdoor grass spaces available (f (2, 32) = .251, p=.780), or the number of outdoor concrete spaces available (f (2, 32) = 1.161, p=.326). the chi-square test of independence was used to compare the availability of facilities including a swimming pool, track, rock climbing wall and a fitness center within each school and school locale. no significant relationship was found between school ses status and the availability of a swimming pool (x2(2) = .725, p=.696), the availability of a track (x2(2) = .217, p=.897), the availability of a climbing wall (x2(2) = 2.553, p=.279), or the availability of a fitness center (x2(2) = .375, p=.829). table 10. one-way analysis of variance (anova) to compare the facilities available to support physical education between school ses status. facilities school ses status lowest tertile (1% to <14.8%) (n=13) middle tertile (14.8% <32.3%) (n=11) to highest tertile (32.3% to 100%) (n=13) f value p-value total facilities 10.1±3.2 9.3±4.0 8.9±4.0 0.303 0.741 indoor spaces 4.0±1.5 2.9±1.9 2.7±1.5 2.248 0.122 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 2; march-april 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 15 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe outdoor grass spaces 3.2±1.9 3.3±1.7 2.8±2.1 0.251 0.780 outdoor concrete spaces 0.8±1.1 0.8±0.8 1.3±0.9 1.161 0.326 note: values with the same superscript within each grade level are significantly different at p<0.05. 4. discussion improving the quality of physical education is necessary to achieve potential health-benefits in children and adolescents (carrel et al., 2005; dietz, 1997;pate et al., 2006; and sallis et al., 1997). to help guide the development of quality physical education programs, the society of health and physical educators (shape) has proposed guidelines for physical education instruction time, physical education teacher qualifications, and availability of physical education facilities. this study focused on describing these components in high schools (10th, 11th, 12th grades) located in southwestern pennsylvania, and examined whether there are demographic characteristics of the school (locale, size, ses status) that affect these factors. this information may be valuable in understanding how to improve the quality of physical education across schools with diverse characteristics, and may lead to the development of interventions and policies to improve the quality of physical education in high schools. results of this study indicates there is no significant relationship between schools size and physical education instruction time, teacher qualifications or facilities. these results are in contrast to the current literature, as reported by jones et al. (2005), which suggests that larger schools may have more health promoting policies and facilities than smaller schools thus offering students increased opportunities physical activity. although this research suggests that school size may affect opportunities for physical activity, the current study measured instruction time for physical education and not participation in physical activity which may account for the lack of association. the results of this study suggest that the locale of the school has limited impact on the physical education variables examined. for example, while this study showed a significant difference in the number of physical education teachers with an undergraduate degree based on school locale, this finding may simply reflect differences in school size, because there was no significant difference for the percent of physical education teachers with an undergraduate or graduate degree when compared school locale categories. moreover, aside from access to a rock climbing wall, access to facilities to support physical education instruction appears to be unaffected by the locale of the school. however, these findings that suggest no effect of school locale of physical education instruction variables may be inconsistent with the current literature. springer et al. (2009) conducted a study to examine physical activity levels of students in 4th, 8th, and 11th grades by urban, suburban and rural locations, and found that urban students mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 2; march-april 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 16 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe reported lower levels of physical activity compared to students in suburban and rural locations. these results suggests that locale may affect participation in physical activity in children and adolescents; however, the current study assessed instruction time rather than time spent engaged in physical activity which may account for the differences in findings between these studies. thus, it may be necessary to further examine the effect of school locale on components of physical education instruction, which may provide insight into how these potential differences affect the quality of physical education programs in these geographical areas. the results of this study suggest that there was no significant relationship between school ses status, instruction time, teacher qualifications or facilities. these results are in contrast with the current literature. butcher et al. (2008) examined if demographic factors such as race/ethnicity, education level, and ses status affected physical activity participation in adolescents and found that adolescents living a household of higher ses status participated in higher levels of physical activity when compared to middle and low ses households. although this research suggests that ses status may affect physical activity participation, the current study measured instruction time in physical education, which may account for the lack of association in the results. 4.1 limitations this study is not without limitations which could impact the application of the observed results. first,the survey used in this study assessed the days per week and the number of minutes that physical education is offered to high school students in southwestern pennsylvania. however, this may not reflect the time that students are actually engaged in physical activity during physical education class. also, this survey did not include participation in physical activity outside of the physical education class. the second limitation of this study was the small sample size and limited geographic region. physical education curriculum components reported for schools in southwestern pennsylvania are not generalizable to schools in other regions. lastly, the study was conducted in 2009 and the data may not reflect what is currently being implemented in these schools. although this study was not without limitations, it is the first study to describe the ability of schools in southwestern pennsylvania to achieve shape’s components for quality physical education and to investigate the effect of demographic factors such as school size, school locale and ses status on the ability to achieve these components. 4.2 conclusion improving the quality of physical education is necessary to achieve potential health-benefits in children and adolescents (american heart association, 2013; carrel et al., 2005; luke et al., 2004; and allis et al., 1997). to help guide the development of quality physical education programs, the society of health and physical educators (shape) has proposed guidelines for physical education instruction time, physical education teacher qualifications, and availability of physical education facilities. this study focused on describing these components in high schools (10th, 11th, 12th grades) located in southwestern pennsylvania, and examined whether there are demographic characteristics of the school (locale, size, ses status) that affect these factors. this information may be valuable in understanding how to improve the quality of physical education across schools mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 2; march-april 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 17 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe with diverse characteristics, and may lead to the development of interventions and policies to improve the quality of physical education in high schools. the results of the current study suggest that teacher qualifications, facilities and demographic factors such as school size, locale and ses status do not influence physical education instruction time and consequently, do not impact the quality of physical education. quality physical education, however, may be necessary for improving health outcomes in children. thus, it becomes important to identify other factors or barriers to implementing quality physical education. results of a study conducted by barroso et al (2005) revealed that physical education teachers identified factors such as large class sizes, low priority compared to other academic subjects and inadequate financial resources as the top three barriers to implementing quality physical education programs. future research is needed to indentify strategies for improving the quality of physical education despite these barriers. although the present study was not without limitations, it is the first study to investigate the ability of schools in southwestern pennsylvania to achieve shape’s components for quality physical education and to determine whether there are demographic factors that affect the ability of the schools to implement these guidelines. while this study examined the effect of these factors on physical education instruction time, it is important to differentiate instruction time from measured physical activity within the period of physical education instruction and participation in physical activity during the school day outside of physical education. in fact, the current literature investigating the influence of demographic factors on physical education has focused on physical activity rather than instruction time (butcher et al., 2008, haug et al., 2008; mckenzie et al., 1996; and springer et al., 2009). however, the shape guidelines for quality physical education focus on instruction time. therefore, it may be necessary to revise the guidelines for a quality physical education to include participation in physical activity rather than duration of instruction time. references american heart association. (2013).physical activity in children. report, american heart association national center, dallas, tx. barroso c.s., mccullum-gomez c., hoelscher d.m., et al. (2005). self-reported barriers to quality physical education by physical education specialists in texas.journal of school health,75, 13–319. butcher k., sallis j.f., mayer j.a., et al. (2008). correlated of physical activity guidelines compliance for adolescents in 100 u.s. cities. j adolesc health,42(4), 360-368. carrel a.l., clark r.r., peterson s.e., et al. (2005).improvement of fitness, body composition, and insulin sensitivity in overweight children in a school-based exercise program: a randomized, controlled study. arch pediatradolesc med, 159(10),963-968. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 2; march-april 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 18 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe centers for disease control and prevention. (2012). youth risk behavior surveillance – united states.morbidity and mortality weekly report 2012, 61(4), 35-36. dietz w.h. (1997). health consequences of obesity in youth: children predictors of adults and disease.pediatrics,101, 518-525. haug e., torsheim t., samdal o. (2008). physical environmental characteristics and individual interests as correlates of physical activity in norwegian secondary schools: the health behavior in school-aged children study. international journal of behavioral nutrition and physical activity, 5(47). jones s.e.,brener n.d., mcmanus t., et al. (2003). prevalence of school policies, programs and facilities that promote a healthy physical school environment. american journal of public health,93(9), 1570-1575. luke a., philpottj., brett k., et al. (2004).physical inactivity in children and adolescents: casm adhoccommittee on children’s fitness.clin j sports med,14, 261-266. mcdaniel t., melton b.f., langdon j. (2014). promoting physical activity through student life and academics. health education journal,73(2), 237-244. mckenzie t.l., nader p.r., stikmiller p.k,.et al. (1996).school physical education: effect of a child and adolescent trial for cardiovascular health. prev med, 25, 423-431. national association for sport and physical education. (2011).physical education is critical to educating the whole child. report, nationalassociation for sport and physical education, reston, va. pate r.r., davis m.g., robinson t.n., et al. (2006). promoting physical activity in children and youth: a leadership role for schools. circulation, 114, 1214-1224. quitério, a. (2012).school physical education: the effectiveness of health-relatedinterventions and recommendations for health-promotion practice. health education journal,72(6), 716-732. sallis, j.f., mckenzie t.l., alcaraz j.e., et al. (1997).the effects of a 2-year physical education program (spark) on physical activity and fitness in elementary school students. american journal of public health, 87(8), 1328-1334. springer a.e., hoelscher d.m., kelder s.h., et al. (2009).prevalence of physical activity and sedentary behaviors by metropolitan status in 4th, 8th and 11th grade students in texas, 2004-2005.preventing chronic disease, 6(1), 1-16. story m., kaphingst k.m., and french s. (2006).the role of schools in obesity prevention.future child,16(1).109-142. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 2; march-april 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 19 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe u.s. department of health and human services.(2008).physical activity guidelines for americans. report, u.s. department of health and human services, washington, dc. u.s. department of health and human services. (2010). the surgeon general’s vision for a healthy and fit nation. report, us department of health and human services, public health service, office of the surgeon general. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 5; september-october 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 12 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe kotter model in action: a case study of a kinesiology department-to-school transformation 1stephen james brock, 2kayla peak smith and 3sarah williams jones 1department of educational leadership & technology, tarleton state university. 2associate dean, college of education/associate professor of kinesiology, school of kinesiology, tarleton state university. 3department of educational leadership & technology, tarleton state university. abstract: this paper describes the transformation of the kinesiology program at tarleton state university from a single departmental unit to a school with two departments. the change initiative was led by dr. kayla peak, an associate dean in the college of education. the key factors that contributed to the success of the change initiative were: (1) strong leadership from dr. peak; (2) a clear vision for the future of the kinesiology program; (3) effective communication with stakeholders; and (4) a commitment to continuous improvement. keywords: kinesiology, change management, change agent, leadership, communication, continuous improvement introduction as an academic concentration, kinesiology is one of the fastest growing and expanding majors in higher education (morrow & thomas, 2010; thomas, 2014). adjusting to the influx of students, administrators have implemented program changes such as shuffling departmental organization, redesigning curriculum, and modifying academic functions (young, 2018). this was the case at tarleton state university, a mid-sized public institution located in texas. for over 90 years, tarleton state university kinesiology program consisted of a single departmental unit. like so many other kinesiology programs, the internal student enrollment in tarleton state university‟s department of kinesiology experienced inflation over the past decade. in connection to rising student enrollment, kinesiology professors faced challenges in addressing student needs such as advising, course availability, and academic support. in the fall 2018 semester, tarleton state university established the school of kinesiology, which currently houses two units – the department of health & human performance and the department of sport science. to complete the department-to-school transformation, administrators and faculty in tarleton state university‟s kinesiology program took part in a complex, tedious change initiative process. the steps taken successfully yielded new administrative units, academic restructuring, and faculty reform. this initiative required an effective leader at the ground level, also referred to as a change agent (weick & quinn, 1999). in the case with the department-to-school kinesiology program transformation at tarleton state university, dr. kayla peak, an associate dean in the college of education, acted as the change agent. in fact, the departmentmailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 5; september-october 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 13 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe toschool change initiative itself was her idea. she led the movement from the initiative‟s origins in 2013 to the school of kinesiology‟s official opening in 2018. as students in a doctoral educational leadership program, two of the investigators were curious about the realworld application of leadership principles. we heard about the transition of a large academic unit (kinesiology) and contacted the leader of the transition to investigate. as a result, to gain insight into how such a successful change process within the higher education settingoccurred, an interview with change agent (peak) was scheduled and completed. the original purpose of this study was to narratively document the department-to-school transformation. however, after conducting the interview and learning about the process behind the departmentto-school transformation,theinvestigators realized that the steps taken during the department-to-school transformationactually followed john kotter‟s (1996) eight stage process for creating a major change. due to this revelation, the authors adjusted the study‟s original purpose and methodology to critically examine how the change agent intuitively followed kotter‟s change model. therefore, this qualitative case study examined how a change agent intuitively followed kotter‟s (1996) eight stage process of creating a major change and completed the academic unit transformation of tarleton state university‟s kinesiology program. 1.1 kotter’s eight stage process of creating major change literature on organizational change management reveals that there are an array of existing models (see armenakis & bedeian, 1999). a change management model acts as guidance for organizational leaders and teams to follow during change implication and mitigation. one of the most popular change management models, in terms of scholarly attention and practical adoption, is kotter‟s (1996) eight stage process. kotter first introduced his model in a 1995 harvard business review article. kottergained national acclaim after the model was published in the 1996 bestselling book leading change. according to his model, kotter (1996)believes that leaders can transform their organizations by completing the following eight stages (p. 21): 1. establish a sense of urgency 2. create a guiding coalition 3. develop a vision and strategy 4. communicate the change vision 5. empower employees for action 6. generate short-term wins 7. consolidate gains and produce more change 8. anchor new culture kotter (1996) argued that the stages needed to be followed in sequence, as completing non-sequentially “almost always creates problems” (p. 24). several case-studies have found kotter‟s model yielded successful organizational change in business sectors (cowan-sahadath, 2010; pollack & pollack, 2015), health professions (small, gist, souza, dalton, magny-normilus, & david, 2016; mørk, krupp, hankwitz, & malec, 2018), k-12 public education reforms (barcelona, 2014), and even in the higher education setting (calegari, sibley, & turner, 2015; eddy, 2003; hackman, 2017; sidorko, 2008). it is important to understand that despite research efforts mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 5; september-october 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 14 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe concluding kotter‟s process was effective towards implementing organizational change, no change management model guarantees success. theoretical in nature, these management models are instead to be viewed as practical guidance. as sidorko (2008) eloquently posited, “no single model can provide a one-size-fits-all solution to organizational change” (p. 316). this statement also applies to kotter‟s model. while some scholars claim that kotter‟s model offered a practical structure (hackman, 2017), others have critiqued and exposed the model for limitations (appelbaum, habashy, malo, & shafiq, 2012). a review of the literature concluded that little to no research has examined the intuitiveness of kotter‟s model. before continuing, it is important to briefly disclose how the authors defined intuition. congruent with francisco and burnett (2008), this study relied on a logical definition of the term. the generally accepted school of thought on intuition defines intuition as a “synthesis of prior knowledge defined as a blend of logic, experience and subconscious information that is stored in your mind and recalled when needed” (robinson, 2006, p. 4). bringing the conversation back to kotter‟s change process, appelbaum et al. (2012) stated that “the model is intuitive and relatively easy to accept since it is based on kotter‟s real-life experiences” (p. 776). however, appelbaum and colleagues (2012) declared that the intuitiveness had been assumed valid, as scholarship had not yet properly “tested and supported” the intuitiveness of the model itself (p. 776). 1.2 purpose of study there were two purposes for this study. first, it aimed to detail the steps taken to accomplish the department-toschool transformation at the research site, while at the same time revealing how the academic unit‟s transition followed kotter‟s change model. the authors also sought to use the case-study as a practical guidance to administrators thinking about change initiatives within their own academic programs. 2. methods 2.1 setting & participants tarleton state university officially established the school of kinesiology during the fall 2018 semester. generally, a school is established by merging two or more pre-existing, like-minded departments. as previously mentioned, the school of kinesiology was created by splitting one large, single department into two separate academic units. to complete such a task required patience, perseverance, and strong leadership built on a solid change foundation. there were two active participants in this qualitative study. the interviewer was a student in tarleton state university‟s doctorate in education program. a tarleton state university employee of over fifteen years, the interviewee served as department chair of kinesiology from 2013 to 2015 and from 2017-2018. at the time of the study, the interviewee was the associate dean of the college of education at tarleton state university. 2.2 data collection – the walking interview for the purpose of this study, a walking interview was conducted. also referred to as a go-along (thompson & reynolds, 2019) or a mobile interview (brown & durrheim, 2009), a walking interview is defined as when “the researcher walks alongside the participant during an interview” (kinney, 2017, p. 1). there are advantages associated with the walking interview arrangement (brown & durrheim, 2009; bulter & derrett, 2014; carpiano, 2009; kinney, 2017). unlike traditional sit-down interview procedures, walking side-by-side democratizes the mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 5; september-october 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 15 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe power balance between researcher and interviewee, structuring the interview process similar to a partnership (brown & durrheim, 2009; kinney, 2017). participants feel more comfortable answering questions while detached from their “politicized” or general work-space (anderson, 2004; hein, evans, & jones, 2008; trell & van hoven, 2010). lastly, walking interviews allow for the participants to use “dialogue as discovery” (denzin, 2003, p. 153). adding to a limited research line (harris, 2016), this study incorporated the walking interview to gain insight into the higher education setting. while several formats exist (anderson, 2004; carpiano, 2009; clark and emmel, 2010; kusenbach, 2003), there are two overarching walking interview designs – geographical and organic. within the geographical design, participants utilizespace and place as a research road-map. in this framework, it is common for the participants to predetermine a route to be followed (chang, 2017; clark & emmel, 2010; evans & jones, 2011). the interview can take place in the participant‟s occupational or personal environment, such as completing an everyday task or habit (kusenbach, 2003). however, the interview route can occur outside of everyday routine. many times a walking interview occurs in a physical location, such as a particular neighborhood, aiming to prompt discussions on a certain topic, add to the interviewee‟s biography, or gain further knowledge about a specific area. on the other hand, the route taken can be organic in nature if the geographical location itself holds no-to-little value (anderson, 2004; moles, 2008). when the interview takes place on an undetermined path, space and place are not intertwined with interview questions as the interviewer is more concerned with creating a fluid conversation (kinney, 2017). the walking interview used within the current study followed the latter format. the equipment used during the interview included a hand-held olympus recording device and a lapel microphone worn by the interviewee. while general questions were scripted, both interview participants understood ad hoc questions would possibly arise due to the interview‟s conversational nature (carpiano, 2009). the interview took place on the institution‟s campus; however, as previously mentioned, a route was not pre-determined. 2.3 data analysis after transcribing the interview verbatim, member-checking validated the transcription for accuracy (creswell & guetterman, 2019). the authors analyzed the interview transcription through deductive coding, using kotter‟s eight stages as overarching themes. according to richards & hemphill (2018), scholars using deductive coding reference pre-existing frameworks for theme guidance. also referred to as predetermined coding, deductive coding “may be based on a previous coding dictionary from another researcher or key concepts in a theoretical construct” (stuckey, 2015,p. 8). incorporating the deductive coding analysis framework, kotter‟s sequential stages were used as predetermined overarching themes. subthemes were also drawn from kotter‟s model. 2.4 organizational history & culture while this section may seem misplaced or even unconventional, the authors believe that peak‟s understanding of the department of kinesiology‟s culture played a major role in the department-to-school transformation success. despite being absent in kotter‟s (1996) change model, several scholars charge that organizational leaders must mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 5; september-october 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 16 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe learn and understand an organization‟s culture prior to implementing changes (galpin, 1996; jaskyte, 2004;owens & valesky, 2015). peak had a deep rooted appreciation for kinesiology‟s rich history at tarleton state university. several times during the interview she mentioned former faculty members associated with the program‟s rich history. a statement from peak indicated that she believed the program‟s continued success and prosperity stemmed from these individuals and their positive impact on the program‟s culture. she stated: i am a big believer in understanding and acknowledging the history of a program in order to move forward. upon researching the roots of the kinesiology program, which was 92 years old at the time, i came to realize that our program was built upon the shoulders of giants. faculty and leaders who worked diligently to make sure that „physical training‟ (the name of the department in 1921) did not take a back seat to other academic disciplines. the leaders in 1921 were revolutionaries in education – they believed that „physical training‟ which eventually became „physical education‟ was a sacred academic discipline that deserved its rightful place in academia. these men and women made sure that they established high standards, held people to those standards, and were always pushing the envelope …so for me, it was important to respect the rich history of the department as it evolved from the 1920s to the 1970s and into the massive growth era of the 2010s. i understood that honoring the history would be paramount to our future success. she provided further detail on this concept: here‟s an example of our rich history – the first african-american student to receive a degree from tarleton state university was a physical education major. powerful! the first african-american hired as a full-time employee at tarleton state university was a physical education instructor and coach. but, before that, all the way back in 1921, kathleen blackshear was hired as the coordinator of women‟s athletics. trailblazers! where did they come from? the kinesiology department! and i love that … i really think that we need to remember, honor, and promote the bold leaders and trailblazers of the past. established in 1921, the kinesiology program is one of the oldest academic units at the university. peak took time to conduct research on the kinesiology program and also brought a cultural understanding associated with her tenure as an undergraduate student within the program itself. peak transferred to tarleton state university during her junior year. shortly after enrolling in the department of kinesiology as a student, she realized “no matter when i went to the office almost everybody [faculty] was there and the door was open.” later on in the interview she elaborated on how the culture directly impacted her as an undergraduate student: i will never forget the first day in class monday morning at 8 o‟clock. i‟ll just never forget it. i had dr. joe gillespie and he called me by name three times in an 8am class. first day. and i thought about the fact that i had been at texas a&m for two years and no one had ever called me by name [laughter], you know i am number 36 or number 102 or whatever it is … but at tarleton state, i was a valued member of the team – even as a young student – so i immediately became a kinesiology major. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 5; september-october 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 17 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 2.5 structure of paper it is now appropriate to detail the paper‟s organizational structure. similar to previous studies (pollack & pollack, 2015; hackman, 2017), this paper follows kotter‟s process. in sequential fashion, the major principles of each stage are introduced in the section‟s outset. following the brief introduction, excerpts gathered from the walking interview places the actions taken during the departmenttoschool transformation within the stage. 3. stage 1: establish a sense of urgency kotter‟s (1996) argued that the first step a leader must take in the change initiative is to establish a sense of urgency. without a shared sense of urgency amongst organizational stakeholders “the momentum for change will probably die far short of the finish line” (kotter, 1996, p. 36). according to kotter, there are several effective methods leaders can use in order to raise urgency surrounding a change initiative, including setting high expectations, utilizing eye-opening data, and taking bold actions. as political, economic, social, and symbolic forces drive an organization (bolman & deal, 2013), leaders/change agents must recognize the type of action required within their environment to effectively spread urgency. 3.1 gathering data 3.1.1 empirical data. according to institutional data on student enrollment, the number of students earning a degree housed in the tarleton state university‟s department of kinesiology had gradually increased each year during a five year span (2012-2017). in fact, over 1,000 students declared kinesiology as their major (13% of total student population) during the 2017 academic year, making the academic concentration the largest undergraduate majors at tarleton state university. peak commented “as a department with over 1,000 students and just under twenty faculty, we had limited resources. we also had a limited budget and limited facilities.”peak determined that a departmental administrative unit could not effectively sustain a continuously enlarging internal student enrollment without financial and administrative support. see table 1 for student population growth within the department of kinesiology. table 1.student population growth within the department of kinesiology, 2012 2017 year undergraduate students graduate students total 2012 655 52 707 2013 687 52 739 2014 732 58 790 2015 853 70 923 2016 903 79 982 2017 930 80 1010 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 5; september-october 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 18 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 3.1.2 anecdotal data. in addition, peak noted several anecdotal rationales behind the change initiative. according to peak, as an academic field kinesiology had experiencedlimited respect in the higher education setting. in her mind, becoming a school would allow kinesiologyadministrators to have a representative voice in aspects of budgeting and campus politics. peak said: for many years, kinesiology has been a neglected discipline in terms of prestige. but, in fact, we are a major part of the stem disciplines. the science, technology, and even engineering (think about biomechanics and the development of sports equipment) are prevalent in the kinesiology curriculum. so i wanted the opportunity to get a seat at the table and perhaps change the perception of kinesiology and shine a bright light on the science and business of kinesiology – let people see it and understand it. she echoed the why behind the change initiative later in the interview: and, it‟s probably not the right way to say it, but just to get more credibility on campus. anyone who has been in kinesiology understands that sometimes people assume that you‟re an old-school traditional roll-outthe-ball type academic discipline and that‟s not who we are. elevating to a school-level provides a new platform to promote an academic discipline that is at the forefront of science, technology, allied heath, sport, and business. speaking from personal experiences as a former chairperson in the department of kinesiology, peak claimed that the individual serving as department chair oftenstruggles to progressively lead the organization forward. the department of kinesiology had one administrator overseeing the educational unit‟s daily operations. tasked with overseeing the needs of 20 full-faculty members, 27 adjunct instructors, 15 graduate assistants, and over 1,000 students, the department chair commonly approaches work with the overwhelmed mindset to, according to peak, “manage what you have, put out fires and you just keep the ship upright and moving forward.” 3.2 bold action peak needed to spread urgency amongst kinesiology faculty, staff, as well as university administrators. recognizing her lack of professional longevity when compared to senior faculty within the department, peak feared others would view her change initiative as a threat to the existing culture. she commented “the last thing you want to do is say „we are going to come in here and change the program.‟” peak reached out to senior faculty members about the need for the transformation, hoping if senior faculty were on-board with the change initiative gaining buy-in from others within the organization would most likely increase. peak described her interaction with senior faculty: so i reached out to the senior faculty and we talked about the possibilities – „what do you think? what might this look like? should we do it? should we not do it? what are the negatives? how could this destroy the culture that has existed for the past 92 years?‟ starting with the senior faculty allowed the concept to bubble up from the faculty level and move upward instead of a top-down approach. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 5; september-october 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 19 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 4. stage 2: create a guiding coalition despite how powerful, productive, persuasive, or even efficient an individual leader is, a successful change initiative requires a team. “individuals alone, no matter how competent or charismatic, never have all the assets needed to overcome tradition and inertia” (kotter, 1996, p. 6). as a result, the second stage in kotter‟s model calls for change agents to assemble a guiding coalition. regarding the guiding coalition composition, kotter (1996) recommended change agents recruit organizational key players, or individuals from outside of the organization (i.e. hiring new employees), that possessed decision making ability, knowledge, experience, and leadership skills. it is the change agent‟s responsibility to assemble the guiding coalition. furthermore, the guiding coalition must work as a team, including placing trust in each other to accomplish the tasks associated with the change initiative. 4.1 senior faculty members the initial guiding coalition for the school of kinesiology consisted of peak and two senior faculty members. both of the senior faculty had a combined 70 years of administrative and teaching experienceat tarleton state university. when approached with the department-to-school transformation idea, peak paraphrased their collected response: what they both said, and i am paraphrasing here, was „look if this gives us a seat at the table, if this gives us an opportunity and it doesn’t really change who we are as a unit, then what’s the harm? why don’t we try it? great things could come out of the move.‟ as previously mentioned, gaining support from two respected senior faculty members within the organization was critical in getting others on board with the change initiative. 4.2 hiring new faculty peak recognized that the guiding coalition needed to be larger than three members. she also noted that it was a necessity to hire effective chairpersons for the two new departments. as a result, search committees were tasked to find individuals with previous leadership experience to fill the chairperson positions. the individuals hired as chairs both held administrative positions at other institutions. one of the new hires served as a former athletic director and the other had previously acted as a department chair at a carnegie r-1 research institution. overall, their experiences in higher education leadership allowed them to positively contribute as members of the guiding coalition as they helped increase urgency, momentum and progression regarding the department-to-school transformation. 5. stage 3: develop a vision once a guiding coalition has been established, a clear, concise change initiative vision needs to be established. according to kotter (1996), a vision provides direction for change, justifies the direction with compelling reasons, and motivates actions from others. leaders often fail at inspiring change because their visions are either too brief or too bogged down with jargon. kotter argued effective visions are focused and simple, yet at the same time also attention grabbing and convincing. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 5; september-october 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 20 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 5.1 official vision when it came time to creating a vision for the school of kinesiology, peak did not reinvent the wheel. instead, she understood the power behind the university‟s vision statement (tarleton state university, 2019): tarleton state university will be the premier student-focused university in texas and beyond. we will transform generations by inspiring discovery, leadership and service through exceptional teaching and research in vibrant learning communities. kinesiology faculty and staff supported the institution‟s vision statement. therefore, when it came time to create an official vision statement for the school of kinesiology, peak used the institution‟s vision served as the inspiration. the vision of the school of kinesiology is: the school of kinesiology will provide tomorrow‟s leaders with purpose-driven educational experiences that will enhance their knowledge, skills, and confidence related to their chosen career field. we will be the premier builder of fearless champions within the kinesiology discipline. using similar verbiage and sentence structure placed the school of kinesiology‟s vision in line with the institution’s vision, potentially helping gain support from stakeholders. 6. stage 4: communicate the vision properly communicating the vision is key to the change initiative‟s success. according to kotter (1996), “communication seems to work best when it is so direct and so simple that it has a sort of elegance” (p. 89). effectively and efficiently broadcasting the vision to stakeholders drives the initiative forward. while a welldefined vision benefits an organization, the “real power” occurs when stakeholders support the vision direction. kotter (1996) offered leaders useful tips to succeed at this fourth stage such as: a) rely on simplistic language; b) use metaphors, analogies, and examples; c) broadcast the vision in multiple venues; d) constantly repeat the vision; and e) keep a twoway communication between yourself and others (p. 90). peak had to communicate the vision to two main stakeholders – faculty and executive administration. she scheduled an informational session to propose the change initiative idea to faculty members. instead of using the meeting as an authoritative declaration, peak approached faculty in a democratic nature. she described the meeting as: we had a faculty meeting the following december 2015 and our dean [name retracted] came over to broached the idea of a school with the faculty at that meeting. most of the faculty, much like our senior faculty, asked „is there a downside?‟ there was free-flowing discussion and, in the end, most faculty couldn‟t find a downside to it. after gaining faculty support, peak had to get executive administrators [i.e. deans, provosts, presidents] to recognize the urgency behind the department-to-school initiative. as a reminder, peak acted as the kinesiology department chair during the change initiative‟s early stages. as department chair, she had the opportunity to talk with university echelons at institutional-wide meetings. 7. stage 5: empower for action in the fifth stage leaders must ensure organizational members feel empowered and relevant regarding the change implementation. often times, leaders fail to “make structures compatible with the vision” (kotter, 1996, p. 115). mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 5; september-october 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 21 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe change agents must remove obstacles hindering stakeholders' ability to contribute to the overall change process. many leaders allow silos to exist within the organizational structure, ultimately hindering the change initiative. in addition to draining independent authority, silos cause individuals to feel frustrated and useless within the overall change initiative process. 7.1 preventing silos. as previously noted, the department-to-school transformation involved splitting a single department into two divisions. peak noticed a natural split already existed within the department based on student major concentrations. based on organizational data, she realized that approximately half of kinesiology students were pursuing a degree focused on allied health and fitness-based career fields while the other half were earning a degree in order to advance as professionals in teaching, coaching, and athletic administration. while it was fortunate for this natural division to exist in the department, creating two individual departments had the potential to disrupt the pre-existing culture. a pressing concerns prior to dividing the department, peak feared the change initiative would create silos amongst faculty, administrators, and even students. she mentioned: we are only going to win…we are only going to grow…we are only going to stay strong if we stay together as a team. we can‟t let one department try to spin-off, try to step on top of the other, in order to get ahead. we‟ve got to keep an eye on the team culture that has provide the firm foundation for our current success. we must stand together and be supportive of everyone. peak continued on this concept: the three of us [members of guiding coalition] as well as our faculty, have had many conversations about the danger of silos. everybody understands that one department is not more important than the other. yes, one department maybe larger, or produce more research, or provide more hours of community and professional service, or even secure more money in grant funding – but it doesn‟t matter. we must remain one cohesive team; we have pledged to never lose sight of that. peak and the guiding coalition were determined to“stay away from those traditional [organizational] structures because again we weren‟t two departments that merged together – the traditional route for creating a school.”they viewed the traditional top-down hierarchical chart as an intentional forecasting of becoming siloed. after researching organizational structure, peak and her the team determined that an organizational chart which was “circular in nature”was ideal. in fact, they found that the circular organizational structure was commonly used by successful and innovative think tank companies such as apple and google. at the center of the organization‟s chart lies the program‟s culture. peak claimed the cultural core acts as “a constant reminder of what, at the very heart of who we are, it‟s about people and it‟s about that „team‟ culture.”next, the departments make up the second layer, followed by academic concentrations offered. the fourth layer includes auxiliary areas such as labs, institutions, and research efforts. the chart‟s outermost layer consists of the word assessment, which peak referred to as “our box score,” functions as a source of organizational accountability. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 5; september-october 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 22 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 8. stage 6: generate short-term wins according to kotter (1996), effective short-term wins are “visible, unambiguous, and clearly related to the change effort” (pp. 121-122). leaders must deliberately plan out short-term wins along the change initiative path. in addition to rewarding artificial accomplishments, short-term wins justify sacrifices made by the stakeholders, impair efforts from critics or resistors, and stimulate change momentum. it is essential for leaders to manage short-term wins regarding complacency build-up because “whenever you let up before the job is done, critical momentum can be lost and regression may follow” (kotter, 1996, p. 133). by utilizing kotter‟s change model, the celebration of short-term milestones helped sustain the vision‟s endgoal. for example, shortly following the informational meeting (see stage 4), faculty came together again to discuss setting the potential academic structures in further detail. throughout the 2014-2015 academic year, scheduled faculty meetings accomplished short-term wins such as determining departmental names, major concentrations offered in each department, and core kinesiology classes. 9. stage 7: consolidate gains and produce more change as previously mentioned, short-term wins are small factors within the interdependency of changing organizational structures. to explain organizational interdependence,kotter (1996) provided a metaphorical example of a work-place office. at the center of the office sits a chair needing to be moved (i.e. the vision). ropes, rubber bands, and cables connect the chair to various objects in the office space, thus making the moving process complex. a leader/guiding coalition must put time, energy, and personnel to address the forces keeping the chair in place. reiterating the challenges of producing more change in light of short-term wins and complacency, kotter wrote (1996) “changing highly interdependent settings is extremely difficult because, ultimately, you have to change nearly everything” (p. 136). therefore, while short-term wins need to be celebrated, change agents should also encourage others towards producing more change. 9.1 interdependence during the change initiative, the guiding coalition had to overcome challenges associated with web-like interdependency. in order to address interdependency, peak detailed “we did a lot of this work simultaneously.” once faculty decided on new department names, concentrations offered within each department, and core undergraduate kinesiology courses, peak and the guiding coalition used short-term wins to springboard onto a much larger project an official 5-year strategic plan. the goal of the strategic plan was to address the ropes, rubber bands, and cables within the change initiative. according to the plan, faculty and staff in the school of kinesiology would establish inhouse academic journals, create clinical labs, plan study abroad trips, and increase applied learning experience opportunities. the strategic plan also noted to recruit new students, promote student success, engage with external partners, and elevate research efforts. peak described the complex process behind creating a strategic plan during the walking interview: every faculty member had input and then it went forward for departmental discussions and finally moved to the school level. the executive leadership team (school head and the two department heads) created a 5-year mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 5; september-october 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 23 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe strategic plan based on faculty feedback. once the plan was constructed, we pushed it back down to the faculty. they made edits. they pushed it back up to us. we made revisions and pushed it back down for another review. the 5year strategic plan for became a comprehensive, aggressive, forward-thinking vision that was built and approved by the entire team. 9.2 produce more change during the interview, peak organically offered advice for educational leaders to follow to avoid complacency build-up from short-term wins. she claimed that educational leaders “can‟t sit back and assume that things will come to you. you have to create a strategic plan that pushes the envelope and embraces the excitement of what‟s next.” 10. stage 8: anchoring new culture the last stage in kotter‟s (1996) model is to embed changes within the organization‟s behavioral norms and shared values. to become rooted within an organization‟s culture, new changes must receive continued support from stakeholders. in addition to being the hardest stage for change agents to accomplish (kotter, 1996; hackman, 2017), the eight stage is also the most difficult to evaluate (appelbaum et al., 2012). evaluating the success of anchoring cultural change depends on the initiative‟s overall results. it is important to emphasis that peak did not intend on changing the core culture. she claimed: we had a really great culture that was established by faculty and students dating back to 1921 … that culture was one which valued hard work, innovative teaching, and commitment to the profession, engaged scholars, and, most importantly, was student-centered. in short, our culture was centered on the team concept – every member (faculty or student) played a vital role in the ultimate success of the program. in this instance she was talking about positive attributes such as student-centered, teaching oriented, and family atmosphere.therefore, her goal was to implement the department-to-school transformation while keeping the positive culture present amongst faculty, administrators, and students themselves. while the department-to-school initiative was completed at tarleton state university, the implications are not yet mature enough to evaluate. the school of kinesiology has only been officially “opened” for one year; thus, infancy makes kotter‟s last stage difficult to analyze. today, kinesiology faculty and administration progressively lead the program forward. a follow-up study is needed to determine if this progressive culture has in fact taken root. 11. conclusion in conclusion, this paper relied on findings from a walking interview to detail the steps taken to transform a department of kinesiology into a school of kinesiology. as evident by the qualitative data gathered, the departmentto-school transformation was tedious, culture centered, and required a team effort. unlike previous studies (calegari, sibley, & turner, 2015;hackman, 2017; pollack & pollack, 2015), the change agent highlighted in this study did not rely on kotter‟s leading change for guidance or change management. instead, the authors placed the steps taken during the department-to-school process within kotter‟s eight stage process for creating a major change. in no way does this study detail all the undertakings associated with the six-year mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 5; september-october 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 24 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe long change initiative. recognized as a limitation, the findings presented in this study do not comprehensively represent the contributions from and challenges faced by the guiding coalition and/or the contributing faculty and staff. a popular critique regarding kotter‟s model is “not many studies set out to validate the full eight stages” (appelbaum et al., 2012, p.776). while outside the original purpose, this study‟s findings revealed that kotter‟s model is intuitive. prior to partaking on the department-to-school transformation, the change agent was unaware of leading change and the eight sequential stages. rather than following “a road map” or change management guide, the change agent, guiding coalition, associated faculty, and administrators in this case study successfully completed the initiative by simply doing what felt right. only after analyzing the steps taken post-initiative completion was it revealed that the actions that “felt right” matched up with kotter‟s sequential model for organizational change. this validation does not stem from theoretical or even conceptual concepts found in academia, but instead in the case-study framework of a single practitioner. it is important to note that while the generalizability of this research is non-existent, the potential impact on the understanding of kotter‟s model is significant. future studies to verify the intuitiveness of kotter‟s change model are needed. in all, the authors acknowledge that the rapid increase in internal student enrollment is causing kinesiology academic units within higher education to experience, or start planning to implement, changes within their organizations. it would be naïve to believe that the department-to-school transformation detailed at this study‟s research site is commonplace within kinesiology. however, the authors encourage kinesiology leaders and change agents to look at change management models, such as kotter‟s eight stage process, as a theoretical and practical guidance during organizational changes. references anderson, j. (2004). talking whilst walking: a geographical archaeology of knowledge. area, 36(3), 254-261. appelbaum, s. h., habashy, s., malo, j.-l., & shafiq, h. (2012). back to the future: revisiting kotter‟s 1996 change model. journal of management development, 31(8), 764-782. armenakis, a. a., & bedeian, a. g. (1999). organizational change: a review of theory and research in the 1990s. journal of management, 25(3), 293-315. barcelona, k. (2014). 21st century curriculum change initiative: a focus on stem education as an integrated approach to teaching and learning. american journal of educational research, 2(10), 862-875. bolman, l. g., & deal, t. e. (2013). reframing organizations: artistry, choice, & leadership (5th edition). san francisco: jossey-bass. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 5; september-october 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 25 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe brown, l. & durrheim, k. (2009). different kinds of knowing: generating qualitative data through mobile interviewing. qualitative inquiry, 15, 911-930. bulter, m., & derrett, s. (2014). the walking interview: an ethnographic approach to understanding disability. the internet journal of allied health sciences and practice, 12(3). calegari, m. f., sibley, r. e., & turner, m. e. (2015). a roadmap for using kotter‟s organizational change model to build faculty engagement in accreditation. academy of educational leadership journal, 19(3), 29-41. carpiano, r. m. (2009). come take a walk with me: the „go-along‟ interview as a novel method for studying the implications of place for health and well-being. health and place, 15, 263-272. chang, j. (2017). the docent method: a grounded theory approach for researching place and health. qualitative health research, 27(4), 609-619. clark, a., &emmel, n. (2010). using walking interviews. realities, 1-6. cowan-sahadath, k. (2010). business transformation: leadership, integration and innovation a case study. international journal of project management, 28(4), 395-404. creswell, j. w., & guetterman, t. c. (2019). educational research: planning, conducting, and evaluating quantitative and qualitative research (6th edition).new york: pearson. denzin, n. (2003). the cinematic society and the reflexive interview. in j. gubrium, & j. holestein (eds.), postmodern interviewing (pp. 141-156). thousands oaks, ca: sage. eddy, p. l. (2003). change in community colleges through strategic alliances: a case study. community college review, 30(4), 1-20. evans, j. & jones, p. (2011). the walking interview: methodology, mobility and place. applied geography, 31(2), 849858. francisco, j., & burnett, c. (2008). deliberate intuition: giving intuitive insights their rightful place in the creative problem solving thinking skills model. paper presented at the meeting of the creativity & innovation management journal, buffalo, n.y. retrieved from http://bridgepointeffect.com/wpcontent/uploads/2012/12/deliberate-intuition-cim.pdf hackman, t. a. (2017). leading change in action: reorganizing an academic library department using kotter‟s eight stage change model. library leadership & management, 31(2), 1-27. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 5; september-october 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 26 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe harris, j. (2016). utilizing the walking interview to explore campus climate for students of color. journal of student affairs research and practice, 53(4), 365-377. hein, j., evans, j., & jones, p. (2008). mobile methodologies: theory, technology and practice. geography compass, 2(5), 1266-1285. galpin, t. (1996). the human side of change: a practical guide to organization redesign. san francisco: josseybass. jaskyte, k. (2004). transformational leadership, organizational culture, and innovativeness in nonprofit organizations. nonprofit management and leadership, 15(2), 153-168. kinney, p. (2017). walking interviews. social research update, 67, 1-4. kotter, j. p. (1996). leading change. boston: harvard business school press. kusenbach, m. (2003). street phenomenology: the go-along as ethnographic research tool. ethnography, 4(3), 455-485. moles, k. (2008). a walk in thirdspace: place, methods and walking. sociological research online, 13(4), 2. mørk, a. , krupp, a. , hankwitz, j. & malec, a. (2018). using kotter's change framework to implement and sustain multiple complementary icu initiatives. journal of nursing care quality, 33(1), 38–45. morrow, j. r., & thomas, j. r. (2010). american kinesiology association: a national effort to promote kinesiology. quest, 62(1), 106-110. owens, r. g., & valesky, t. c. (2015). organizational behavior in education: leadership and school reform (11th edition). boston: pearson. pollack, j., & pollack, r. (2015). using kotter‟s eight stage process to manage an organisational change program: presentation and practice. systematic practice and action research, 28(1), 51-66. richards, k. a. r., hemphills, m. a. (2018). a practical guide to collaborative qualitative data analysis. journal of teaching in physical education, 37, 225-231. robinson, l. a. (2006). trust your gut: how the power of intuition can grow your business. chicago: kaplan publishing. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 5; september-october 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 27 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe sidorko, p. e. (2008). transforming library and higher education support services: can change models help? library management, 29(4/5), 307-318. small, a. , gist, d. , souza, d. , dalton, j. , magny-normilus, c. & david, d. (2016). using kotter's change model for implementing bedside handoff. journal of nursing care quality, 31(4), 304–309. stuckey, h. l. (2015). the second step in data analysis: coding qualitative research data. journal of social health and diabetes, 3(1), 7-10. tarleton state university. (2019). mission/vision/core values. retrieved from https://www.tarleton.edu/strategicplan/2016-2020/mission-vision.html thomas, j. r. (2014). the public face of kinesiology in the 21st century. quest, 66(3), 313-321. thompson, c., & reynolds, r. (2019). reflections on the go-along: how „disruptions‟ can illuminate the relationships of health, place and practice. the geographical journal, 185, 156-167. trell, e. & van hoven, b. (2010). making sense of place: exploring creative and (inter) active research methods with young people. fennia-international journal of geography, 188(1), 91-104. weick, k. e., & quinn, r. e. (1999). organizational change and development. annu. rev. psychol. 50, 361-386. young, g. (2018). forgive the pun: things are really moving in kinesiology. texas tech today. retrieved from http://today.ttu.edu/posts/2018/06/kinesiology mailto:topacademicjournals@gmail.com http://today.ttu.edu/posts/2018/06/kinesiology american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 1 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe perception of environmental quality in sports facilities and its impact on indoor air quality 1giuseppe mario rossi, 2luca andrea bianchi and 3maria teresa verdi 1department of technological innovations and safety of plants, products and anthropic settlements, rome, italy 2public health unit, university of rome “foroitalico”, rome, italy 3department of technological innovations and safety of plants, products and anthropic settlements, rome, italy abstract: the individual perception of an indoor environment is a useful tool for assessing the livability and usability of sports facilities. different approaches have been developed to investigate the individual wellbeing, such as collecting data by questionnaires or monitoring techniques. these approaches can be used to assess the reciprocal impact of microclimate, environmental conditions, and clothing on physical activity. keywords: individual perception, indoor environment, sports facilities, livability, usability, wellbeing. introduction the individual perception of an indoor environment represents a useful tool for assessing livability and usability of sports facilities and for developing strategies for their improvement. different approaches have been developed to investigate the individual wellbeing such as collecting data by questionnaires or monitoring techniques, in order to assess the reciprocal impact of microclimate, environmental conditions and clothing on physical activity (nathan, 2013; leemrijse, 2015). other methods include interviews, use of maps and blog focus groups to evaluate the perception of indoor buildings quality, including schools or sport facilities (kirby, 2013; moran, 2014). as modern societies spend most of their time in buildings, the indoor air quality, thermal comfort, edifice maintenance, play a relevant role. these parameters assume a particular interest in sport facilities not only because physical activity challenges microclimate perception, but also for the higher expectancies for a healthy environment to practice sport. indoor air quality (iaq) assumes a special meaning in these workplaces, influencing human health and athletic performance (romano spica v, 2015). this is an emerging issue for sport hygiene involving a growing number of people and workers in the field of sport. a survey commissioned by the european commission's directorate general for education and culture (dgeac) on a sample of 26,788 european citizens, indicated that the people of the nordic countries are the most physically active in the eu (70% sweden, 68% denmark, 66% finland, 58% netherlands, 54% luxemburg), while the residents of the mediterranean countries, including bulgaria (78%), malta (75%), portugal (64%), romania (60%) and even italy (60%) are among those play sporting activities less than once a week (ec, 2014). mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 2 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe nevertheless, in italy, this sport industry counts 4.500.327 athletes and 1.016.598 operator, belonging to 64.829 clubs (coni, 2014). sports facilities are complex and heterogeneous buildings and they are unique in their kind, for energy consumption, used materials, comfort requirements (revel, 2014). moreover, performing sport in healthy environments strengthens motivation in addition to other factors such as age, sex, socio-economic conditions, school, food habits, plant accessibility (sani, 2012; eime, 2013; chen, 2013; reimers, 2014; coledam, 2014; adlakha, 2015; laxer, 2013). athletes can develop respiratory and allergic diseases not only due to the exposure to inhaled pollutants but also to the increased ventilation rate (sugiyama, 2008). the increase of air flow, with the fact that most of the air is inhaled through the mouth thus avoiding the normal nasal mechanisms for the filtration of soluble particles, allows the pollutants to proceed deeper into respiratory tract (carlisle, 2001). the most common pollutants detected in these environments include vocs (volatile organic compounds), fungi/molds, bacteria (gedikoglu, 2012; alves, 2013). swimming facilities pose an additional problem related to management of water, requiring surveillance on disinfection, humidity and environmental maintenance (who, 2006). the present paper reports local and international regulations on iaq in sport facilities and data from an original pilot study performed in two sport environments. 2. materials and methods the review of regulations and monitoring parameters was performed using online database and search engines. a local pilot study was conducted in two sports facilities in rome, to apply and test in field environmental indicators. several samplings points were identified to assess microbiological air quality through active sampler, and microclimate investigations by a data logger with different probes. in addition, in both sites were distributed questionnaires to users and workers, to ascertain the individual perception of the plants quality. analyses of the water safety and quality were tested in a swimming pool. 2.1. study area the first plant (site i) is a polyvalent sports center, which is the space of sport activity with related grandstands, support services such as dressing rooms, a store, a gym, all gathered in one building in front of an outdoor playground. the second plant (site ii) includes a gym, two fitness rooms, two tanks, a big pool, 25 m length (max depth 3.60 m) and a small pool, 10 m length (maximum depth 0.60 m), where are carried out baby and neonatal swimming lessons. 2.2. sampling procedure in site i six air samplings were conducted at the following points: the secretariat offices, the gym, 3 dressing rooms, and the store. in site ii three air samplings were performed: the big pool, the small pool and dressing room. the studies were carried out between january and may 2015. 2.2.1. microclim ate. the instrument used is the hd32.3 data logger (delta ohm ltd, italy) which has three probes, thermo hygrometric (temperature and relative humidity), anemometer (air velocity) and globe thermometer (radiant temperature). to determine the individual wellness, the instrument calculate the discomfort mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 3 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe indices pmv (predicted mean vote) and ppd (percentage of persons dissatisfied), comparing the environmental data with metabolic and clothing parameters. the pmv is a mathematical function which gives as result a numerical value in the range -3 (feeling too cold) to +3 (feeling too hot), where 0 represents the thermal comfort. the ppd expresses the percentage of dissatisfied people in a particular environment. the tool has been positioned in the sites center, for 15 minutes, with 15 seconds intervals in measurement at the worker’s chest height. to evaluate the thermal comfort we referred to standards iso 7730, 7726, 27243, 7933, 11079, 8996 (table 1). pmv ppd% evaluation of thermal comfort 3 100 very hot 2 75.7 hot 1 26.4 slightly hot 0.85 20 thermal environment within acceptable 0.5<pmv<0.5 <10 thermal comfort -0.85 20 thermal environment within acceptable -1 26.8 slightly cold -2 76.4 cold -3 100 very cold table 1: reference values of thermal comfort according to iso 7730, 7726, 27243, 7933, 11079, 8996. 2.2.2. microbiological air sampling. the microbiological air samplingwas performed by sas (surface air system, vwr international, llc, and radnor, usa), a plate impact active sampler, type slot, using petri dishes ø 55mm. the air aspiration volume was 180 l (for 60s) for each sampling. we used two culture media types: tsa agar medium for bacteria (tryptic soy agar oxoid, germany), sda agar medium (sabouraud dextrose agar oxoid, germany) supplemented with chloramphenicol (oxoid, germany) for fungi/molds. the tsa and sda plates were incubated both at 37°c (for 48 hours) and at 22°c (for 72 hours). for each plate, the calculation of the cfu/m3 was obtained as follows: cfu/m3 = (mpn/plate x 1000) / air volume (l).mpn/plate was obtained by comparing the cfu of each plate with the conversion table, in attachment to the device manual. 2.2.3. analysis of water quality in the pools. the water of the two swimming pools was sampled using two glass bottles (1l for each sampling) containing sodium thiosulfate (20 mg/l), necessary to block the action of disinfectants. following the italian regulation (italy, 2003), we have been investigated the following indicators: escherichia coli (iso 9308-2:2012), enterococci (enterolert, quanti-tray™ test), pseudomonas aeruginosa (pseudalert, quanti-tray™ test), staphylococcus aureus (iso 6888-3:2003) and was performed the counts at 22°c and 36°c hours. moreover, were monitored temperature, ph, free and combined chlorine data of the water. the chlorine was analyzed by colorimetric method (orto-tolidine molecule) for free active chlorine and by dpd mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 4 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe method (diethyl-p-phenylenediamine) for free and combined chlorine. global index of microbiological contamination (igcm) values have been also computed. 2.2.4. questionnaire. starting from a previous template developed byan environment and consumers protection association (adiconsum toscana), a specific questionnaire was prepared in order to assess and quantify the level of satisfaction of the site i visitors, in relation to hygiene and safety of the facility. it was subjected to 44 persons, 14 33 year aged. the questionnaire was characterized by two different sections: a structural assessment of the assembly (e.g. maintenance, safety, usability, condition of the equipment) and hygiene assessment (e.g. cleanliness, temperature, humidity). for each question was asked to express an opinion as "dissatisfied", "not very satisfied", "satisfied", "very satisfied". in site ii the questionnaire was proposed to 18 people, selected among the current members of the facility, and it asked the issues should be improved about the suitability of the structure, safety, hygiene, dressing rooms and personal notes. data collected and analyzed by excel. 3. results in this study, we report an overview of hygiene-related regulations from different countries and tested some indicators and instruments, samplings two sports facilities of rome. microclimate parameters, microbiological air quality, swimming pool water quality and the perception of indoor environments by users and employees were considered. 3.1. iaq regulations in sports facilities. several laws and regulations on construction and maintenance of sports facilities are available and relate to safety and public health. the following summary shows several institutions and regulations, involved in iaq management in sports facilities, in europe and other countries. 3.1.1. sport facilities. the legislation about sports facilities is very heterogeneous and depends on several factors, such as the state organization and the intended use of the facilities. sports facilities are often polyfunctional buildings, where different type of sport can be carried out, but that can be used also for other purposes such as recreational or leisure activities. different countries have different approaches. for example, the majorities of sporting facilities in australia are operated and maintained by local governments, schools (both public and private) and private sector business institutions which include sporting organizations or various commercial operators. in this nation there is not a unique authority with responsibility for iaq in indoor buildings and the guidelines are developed by several institutions, such as the national health and medical research council (nhmrc), the national occupational health and safety commission (nhmrc) and standard australia (sa). to assess iaq, australia refers to the guidelines drawn up by the american conference of governmental industrial hygienists (acgih, 1995) and by the commission of the european communities (cec, 1993; australia, 1997). in the united states of america (usa), several states have regulations on exposure to indoor pollutants for nonindustrial environments. recommended methods for prevention and remediation have been issued by the center for disease control and prevention (cdc), occupational safety and health administration mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 5 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe (osha), the environmental protection agency (epa), the american industrial hygiene association (aiha) and the new york city department of health and mental hygiene (dohmh). guidelines on iaq are provided by the epa-supported american society of heating, refrigerating, and air-conditioning engineers, ashrae (usa, 2012). health canada is the administrative authority which decides the sanitary standards for indoor environments in canada. in particular, several laws, like the hazardous products act and provincial occupational health and safety acts, are related to the management of biological risk in non-industrial buildings. the legislative framework for iaq indicated that there is no specific mention of most contaminants present in residential settings. the regulations suggest or require the adherence to the advice of cognizant authorities, including committee on environmental and occupational health (ceoh), the american society of heating air-conditioning & refrigerating engineers (ashrae-standard 62), and the acgih threshold limit values (tlvs), as well as determinations or policies of provincial and territorial labor and health departments (canada, 2004). in china, the ministry of construction and the china state quality supervision-inspection-quarantine administration (sqsiqa) promulgated the “code for indoor environmental pollution control of civil building engineering” (gb 50325-2001) where comprehensive standards for iaq are enunciated. in addition, the china ministry of health also issued the directive entitled “hygienic norm for indoor air quality”, which sets the standards and sanitary requirements for iaq and the sanitary requirements for air ventilation and purification and useful standard methods (china, 2002). moreover, in 2006 was promulgated “a new national design code for indoor air environment of sports buildings", that provided guidelines for indoor airflow of sports buildings in china, including the parameters of indoor air environment in gym and pools, such as air velocity, temperature, humidity and fresh air volume replenishing (china, 2006). in the russian federation, the quality of indoor air in occupational premises is determined by the statute “occupational safety requirements for working zone air”, dated 1989. this law establishes the general requirements of the microclimate and sets out the maximum allowable concentration (mac) of pollutants in the working zone air. the laws on air quality are part of the russian federation legal system and are secured in the constitution. the air quality must be controlled by the ’goscomgidromet’ and the ’sunepidnadzor’ of russia (russia, 1997). moreover, the attention on the issues regarding indoor environments has led some international scientific organizations, including the world health organization (who), to provide guidelines for iaq (who, 2010). in south africa, there is no specific law about iaq and moreover, in the several acts of the parliament regarding health matters, iaq does not feature prominently. the health act n. 63 of 1977 provides for measures for the promotion of the health of the inhabitants of the republic, hinting of indoor settings, over-crowding and poorly ventilated design as a source of dangers to health (south africa, 2002). mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 6 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe in europe, the activities of the commission of the european union (ue) have been characterized, over the past twenty-five years, by a growing attention to indoor pollution. the different studies financed in this context have tried to increase the knowledge framework and set priorities or objectives to be achieved (settimo, 2012). in this context, the member states operate by drawing up national guidelines in coherence to the eu standards. so, in finland, guidelines on indoor air control are drawn up in the national building code of finland, where are explained all the regulations about indoor climate and ventilation (finland, 2010). in the netherlands, the guideline values are established as values for the iaq in homes, but also offices, schools, recreational environments can be involved. the recommended values are based on the maximum permissible risk, mtr (netherlands, 2007). in france, the government established in 2001 the observatory for indoor air quality (oqai), which aims to draw up an inventory of indoor air pollutants and their determinants. in addition, french agency for food, environmental and occupational health & safety (anses), an administrative public establishment which provides assessment for veterinary medicinal products, pesticides, biocides and chemicals, in 2004 has developed iaq guideline values (iagvs), based on health criteria (france, 2011). in different countries, additional indications may be available for each sport, even if the international olympic committee and the sport federations represent a main source of information at least for athlete’s official competitions. however, the diffusion of sport and movement activity as a who priority for prevention in populations of different ages and health conditions poses the question of quality standards in gym, pools and other environments dedicated to physical activity. in italy, the reference standards for safety of sport facilities have been established by the ministry of internal affairs, by coni (italian national olympic committee) and by the welfare and occupation ministry. the decree of the ministry of internal affairs 18/03/1996, supplemented by ministerial decree of 06/06/2005 (italy, 2005), considers different aspects to ensure a good security level, determining for example, the characteristics of the emergency space, ways out, seating, changing rooms, electrical system, structures and furniture, fire regulations and other standards. relating to sports facilities buildings, was enacted directive coni n. 1379 of 25 june 2008 (coni, 2008), which provides specific references to air quality, aspect not taken into account by previous decrees. for example, it gives recommended values as regards the microclimatic parameters (ventilation, temperature, relative humidity). regarding the occupational aspects, the decree n°81 of 2008 (italy, 2008) encloses all the rules relating to health and safety at work and all the rules for the safe construction and maintenance of the workplaces. 3.1.2. natatorium facilities. the legislation at international level regarding swimming pools is very varied and heterogeneous. the difference is closely linked to the different approaches of individual health authorities which are related to the different social, economic and cultural needs of each country. in the usa there are not federal health standards, but the requirement of design, construction and management of the pools must be authorized by the municipal authorities. among the relevant social principles is included easy access to a swim structure for all kind of population groups (e.g. elderly, disables). mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 7 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe us health authorities entrust to the managers and professionals involved in the management of pools the responsibility to apply the principles of haccp (cdc, 2003). in canada, hygienic issues are regulated by legislation drawn up in 2007, establishing the water quality criteria and obligations for managers of indoor and outdoor swimming pools used for swimming, sport or relaxation (canada, 2006). similarly in australia, the legislation on swimming pools, dated 1990 (australia, 1990) and revised by the act of 1992, legislates in different fields of application, including even thermal pools, basins or similar environments (australia, 1992). in egypt, the principal legislation relating the control of swimming pool is the “egyptian standards no. 418/1995”, which establishes the microbial indicators and the physical–chemical parameters for water control (el-salam, 2012). within the european union countries, the situation is very diverse and heterogeneous. the directive 2006/7/ec (council of europe, 2006), concerning the quality of bathing waters, has been historically a great social impact on member states and has greatly influenced the approach to the regulation on matter pools, such as establishing the basic parameters for the evaluation of quality of bathing and recreational water and setting the necessary organization and nature of official controls on water. in the transposition of the directive into their national legal systems of the member states, a number of situations have occurred. some countries (e.g. belgium, finland, germany, greece, ireland, luxembourg, portugal, united kingdom) have included in the same standard on bathing waters, all measures deemed necessary for public toilets, thermal baths and pools, specifying the nature of the controls needed for such places. in france, the current legislative framework on swimming pools is based on the public health code. moreover, the national agencyforhealth food environment and labor (anses) in 2010 published a document on health risks in pools (france, 2006). in united kingdom, the health and safety executive (hse) is the authority competent concerning the pools matter in connection with local authorities and schools. this institution in 2008, with the health protection agency (hpa), has published guidelines on the control of the risk of infection in pools. these protocols are designed to improve the understanding of microbiological hazards and give advice on risk management (uk, 2006). similarly, since 2005 in ireland, pools must be managed in accordance with "safety, health and welfare at work act" (ireland, 2005). in addition, specific guidelines, with criteria and more detailed information, have been outlined to help managers in the task (ireland, 2010). in germany, technical requirements for the management of the pools are summarized in din19643, which ensures the hygiene safety standards in the pools, saunas, hot tubs and spas (germany, 1997). in italy, the current reference point about construction, maintenance and sanitary surveillance of pools is the agreement of 16 january 2003 (italy, 2003), between the minister of health and the regions. the text provides the requirements for the water control, in particular those related to temperature and ph, the use of disinfectants (cl2, ozone), the microbiological values and standard control. however this agreement has no legislative value, but it is only a political manifestation of intent, and all italian regions have to join and adapt it to local needs and hygiene objectives within a public health perspective (italy, 2007; liguori, 2013; giampaoli, 2012). 3.2. microclimate, microbiological air sampling and iaq evaluation. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 8 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe table 2 shows the results obtained in the two sites respect microclimate and microbiological air quality. the standard methods reported in different local or international regulations or previous studies revealed effective and informative. in particular, data on temperature, air velocity, relative humidity and pmv, ppd and igcm values are reported. in site i the temperature was around 16°c. the pmv values are negative in all environments, except the gym (4.9) and the store (0.6). the ppd values are similar in the gym (100%), dressing room 2 (99%) and dressing room 3 (93%). in site ii, the temperature is around 27°c. the pmv values range from 1 (dressing room) and 1.3 (big and small pool); ppd is similar in the three environments, with a mean of 35%. we referred to the guidelines of “american conference of governmental industrial hygienists” of 1995 (acgih, 1995) for the evaluation of igcm index (table 2). in the secretary and in the dressing room 1 of site i the igcm is intermediate; the dressing room 2 has the highest index of contamination; in others environments is low. in site ii, big pool and dressing room have both an intermediate pollution degree; the small pool low one. in table 3 is shown the iaq evaluation in the two sites referring to the guidelines drawn up by "european collaborative action" of 1993 (cec, 1993), which established the guidance ranges of air contamination for non-industrial indoor environments. in site i, air quality shows bacterial pollution degrees rather heterogeneous in the various sampled environments: very low values at 22°c in the dressing room 3 and store; high values at 37°c in the secretary and gym; very high at 37°c in the dressing rooms 1 and 2. the fungal growth had a more constant trend, in fact all the environments show intermediate values. in site ii, bacterial pollution at 22°c is intermediate in the big and small pool, while high in dressing room; at 37°c it is low in the small pool, while intermediate in the other two environments; fungal growth is intermediate for all environments. microclimate igcm/m³ (acgih, 1995) sampling point ta (°c) va (m/s) rh (%) pmv ppd (%) very low <500 low <1000 intermediate >1000 high >5000 very high >10,000 site i secretary 19.5 0 45.5 -0.3 7 √ gymnasium 16.5 0.2 58.6 4.9 100 √ dressing room 1 20.5 0 50 -1.6 56 √ dressing room 2 17.8 0 57.3 -2.7 93 √ dressing room 3 15.9 0.01 69.6 -3 99 √ store 22 0.02 50 0.6 13 √ site ii small pool 27.6 0.03 52.7 1.3 39 √ big pool 27.8 0.01 58 1.3 43 √ dressing 26.4 0.03 59.8 1 26 √ mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 9 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe room table 2: evaluation of microbial conditions in site i and site ii 3.3. water analysis microbiological analysis confirmed the absence of any of the tested microorganisms. table 4 shows the results of temperature values, the free and combined chlorine levelandph. the temperature values were 27°c in both pools. the active free chlorine in small pool, respectively for the first and second method, was 0.94 and 1 g/l; for the larger pool 1.23 and 1.40 mg/l. the combined chlorine in small pool was 0.30 mg/l and in the big pool 0.26 mg / l. the ph in the small pool is 7.32 and 7.09 in the big pool. indicators big pool small pool range of values temperature (°c) 27°c 27°c 24°c 30°c free active chlorine (mg/l) ortotolidine dpd ortotolidine dpd 1,23 1,4 0,94 1 0,7-1,5 mg/l combined chlorine (mg/l) 0,26 0,3 ≤ 0,4 mg/l ph 7,32 7,09 6,5-7,5 table 3: results of temperature, free/combined chlorine and ph in the pools of site ii. range of values (italy, 2003). 3.4. questionnaire in site i, hygiene-structural questionnaires were distributed to users. as for structural assessment (figure 1a), 71% were satisfied respect quality of the plant, 70% were satisfied respect service, 64% respect safety. the percentages of non-satisfied are below 10% for both questions. the not very satisfied percentages are slightly higher, between 14% and 18%. figure 1b shows the results regarding the cleaning assessment. the general perception of the plant status is considered satisfactory. the percentages of satisfied ranging from a minimum of 41% (room temperature and showers cleaning) to a maximum of 68% (dressing rooms cleaning); the highest percentage of very satisfied people has been found for dressing rooms cleaning (21%); the percentages of not very satisfied are around or below 30%; the unsatisfied are 0% respect temperature and a maximum of 18% respect cleaning. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 10 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe finally, the survey distributed in site ii, asked the issues should be improved about the suitability of the structure, safety, hygiene issues, dressing rooms, personal notes. for 45% of subjects the organization and structure of the dressing rooms should be improved; the 44% would not improve anything. figure 1a: histogram on the structural section of the survey distributed in site i. figure 1b: histogram on the hygiene section of the survey distributed in site i. 4. discussion mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 11 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe the quality and safety of sports facilities are key elements in the practice of physical activities, especially for those most vulnerable people, including elderly, children, and people with disabilities. the role that physical activity, adapted or not, is well known and established, not only in preventing diseases but also in the promotion of health and psycho-physical well-being of the person as well as in the care and rehabilitation (romano spica, 2015; romano spica, 2015). the quality of a structure dedicated to such activities is determined by multiple factors: topographical features, structural maintenance, the presence of pollutants, crowding of environments. air quality, however, can be affected by different substances resulting by the building materials, by interior materials (e.g. furniture) and by human activities. some parameters are quantifiable with technical procedures (e.g. micro-climatic control units, air samplers, chemical test), others with custom tools, such as questionnaires (alves, 2013). in a perspective of occupational prevention and health promotion, the approach presented in this study was aimed to integrate both objective parameters related to iaq assessment and subjective perception of the environmental quality and safety. previous studies investigated sport facilities focusing on single issues such as only questionnaires, or microclimate (soares, 2015), personal information (eime, 2013; chen, 2013; reimers, 2014), aptitude playing sport (coledam, 2014; laxer, 2013). here we considered an integrated approach, to evaluate a possible multiple strategy to assess environmental quality in sport environments. in the environments where sport was carried out and in the dressing room the pmv values were negative and the percentage of dissatisfied people (ppd) was equal or next to 100%. in site ii the microclimate is resulted slightly better, but non optimal. when comparing these results with the questionnaires distributed in site i, we saw how the perception of the environmental quality can deviate considerably from the data obtained through the monitoring techniques. if room temperature and the humidity were evaluated satisfactory, by contrast, in the environments where was carried out sport activity and in the dressing room the temperature was considered cold and the relative humidity high. even for air exchange rate, there are discordant results: the mean air velocity recorded was around zero, while in the questionnaire it was evaluated satisfactory. the reason for this discrepancy may be sought in the fact that probably this survey presents questions in too subjective point of view and therefore should be reviewed. the hygiene perception was satisfactory and this is also confirmed by the microbial contamination index, which does not show worrisome values (in fact only the dressing room 2 of site i shows high igcm). the questionnaires distributed in site ii show that generally most clients consider the hygiene and safety do not require improvements. it is not so regard dressing rooms: this is in line with our results, in fact relative humidity and temperature data were not acceptable. however, for both kinds of surveys, should be desirable to increase the number of the respondents. our result are in line with another study: the cleanliness is considered the major weakness of this industry and it also has a significant impact on shaping customers' perception and classifying different levels of overall service quality. by contrast, accessibility is the main strength due to its high satisfaction level and low service quality gap (liu, 2009). the total fungal count results different in the two plants. the odds can be probably attributed to the different type of these facilities: a swimming environment, which is site ii, may further promote the fungi/mold growth. the mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 12 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe microbiological investigations have confirmed the total mesophilic count (37°c) is the main contributor to contamination in site i, while the psychrophilic count (22°c) is the main one in site ii. this situation is not in line with microclimate data, as in the site i there were low temperatures but high relative humidity, in the second site there were high temperatures and humidity. the iaq in both sites complies to the standards of non-industrial premises, but, is desirable for both plants the improvement of the ventilation system and air exchange, especially in the dressing areas, where the pollution, especially by bacteria, were intermediate/high. finally, water quality data in the pools show accordance with italian guidelines (italy, 2003), both to microbiological indicators as to the physical and chemical requirements. 5. conclusions the characterization of a sports facility in terms of overall quality and safety is considered by several national and international regulations. it cannot be exhausted by using only a single type of monitoring technique. a wider approach can take advantage from the combined determination of microclimatic parameters, microbiological air analysis, as well as evaluation of individual perceptions by customized ad hoc questionnaires (dacarro, 2003). variables significantly affecting indoor microbiological contamination, such as structural features, microclimatic and seasonal variations, should be investigated within an integrated approach to get a global view (valeriani, 2015). the data obtained in this study did not reveal critical situations for human health and safety, but evidenced a role for environmental quality. surveillance on quality parameters can implement safety assurance with an impact on human health both for users and workers. references adlakha, d., hipp, a.j., marx, c., yang, l., tabak, r., dodson, e.a., brownson, r.c. (2015). home and workplace built environment supports for physical activity. am j prev med, 48, 104-107. alves, c.a., calvo, a.i., castro, a., fraile, r., evtyugina, m., bate-epey, e.f. (2013). indoor air quality in two university sports facilities. aerosol air qual res, 13, 1723-1730. american conference of governmental industrial hygienists (acgih). (1995). industrial ventilation: a manual of recommended practice. cincinnati, oh. australia. (1990). new south wales consolidated acts. swimming pools act 1990 n. 31. australia. (1992). new south wales consolidated acts. swimming pools act 1992 n. 49. [online] available: http://www.austlii.edu.au/au/legis/nsw/consol_act/spa1992192/ australia. (1997). brown sk. indoor air quality, state of the environment technical paper series (atmosphere). department of the environment, sport and territories, canberra. 1997. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 13 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe canada. (2004). minister of health. miller jd, gilbert nl, dales re. fungal contamination in public buildings: health effects and investigation methods. [online] available: http://healthycanadians.gc.ca/indexeng.php canada. (2006). règlementsur la qualité de l’eau des piscines et autresbassinsartificiels. loisur la qualité de l’environnement. gazetteofficielledu québec, 13 décembre 2006, 138eannée, n.50. carlisle, a.j., sharp, n.c.c. (2001). exercise and outdoor ambient air pollution. br j sports med,35, 214-222. cdc. (2003). surveillance data from swimming pool inspections — selected states and counties, united states, may–september 2002. mmwr morb mortal wkly rep, 52(22), 513-516. chen, t., lee, j.s, kawakubo, k., watanabe, e., mori, k., kitaike, t., akabayashi, a. (2013). features of perceived neighborhood environment associated with daily walking time or habitual exercise: differences across gender, age, and employment status in a community–dwelling population of japan. environ health prev med, 18, 368-376. china. (2002). bai z, jia c, zhu t, zhang j. proceedings: indoor air 2002: indoor air quality related standards in china. [online] available: https://www.irbnet.de/daten/iconda/cib7659.pdf china. (2006). xiaojun m, yiwen j, yue c. "a new national design code for indoor air environment of sports buildings", facilities, 24, 458-464. coledam, d.h.c., ferraiol, p.f., pires, r.j., dos-santos, j.w., de oliveira, a.r. (2014). factors associated with participation in sports and physical education among students from londrina, paraná state, brazil. cad. saúdepública, 30, 533-545. commission of the european communities (cec). (1993). indoor air quality and its impact on man. report no. 12. biological particles in indoor environments. luxembourg. coni. (2008). directive coni n. 1379 of 25/06/2008. “coni regulations for sport facilities”. coni-fsn-dsa. (2014). the numbers of sport. studies and statistics observers center for sport. council of europe. (2006). directive 2006/7/ec. “management of the quality of bathing water”. [online] available: http://eur-lex.europa.eu/legal-content/en/txt/?uri=uriserv%3al28007 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 14 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe dacarro, c., picco, a.m., grisoli, p., rodolfi, m. (2003). determination of aerial microbiological contamination in scholastic sports environments. j. appl. microbiol, 95, 904-912. eime, r.m., harvey, j.t., craike, m.j., symons, c.m., payne, w.r. (2013). family support and ease of access link socio-economic status and sports club membership in adolescent girls: a mediation study. int j behavnutrphys act, 10, 50. el-salam, m.m.a. (2012). assessment of water quality of some swimming pools: a case study in alexandria egypt,. environ monit assess, 184, 7395-7406. european commission. (2014). special eurobarometer 412. sport and physical activity report. [online] available: http://ec.europa.eu/health/nutrition_physical_activity/docs/ebs_412_en.pdf finland. (2010). finnish ministry of the environment. housing and building department. indoor climate and ventilation of buildings regulations and guidelines 2010. helsinki. [online] available: http://www.ym.fi/enus/search?n=25247&d=1&s=indoor+climate+and+ventilatio n+of+buildings+regulations+and+guidelines+2010 france. (2011). agencenationale de sécurité sanitaire (anses). air intérieur: valeurs guides. 2011. [online] available: www.afsset.fr/index.php?pageid=829&parentid=424. france. afssetevaluation des risquessanitairesliés aux piscinespartie i: piscinesréglementées. saisineafsset «2006/11». rapport final. [online] available: https://www.anses.fr/fr/system/files/eaux2007sa0409ra.pdf gedikoglu, y., gedikoglu, g., berkin, g., ceyhan, t., altinoz, m.a. (2012). employing volcanic tuff minerals in interior architecture design to reduce microbial contaminants and airborne fungal carcinogens of indoor environments. toxicolind health, 28, 708-719. germany. (1997). din-19643. ausgabe:1997-04,aufbereitung von schwimm und badebeckenwasser–teil 1: allgemeineanforderungen. beuth, berlin. 1997. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 15 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe giampaoli, s., valeriani, f., romano spica, v. (2012). thermal water for recreational use: overview of international standards. ig sanitapubbl, 68, 863-873. ireland. (2005). safety, health and welfare at work act. health and safety authority, 10 hogan place, dublin 2. [online] available: http://www.hsa.ie/eng/legislation/acts/safety_health_and_welfare_at_work/ ireland. (2010). swimming pool safety guidelines. irish water safety, ilam and swim ireland. 2010. [online] available: http://www.iws.ie/swimming/pool-safety.315.html italy. (2003). agreement between the minister of health, the regions and autonomous provinces of trento and bolzano: “interregional discipline of swimming pools”. in implementation of the state-regions agreement and public administrations. 16 january 2003. [online] available: http://www.bagnini.org/it/down/accordo_interregionale_piscine.pdf italy. (2005). interior ministry. ministerial decree 18/03/1996 (supplemented by ministerial decree of 06/06/2005). “safety regulations for construction and operation of sports facilities”. italy. (2007). istisan report 7/11. bonadonna l, donati g. swimming pools: sanitation and management aspects for the application of the new legislation. istituto superiore di sanità, roma 2007. [online] available: http://www.iss.it/binary/aqua/cont/rappistpiscine.1204716480.pdf italy. (2008). legislative decree n. 81 of 09/04/2008 (consolidated law for health and safety at work). gazzettaufficiale n. 101, of 30 april 2008. kirby, j., levin, k.a., inchley, j. (2013). socio-environmental influences on physical activity among young people: a qualitative study. health educ res, 28, 954-969. laxer, r.e., janssen, i. (2013). the proportion of youths’ physical inactivity attributable to neighbourhood built environment features. int j health geogr, 12, 31. leemrijse, c.j., de bakker, d.h., ooms, l., veenhof, c. (2015). collaboration of general practitioners and exercise providers in promotion of physical activity a written survey among general practitioners. bmc fampract, 16, 96. liguori, g., capelli, g., carraro, e., di rosa, e., fabiani, l., leoni, e., marensi, l., napoli, c., pasquarella, c., romano spica, v., canossa, c., dallolio, l., di onofrio, v., gallè, f., giampaoli, s., sitiworking group movementsciences for health (gmsh). (2014). a new checklist for swimming pools evaluation: a pilot study. microchemical journal, 112, 181-185. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 16 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe liu, y.d., taylor, p., shibli, s. (2009). measuring customer service quality of english public sport facilities. int. j. of sport management and marketing, 6, 229-252. moran, m., van cauwenberg, j., hercky-linnewiel, r., cerin, e., deforche, b., plaut, p. (2014). understanding the relationships between the physical environment and physical activity in older adults: a systematic review of qualitative studies. int j behavnutrphys act, 11, 79. nathan, n., wolfenden, l., morgan, p.j., bell, a.c., barker, d., wiggers, j. (2013). validity of a self-report survey tool measuring the nutrition and physical activity environment of primary schools. int j behavnutrphys act, 10, 75. netherlands. (2007). inspectorate of the netherlands ministry of housing, spatial planning and the environment. rivm report 609021044: health-based guideline values for the indoor environment. 2007. [online] available: http://www.rivm.nl/bibliotheek/rapporten/609021044.pdf reimers, a.k., wagner, m., alvanides, s., steinmayr, a., reiner, m., schmidt, s., woll, a. (2014). proximity to sports facilities and sports participation for adolescents in germany. plos one, 9, 93059. revel, g.m., artesano, m. (2014). perception of the thermal environment in sport facilities through subjective approach. build environ, 77, 12-19. romano spica, v., giampaoli, s., di onofrio, v., liguori, g. safety of sports facilities and training of graduates in physical education. ann ig, 27, 3-10. romano spica, v., macini, p., fara, g.m., giammanco, g., gsms working group on movement sciences for health italian society of hygiene preventive medicine and public health. (2015). adapted physical activity for the promotion of health and the prevention of multifactorial chronic diseases: the erice charter. ann ig , 27(2), 406414. russia. (1997). baitkolov n, musijchukb y. standards and laws for indoor air quality in russia. indoor built environ, 6, 213-216. sani, s.m.t., talebpour, m., tojari, f., jabbari, h. (2012). the relationships between the health status of athletic facilities and participation in physical exercises. eur j expbiol, 2, 1240-1244. settimo, g. (2012). the air quality in confined environments: new national and community guidelines. news of italian institute of health (iss), 25, 5. [online] available: http://www.iss.it/binary/iasa/cont/settimo_notiziario_iss.pdf mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 17 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe soares, s., fraga, s., delgado, m.p.q. j., ramos, m.m.n. (2015). influence of indoor hygrothermal conditions on human quality of life in social housing. journal of public health research, 4, 589. south africa. (2002). gansan j, gqaleni n, ehiri je. proceedings: indoor air 2002: indoor air quality legislation in south africa. [online] available: http://www.irbnet.de/daten/iconda/cib7266.pdf sugiyama, t., thomson, c.d. (2008). associations between characteristics of neighbourhood open space and older people's walking. urban forestry & urban greening, 7, 41-51. uk. (2006). management of spa pools: controlling the risk of infection. health protection agency. [online] available: http://www.hse.gov.uk/legionnaires/spa-pools.htm usa. (2012). national institute for occupational safety and health (niosh). preventing occupational respiratory disease from exposures caused by dampness in office buildings, schools, and other nonindustrial buildings. [online] available: http://www.cdc.gov/niosh/docs/2013-102/ valeriani, f., protano, c., gianfranceschi, g., santucci, s., giampaoli, s., vitali, m., romano spica, v., mucci, n. (2015). qualità dell’aria in ambienti confinati di vita e di lavoro: aspetti normativi e applicazioni al contesto sportivo e ricreativo. l’igienemoderna, 6, 45-74. world health organization (who). (2006). guidelines for safe recreational water environments. volume 2: swimming pools and similar environments. geneva: world health organization. world health organization. (2010). who guidelines for indoor air quality: selected pollutants. 2010. [online] available: http://www.who.int/indoorair/publications/9789289002134/en/ mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 1; january-febuary 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 1 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe strategies for increasing access to physical and sport activities for individuals in social vulnerability javianna (maria) de morais, matheus (ramos) silva and ana rosa (jaqueira) coelho universidad federal de río grande del sur abstract: the millennium development goals (mdgs) were a set of eight goals established by the united nations in 2000 to reduce poverty, hunger, disease, illiteracy, environmental degradation, and discrimination against women. the mdgs were largely successful in achieving their goals, and they helped to improve the lives of millions of people around the world. the sustainable development goals (sdgs) are a set of 17 goals that were adopted by the united nations in 2015 to build on the successes of the mdgs. the sdgs are more ambitious than the mdgs, and they address a wider range of issues, including climate change, inequality, and peace and justice. this paper discusses the evolution of the mdgs and the sdgs, and it examines the challenges and opportunities of achieving the sdgs. keywords: millennium development goals (mdgs), sustainable development goals (sdgs), poverty, hunger, disease, illiteracy, environmental degradation, discrimination against women, climate change, inequality, peace and justice introduction the world concerns about human development, the social inclusion, the poverty eradication and the other vulnerable population privacies have been manifested through goals elaborated by the united nations (un), that created the first document in order to guide the implementation of public policies in the international, national and local levels in 2000 millennium development goals (mdg).during 15 years, the mdg fomented the initiatives from countries in the un to face the challenges of eradicating extreme poverty and hunger in poorer countries, universalize basic education; promote gender equality and women's empowerment; reduce child mortality; improve maternal health; fight aids, malaria and other diseases; ensure environmental sustainability and; establish the global partnership for development (millennium goals) (shetty, 2005). the efforts to build a society that contributes to poverty reduction and economic and social development continued at the rio earth summit (rio 92), in which representativesfrom the participating countries agreed to promote sustainable development with focus on human beings as fundamental and integrated parts of the process of protecting the environment (agenda 21) (declaração do rio de janeiro, 1992). at the rio + 20 conference, the goals of green economy and poverty eradication were strengthened with the establishment of intergovernmental goals for beyond 2015. in 2015, the members of the un recognized the need to eradicate poverty and to promote dignified life for allas an indispensable requirement to achieve the 17 goals mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 1; january-febuary 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 2 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe of the 2030 sustainable development goals (sdg), which must be integrated in the economic, social and environmental dimensions. the sdg advanced in relation to the mdg and focused on poverty and hunger eradication; sustainable agriculture; health and well-being; gender equality; potable water and sanitation; affordable and clean energy; decent work and economic growth; industry, innovation and infrastructure; reduction of inequalities; sustainable cities and communities; responsible consumption and production; action against global climate change; life in water; terrestrial life; peace, justice and effective institutions and; partnerships and means of implementation. according to specialists in brazil, the chances of brazilto achieve the established goals are low, even so, priorities should be placed on quality education and poverty eradication as means to contribute to the improvement of the population's health and well-being (moreira et al., 2019). several areas of knowledge and human production are integrated in the efforts of nations to achieve the sdg. in the field of physical education, the regular practice of physical and sports activities may be related to the sdg as a factor for human development with regard to health and well-being, gender equality or other goals, in which, equality in access to education, health, work, culture, leisure, social protection needs and other interinstitutional policies is valued in fomenting friendship and peace between groups, peoples and nations (undp, 2017). the recognition of physical and sports activities as an important mean of socialization and well-being can be seen in the un‟s initiative to create an inter-agency task force (oms, acnur, pnud) on sport for development and peace (sdp), to encourage the efforts of international agencies that work with sports (clarke, jones& smith, 2021). according to clarke, jones and smith (2021), the use of sport as peacebuilding toolsis growing along with movements to achieve global peace. in a review study, the authors identified 30 academic papers in recent decades that investigated projects in different parts of the world that used the sport for development and peace in post conflict areas. in brazil, the initiatives of private and governmental institutions to promote the right to the access of physical and sports activities as a mean to promote individual and collective development and to mitigate social inequalities, dates back to the 1980s with the implementation of social inclusion projects by sport (sip) as a way of socialization or social inclusion of children and young people from vulnerable populations, with the aggravation of being at physical and psychological risk, imposed by the socialization exercised by drug trafficking and violent confrontations between rival groups and between these and the police (vianna&lovisolo, 2009, 2011, 2018). the increase in the number of physical and sports activities projects and academic production on the subject in brazil motivated kravchychyn and oliveira (2015) to prepare a systematic review to identify studies published in brazil between 2004 and 2013 on the phenomenon in question. the authors observed that the investigations focused primarily on the management of projects and programs, teaching activities and methodologies, teacher training and the intervention of teaching professionals. for kravchychyn and oliveira (2015), the effect of sip on beneficiaries and social groups involved, the pedagogical and management methodologies of sip and the initial and continuing training of teachers who work in this context, are aspects that need to be further investigated. however, the work of the authors was limited to studies published in portuguese, which suggest the necessity to mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 1; january-febuary 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 3 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe expand and deepen this type of research in other centers of knowledge production that disseminate their publications in other languages. the amplitude of the actions proposed from the sdg, with several nations, private institutions and third sector organizations operating internationally and many initiatives crossing cultural borders, is one of the aspects that reinforce the need to understand the similarities and differences in scientific production produced in other knowledge centers on the phenomenon of physical and sports activities as a way of social inclusion of children, adolescents and young people from the most vulnerable layers, which can favor the review of interpretations and inconsistencies that might or might not be discovered in research involving only one country. as it is a phenomenon that can occur in different cultures and in different countries, this study aimed to carry out an integrative review to compare academic data on programs and projects that use the sport as a mean of social inclusion of children, adolescents and young people in situation of social vulnerability. this work identifies, analyzes and synthesizes the results of studies published in english, spanish and portuguese in the period between 2010 and 2021 contained in the scopus database. thus, with the mapping of the study area, it is expected that this study will contribute to the theoretical and methodological improvement and encourage more investment in researches that aim a greater internationalization of the subject and are based on the following questions: a) why is sport used in sport projects for the social inclusion of children, adolescents and young people in situations of social vulnerability? b) what are the main characteristics of the studies? c) what are the effects of physical and sports activities on the development of the participants? 2 methodology in order to provide a synthesis of published knowledge on the subject and incorporate the applicability of significant studies, we propose an integrative review whose methodological approach allows the inclusion of different methods and admit the use of quantitative and qualitative data. according to souza, silva and carvalho (2010), integrative review is broader than meta-analysis and systematic review, as it allows the inclusion of experimental and non-experimental studies to fully understand the phenomenon and generate a consistent and understandable panorama of the concepts, theories or problems related to the phenomenon studied (whittemore&knafl, 2005). to ensure the methodological rigor in the integrative review, this investigation followed the phases proposed by souza, silva and carvalho (2010) for the research: 1st phase definition of the guiding question, in which the studies to be included, the means adopted to the identification of sources and the information collected on each selected articlewere determined; 2nd phase –the use of the vosviewer tool (instrument for construction and visualization of bibliometric networks https://www.vosviewer.com/) to a broad and diversified search in electronic databasesbased on a pre-defined criteria of inclusion and exclusion. the program organizes the references exported by the databases and identifies the quantitative data referring to an area of knowledge, the number of citations, territory of works and number of authors; 3rd phase –data extraction from each article regarding the type of study, definition of data and sample size and technique used for data collection; 4th phase critical analysis to consider the rigor and characteristics of the selected studies; 5th phase preparation of inferences from the comparison of the results with the information present in the literature; 6th phase reduction mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 1; january-febuary 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 4 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe and comparison of the data in which the studies were divided into subgroups according to the classification determined. this research selected complete articles in english, spanish and portuguese published in peer-reviewed journals between 2010 and 2021 indexed in the scopus database. as a search refinement strategy, the following terms were used: “social project” or “social program” and “education” or “education” and “child” or “adolescent” or “youth” and “popular layers” or “social risk” or “marginalized” or “poverty” or “not met” or “vulnerability” and “sport” or “sports education” or “sports project”. inclusion criteria: only empirical articles, published between 2010 and 2021 in peer-reviewed journals were selected, in which children, adolescents and young people participating in physical and sports activities targeted at a population in a situation of social vulnerability were investigated. exclusion criteria: review studies; document analysis research; works that did not include subjects in the childhood, adolescence and youth age groups; course completion papers, monographs, dissertations and theses; closed access studies; studies published outside the established search period; articles out of focus and desired scope. the analysis of the data obtained was carried out through the ordering, categorization and subsequent summary of the results in order to highlight any differences and commonalities of the articles included in the research (whittemore&knafl, 2005). descriptive statistics was used as a procedure for the initial treatment of the data. in this way, it was possible to observe both the occurrence of publications over the years, as well as the more or less recurrent themes. the exhaustive reading of the data allowed the researchers to identify the approaches, the type of study, the results and directions of each one of the works. the synthesis of the results was carried out in a descriptive way, allowing to observe, count, describe and classify the data in order to gather the knowledge produced about physical and sports activities in sip and to identify, analyze and synthesize the results of studies on the subject. the categories that emerged from the data were expressed in figures, tables and charts, which facilitated the analysis by comparing the results and identifying regularities and differences. 3 results 3.1 identification of relevant studies the compilation of information in articles published in the scopus database allowed the verification of similarities and differences in the selected works based on the inclusion criteria and the established exclusion criteria. the studies found in the database were exported to the vosviewer tool to help to organize, select and describe the productions used in the integrative review. afterwards, the duplicated articles were removed and the title, abstract and the full paper of the remaining works were finally read. figure 1 presents the flowchart of the article selection process. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 1; january-febuary 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 5 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe figure 1 – refinement on search and selection of articles. the final selection of articles took place on april 13, 2021. from a total of 257 articles identified from the combination of search descriptors, 11 works were analyzed and will be presented in table 1. the increasing academic interest in the area of sports for social inclusion and sports for development and peace has motivated the production of books, special editions of magazines, research reports and important articles on the subject in several countries (haudenhuyse et al., 2020). table1 – selected articles authores / year title research site placeofpublic ation magazine 1 cortês-neto et al. elaboração de indicadores de sucesso (2010) em programas de saúde pública com foco sócio-esportivo brazil spain revista salud pública 2 castro& souza (2011) significados de umprojeto social esportivo: umestudo a partir das perspectivas de profissionais, pais, crianças e adolescentes. brazil brazil revista movimento mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 1; january-febuary 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 6 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 3 schaillée, theeboom,& van cauwenberg(2015) what makes a difference for disadvantaged girls? investigating the interplay between group composition and positive youth development in sport belgium belgium social inclusion 4 bean et al. (2015) putting program evaluation into practice: enhancing the girls just wanna have fun program canada canada evaluationand programplanni ng 5 brauner, valentini& souza (2017) programa de iniciação esportiva influencia a competênciapercebida de crianças? brazil brazil psico-usf 6 de martini ugolotti(2017) „we are rolling and vaulting tonight‟: sport programmes, urban regeneration and the politics of parkour in turin, italy italy unitedkingdo n international journal of sport policy and politics 7 pike, page& vinas (2018) playing out: a movement for movement? unitedkin gdon unitedkingdo n frontiers in sociology 8 bento et al.(2019) prevalenceandfactorsassociatedwithph ysicalactivity in sociallyvulnerablechildren brazil brazil revista brasileira de medicina do esporte 9 hills, walker& barry (2019) sport as a vehicleforhealthpromotion: a sharedvalueexampleofcorporate social responsibility unitedkin gdon unitedkingdo n sport management review 10 bhanet al.(2020) sport as a vehicle of change for livelihoods, social participation and marital health for the youth: findings from a prospective cohort in bihar, india india unitedkingdo n eclinicalmedicine 11 cortês-neto et al.(2020) the resilience of adolescent participants in social projects for sport brazil brazil ciência&saúde coletiva source: elaborated by the authors. 3.2 data related to the studies: area of knowledge, research site and place of publication in several countries, sport has been used to promote health by public policy makers and been defended by researchers due to the its benefits in the participants, that range from psychological, physiological and cultural mailto:topacademicjournals@gmail.com https://www.cogitatiopress.com/socialinclusion/index https://www.cogitatiopress.com/socialinclusion/index https://www.cogitatiopress.com/socialinclusion/index https://www.sciencedirect.com/science/journal/01497189 https://www.sciencedirect.com/science/journal/01497189 https://www.sciencedirect.com/science/journal/01497189 https://www.sciencedirect.com/science/journal/01497189 https://www.sciencedirect.com/science/journal/01497189 http://www.scielo.br/scielo.php?script=sci_serial&pid=1413-8271&lng=en&nrm=iso http://www.scielo.br/scielo.php?script=sci_serial&pid=1413-8271&lng=en&nrm=iso http://www.scielo.br/scielo.php?script=sci_serial&pid=1517-8692&lng=en&nrm=iso http://www.scielo.br/scielo.php?script=sci_serial&pid=1517-8692&lng=en&nrm=iso http://www.scielo.br/scielo.php?script=sci_serial&pid=1517-8692&lng=en&nrm=iso http://www.scielo.br/scielo.php?script=sci_serial&pid=1517-8692&lng=en&nrm=iso http://www.scielo.br/scielo.php?script=sci_serial&pid=1517-8692&lng=en&nrm=iso http://www.scielo.br/scielo.php?script=sci_serial&pid=1413-8123&lng=en&nrm=iso http://www.scielo.br/scielo.php?script=sci_serial&pid=1413-8123&lng=en&nrm=iso http://www.scielo.br/scielo.php?script=sci_serial&pid=1413-8123&lng=en&nrm=iso american journal of medical and physical education vol.6, issue 1; january-febuary 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 7 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe aspects. more recently, private and governmental organizations related to sports have started to develop and implement health promotion projects and programs linked to corporate social responsibility (hills, walker& barry, 2019). the bibliometric analysis of the data reveals that most of the selected articles were published in brazil (4) and the united kingdom (4). the investigated theme was also the object of research that resulted in a publication in each of the following countries in the investigated period: belgium, canada, italy and india. studies that focused on physical and sports activities in brazil were predominant in the selected investigations (5), while three selected studies focused on physical and sports activities programs and projects in the united kingdom (table 1). although the main focus of the selected studies is on physical and sports activities for children, adolescents and young people in situations of social vulnerability, the issue in question was approached from the perspective of health promotion (1, 8, 9, 10), public policy (9, 10), social capital (3, 6, 7, 10), psychology (motivation 5; resilience 11), business (9), gender (3, 4) and social representations (2) (it is considered that the same article had more than one approach simultaneously). the range of the selected works reflects the efforts of researchers to adopt different perspectives to broaden the understanding of the phenomenon of socialization and well-being through physical and sports activities of subjects in a situation of social vulnerability (clarke, jones& smith, 2021). in this integrative review, 5 studies were selected with investigated subjects from the brazilian population, 5 works with individuals surveyed in countries considered developed and a survey in the indian population (as well as brazil, india is considered a developing country) (table 1) that observed the relationship between sports and the vulnerable population, with diversified approaches. the selected sample suggests that the researchers‟ concern with social inequality in brazil may justify the increase in the amount of research on social inclusion of the vulnerable population in the country (kravchychyn& oliveira, 2015; vianna&lovisolo, 2018). another focus of attention in investigations in brazil may be the low percentage of active brazilians (30% of the population), which mainly affects individuals in a situation of social vulnerability (undp, 2017). researches that investigated physical and sports activities and the social inclusion of vulnerable populations in other countries suggest that the concerns that resulted in investigations linking physical and sports activities and social vulnerability are not unique to the brazilian reality, and the same occurs in other social contexts, including in developed nations. these arguments are supported by the article of buelens et al. (2015), indicating that there is a considerable number of young europeans who live or are at risk of ending up in situations of social vulnerability. at the same time, the study of collins and haudenhuyse (2015) describes the growth trends of poverty in england and identifies the groups who are at risk of social exclusion, and the work of johns et al. (2014) in oceania study team sports as a mean of combating the violent extremism of young muslims in australia. the possibility of sport being a mean for social inclusion and for increasing social opportunities for vulnerable children, adolescents and young people was the common perspective in the aforementioned works. therefore, it is admitted that the inequality of social opportunities and social exclusion motivate the implementation of projects and programs with physical and sports activities to minimize the risks arising from social vulnerability. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 1; january-febuary 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 8 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 3.3 type of study, source (subject definition / sample size), data collection technique and characteristics of selected studies the final sample of this integrative review brought together a wide variety of study types: ethnographic, case, descriptive, cross-sectional, longitudinal, comparative, survey and quasi-experimental. in qualitative studies (4 occurrences case study, focused investigation, ethnographic, descriptive) (bean et al., 2015; castro& souza, 2011; de martini ugolotti, 2017; pike, page& vinas, 2018) the authors used as technique for data collection the document analysis, interviews and field notes to investigate the cases. the quantitative studies identified were two quasi-experimental surveys (cortês-neto et al., 2010; hills, walker& barry, 2019), two surveys (bento et al., 2019; cortês-neto et al., 2010), one correlational study (schaillée,theeboom& van cauwenberg, 2015), a cross-sectional study (cortês-neto et al., 2020) and a longitudinal survey (bhan et al., 2020). as an instrument for data collection, document analysis, interviews, scales and structured questionnaires were identified (table 2). although managers, leaders, parents, teachers and other professionals have been investigated, children and adolescents aged from 5 to 24 years were the main object of study in the selected articles, which reinforces the tendency of physical and sports activities projects to have its proposals centered on individuals in development, who are the most vulnerable subjects in the population. however, there is little evidence to explain why most physical and sports activities projects for the vulnerable population do not provide the same breadth of access to physical and sports activities so that a greater number of subjects in other age groups, including the elderly, can benefit fromthe practice. table 2 – methodological framework of selected articles. typeofstudy source instrument 1 survey 1 program 51 students (8 to 17 years old) documental analysis interviews 2 case study qualitative-exploratory 1 program 52 students (8 to 15 years old) 9 parents 17 professionals semi-structured interviews 3 correlational 15 programs 200 female students (10 to 24 years old) quiz:youth experience survey for sports (yes-s) 4 focusedevaluation 1 program 13 female students (11 to 16 years old) 5 leaders semi-structured interviews mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 1; january-febuary 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 9 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 5 longitudinal / developmental and comparative of type quasiexperimental 118 students (5 to 9 yearsold) self-perception scale for children pictorial scale of perceived competence and social acceptance(pspcsa) 6 ethnographic 1 program 20 participants (16 to 21 years old) managers field notes interviews 7 descriptive 1 program 23 adults 37 students (1,5* to 13 years old) 6 managers (politics) semi-structured interviews 8 survey descriptive stratified sample in 8 regions of brazil 3066 students (7 to 11 yearsold) physical activity questionnaire older children (paq-c) participation motivation questionnaire (pmq) anthropometricmeasurements 9 multimethods quasi-experimental 1 program 272 students (8 to 11 years old) physical activity questionnaire for children youth physical activity questionnaire (yapaq) focus group interview 10 longitudinal / developmental analytical sample in bihar (india) 2.322 alunos (15 to 19 yearsold) logisticandmultinomial models 11 cross-sectional 3 schools 134 students (12 to 17 years old) interviews resiliencescale source: elaborated by the author; *loyal to the original text. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 1; january-febuary 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 10 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe by considering that the agreement between the institutional proposals and the attention to the beneficiaries wishes, derived from the evaluations of their own experiences, is important for the success of sip, vianna and lovisolo criticized the elaboration of public sports policies in brazil aimed at people from the lower classes, as they are premised only on the perspectives of the sip developers and managers and do not consider the participants‟ opinions in the elaboration, implementation and conduct of projects and programs – local rationalities (vianna & lovisolo, 2011, 2018). according to the authors, when they do not realize their concerns, participants tend to abandon the sip, compromising the socialization process. thus, surveys that observe the expectations of the actors in the projects can provide elements for the refinement of institutional proposals and for aligning agreements between the parties involved. this position is in line with the conclusion of nols et al. (2017) in their investigation of young people from belgium. they suggest that when designing and evaluating projects, the approach should include the participants‟ evaluations, their criticisms and real-life situations. the investigations made by cortês-neto et al. (2010), castro and souza (2011), schaillée, theeboom and van cauwenberg (2015), bean et al. (2015), de martini ugolotti (2017), hills, walker and barry (2019) andbhan et al. (2020) also proposed to give voice to the participants (collison et al., 2017), and thus, they were able to capture the complexity of the processes behind the effects generated by the sip. brauner et al (2017), bento et al. (2019) and cortês-neto (2020) limited the effects of the projects on the psychological and social aspects of the participants. one aspect that should also be considered resides in coalter‟s (2015) arguments, stressing that even if systematic and robust evidencesare produced in the studies at the local level showing the relative effectiveness of certain types of physical and sports activitiesprograms in sip, the possibility of erroneously generalizing the effects from the micro (social) to the macro (social) level must be regarded.it can be understood that despite the program’s rhetoric often claims that it addresses social issues, most programs have an inevitably local perspective. we understand that more than representing an antagonism between the two conceptions, local level studies and researches with a macro-social focus seem to be complementary, as both provide subsidies for the dialogue between the parties involved and for optimization of the preparation, conduction and experimentation of physical and sports activities in pis. 3.4 assessment indicators and instruments for data collection despite the prevailing thought that physical and sports activities are beneficial to subjects in vulnerable situations and that it can be a mean by which young people increase their chances of improving their social position, there is little understanding of the mechanisms by which sports promote the development of the participants (buelens,theeboom, vertonghen & de martelaer, 2015; super et al., 2017), which implies the need for research to evaluate physical and sports activities projects and programs (corazza & dyer, 2017;vianna & lovisolo, 2018). considering the analysis of the potential of the investigated projects, we found that the selected studies focused on social, biological and psychological aspects of the participants. highlighting the study by cortês-neto et al. (2010) who sought to develop indicators for project evaluation, aiming to establish representative aspects of the effects of physical and sports activities in the development of individuals in vulnerable situations. the results of mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 1; january-febuary 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 11 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe the study suggest as indicators for the assessment the school performance, the developed skills, the participation in activities, the motivation to participate, and the behaviors and attitudes. another aspect that can be considered in evaluating the impact of physical and sports activities is the adaptation of students to the project as a natural process in the implementation and development of the program, which according to bean et al. (2015), is shown as fundamental to understand how this adaptation process can influence the sustainability of the projects. as for the approaches, pike et al. (2018) investigated a community initiative sports project that focused on expanding the participants‟ social capital. bento et al. (2019), in a health promotion approach, used three structured instruments (physical activity questionnaire older children paq-c; participation motivation questionnaire pmq and anthropometric measures) to investigate the prevalence of physical activity, weight and motivation to practice sports among 3,066 "active" and "moderately active" children of "normal weight", in a situation of social vulnerability who participated in social projects that focused on sport, highlighting comparatively the results according to age and gender. using structured instruments to verify the effects of physical and sports activities on the psychological aspects of the participants, the research made by brauner et al (2017) stands out. they applied the pictorial scale of perceived competence and social acceptance (pspcsa) to verify the impact of a sport initiation program in the self-perception of motor, cognitive and global competence over time. from the studies referred to in the previous paragraphs, evidence indicates that the effects of physical and sports activities on participants as a mean of evaluating sip can be verified from different perspectives and with diversified instruments, and it is not possible to identify indicators to an agreement or hierarchy of investigated variables or instruments used for evaluation. 3.5 main evidences in the selected studies all selected studies assumed that physical and sports activities are an important tool in the process of social inclusion of vulnerable individuals, which reinforces the arguments found in other articles on the subject (collison et al., 2017; corazza & dyer, 2017; super et al., 2017; vianna & lovisolo, 2018). most researchers have found promising effects in researches at the local level (bean et al., 2015; brauner et al., 2017; castro& souza, 2011; cortês-neto et al., 2020; cortês-neto et al., 2010; de martini ugolotti, 2017; hills, walker& barry, 2019; pike, page& vinas, 2018) and in investigations with broader sample representation (bento et al., 2019; bhan et al., 2020; schaillée, theeboom & van cauwenberg, 2015). in the selected studies produced in brazil or other countries -, some critical mention of the value of sports was only identified in the article of de martini ugoloti (2017). the ambivalent theoretical position of the benefits and limitations of the sport for popular classes that can be found in studies in brazil (kravchychyn& oliveira, 2015) was questioned by the author when analyzing and discussing the use of public space by young parkour practitioners in a community sports project in turin. the study provides a critical perspective on the practice of sports in the urban context as a lens to discover the manifestations of social inequality. we agree with the author‟s conclusions that competing values in playing sports depend on how it is used and for what purpose. the evidence reinforces the thesis of multiplicity in the dimensions of sports and that there is a multiplicity of approaches and of the use made of it, andcasts doubt on the thesis that sport is an evil by itself or mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 1; january-febuary 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 12 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe that it is the magic formula for solving exclusion problems. the use of physical and sports activities as a tool to be adapted to the social context in which the project is inserted seems to be better adjusted. as mentioned in this review, the studies under analysis were located in different theoretical approaches to support research and verify the effects of physical and sports activities on participants and the social context, highlighting the focuses on health promotion, gender, psychological aspects, social capital and social opportunities, for which we believe that the results derived from them deserve to be highlighted, which we consider to be relevant contributions of knowledge on the theme developed here. 3.5.1 health promotion from the perspective of physical and sports activities as a mean of health promotion, bento et al. (2019) found subjects with a level of physical activity and body weight within the recommended levels. pleasure, physical fitness, technical competence, general membership, specific membership, and status and emotions were considered “very important” reasons for physical and sports activities practice, while the competition was considered only “important”. when analyzing comparatively the participation of boys and girls in physical and sports activities, the results from the study highlighted the girls as "moderately active", "overweight" and "obese", considering technical competence as an "important" motivational domain for physical activity. 3.5.2 gender votre et al. (2011) identified that the local habitus related to gender can explain the disinvestment of girls in sport, which suggests the need of mechanisms to increase permanence. the issue of gender was addressed in the study ofschaillée et al. (2015) with belgian girls, in which the authors examined the relationship between group composition and the positive development in sports of girls from disadvantaged social backgrounds. according to the authors, the benefits of the participation of disadvantaged girls in sports depend on the composition of the group. when girls join a group of similar peers, girls born to a single mother or separated from their biological father will benefit more than those from families where the parents live together in the same house. based on research in canada, bean et al. (2015) argue that in making efforts to provide young women with unique experiences, offer formal services and informal leadership responsibilities, and expose young people to positive aspects of adult livelihoods, the programs based on physical and sports activities can promote positive results in the training of participants, thus meeting the results found in the investigation by medeiros and vianna (2021). thus, both studies emphasize that the benefits to young women depend on teaching strategies and procedures adopted by the sip. 3.5.3 psychological aspects psychology can provide elements to assess attitudes and behavior in sports. brauner et al. (2017) argue that the strategies used in the investigated program were effective in strengthening perceptions of competence, especially among the investigated boys. the effects of physical and sports activities seem to be more necessary to raise the subjective well-being scores of children who report situations of greater social disadvantage (viñas et al, 2019). the resilience of participants in physical and sports activities projects was analyzed in the study ofcortêsneto et al. (2020), in which the resilience of participants and non-participants in a project was compared, relating their mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 1; january-febuary 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 13 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe resilience to their socio-demographic profiles. the results revealed that participants of physical and sports activities had a better level of resilience than non-participants, even in unfavorable situations or with the presence of risk factors, which reinforces the data found by bhan et al (2020). 3.5.4 social capital the results of the study by pike et al. (2018) indicated that the expansion of the social capital of the participants is the cause and the effect in the project‟s success when social capital is combined with an organized social movement to increase outdoor play and to increase the practice of physical activities among young people in the neighborhood. by exploring the meanings attributed to the sip by students, guardians and professionals working in the project castro and souza (2011), it was identified, in the expression of those investigated, that the sip is a space for learning and socialization through games, in which participants are protected from the risks of violence and social deviations. another study that adopted the perspective of expanding the participants' social capital was the investigation made by bhan et al. (2020) with young people in india. based on the assumption that the participation of young people in pro-social activities, such as sports, can promote the formation of identity, selfefficacy and social support, in a longitudinal study with a macro-social focus, the authors sought to verify the effects of sports participation in adolescents in bihar. the results revealed that sport can increase the social participation and the benefits for subsistence of adolescents, in addition to delaying marriage and increasing the use of contraceptive among girls. according to the authors, sport-based youth engagement programs in india can influence self-efficacy and prosocial values through bonding with peers and changing unequal gender norms. different benefits were identified for boys and girls. associated with the boys, the participation of adolescents in sports provides greater chances of vocational training, engagement in the social program and a tendency towards political participation. among girls, sport in adolescence was associated with a lower tendency towards child marriage and use of family planning, and greater involvement in vocational training. the authors suggest that in india, programs to develop opportunities for young people through sports can collaborate to build resilience among participants. 3.5.5 social opportunities the perspective of professionalization from the development of skills and competences in sport was investigated by hills et al. (2019) with young people in the united kingdom. the results show that the effects centered on business/professionalization were stronger among a group of young beneficiaries than among some variables centered on health and well-being. although,hermens et al. (2015) have found that in young people from a project linked to a club in the netherlands, the participation in sports is positively related to self-esteem, self-regulation skills and social inclusion. these data reinforce the results in the investigations made by votre et al. (2011) and vianna and lovisolo (2018) in brazil, in which the authors also verified in the speech of boys who practice physical and sports activities in sip the aspiration of becoming athletes or sports teachers, as a possibility of social mobility. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 1; january-febuary 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 14 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe although in different social and economic contexts, the common aspect is the discontinuity or disinvestment of resources in projects, and the absence of partnerships and strategies for participants to progress in sports and through sports. 4 conclusions the results found in this integrative review research can contribute to the updating and comparison of the evidences found in research investments in developing countries and in countries with greater economic development, which focused on social inclusion of subjects in a situation of social vulnerability through sports. the data indicate that the sport has been used in sports projects for the social inclusion of children, adolescents and young people in situations of social vulnerability, as it helps in the development of personal and social skills and abilities of the participants. there is a common perception that physical and sports activities projects and programs provide these subjects with the opportunity to access the benefits arising from the practice. qualitative studies (single case, multiple cases, ethnography), quantitative studies and mixed methods (survey, correlational and quasi-experimental)were identified in theoretical matrices based on social sciences, humanities and health sciences, which used interviews, questionnaires, field notes, observation and structured instrumentsas techniques for data collection. apparently, this is a reflection of the multidisciplinary nature of this phenomenon. assessing the effects of physical and sports activities on the development of participants in sip was the mean used to assess the impact of the projects. a risk in preparing assessments that focus on the benefits of health promotion, gender relations, the expansion of social capital, the improvement of psychological aspects and social opportunities may lie in overvaluing the benefits and minimizing the limitations and restrictions to the practice. investigations that verify both positive aspects and unexpected effects can provide evidence to be used by public policy makers, project managers and teachers, for the refinement of institutional proposals and improvement of the participants' social inclusion process. based on the investigations described in this integrative review, it is recommended new researches that observe what are the institutional management strategies and what are the didactic procedures adopted in teaching physical and sports activities that further favor the social inclusion of individuals in situations of social vulnerability and further expand the social opportunities of the participants. references bean, cn, kendellen, k, halsall, t, &forneris, t. (2015). “putting program evaluation into practice: enhancing the girls just wanna have fun program”. evaluationand program planning 49:31–40. doi: 10.1016/j.evalprogplan.2014.11.007 bento, gg, ferreira, eg, silva, fc, castro, tls, silva, ba, & silva, r. (2019). prevalence and factors associated with physical activity in socially vulnerable children”. revista brasileira de medicina do esporte 25(4):285–89. doi: 10.1590/1517-869220192504162575. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 1; january-febuary 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 15 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe bhan, n, bhadra, k, rao, n, yore, j & raj, a. (2020). “sport as a vehicleofchange for livelihoods, social participationand marital health for the youth: findingsfrom a prospectivecohort in bihar, india”. eclinicalmedicine 20:100302. doi: 10.1016/j.eclinm.2020.100302. brauner, lm, valentini, nc, & souza, ms. (2017). “programa de iniciação esportiva influencia a competência percebida de crianças?” psico-usf 22(3):527–39. doi: 10.1590/1413-82712017220312. buelens, e, theeboom, m, vertonghen, j& de martelaer, k. (2015). sociallyvulnerableyouth andvolunteering in sports: analyzing a brussels training program for young soccer coaches. social inclusion, v. 3, n. 3, p. 82– 97, 25 jun. 2015. https://doi.org/10.17645/si.v3i3.188. castro, sbe, & souza, dl. (2011). “significados de um projeto social esportivo: um estudo a partir das perspectivas de profissionais, pais, crianças e adolescentes”. movimento (esefid/ufrgs) 17(4):145– 63. doi: 10.22456/1982-8918.22268. clarke, f, jones, a, & smith, l. (2021). building peace through sports projects: a scopingreview. sustainability, v. 13, n. 4, p. 2129, 17 fev. https://doi.org/10.3390/su13042129. coalter, f. (2015). sport-for-change: some thoughtsfrom a sceptic. social inclusion, v. 3, n. 3, p. 19–23, 25 jun. https://doi.org/10.17645/si.v3i3.222. collins, m&haudenhuyse, r. (2015). social exclusionandausterity policies in england: the role of sports in a new area of social polarisationandinequality? social inclusion, v. 3, n. 3, p. 5–18, 25 jun. 2015. https://doi.org/10.17645/si.v3i3.54. collison, h,darnell, s,giulianotti, r& howe, pd. (2017). the inclusionconundrum: a criticalaccountof youth andgenderissueswithinandbeyond sport for developmentand peace interventions. social inclusion, v. 5, n. 2, p. 223–231, 29 jun. https://doi.org/10.17645/si.v5i2.888. corazza, m& dyer, j. (2017). a new model for inclusive sports? na evaluationofparticipants‟ experiencesofmixedability rugby. social inclusion, v. 5, n. 2, p. 130–140, 29 jun. https://doi.org/10.17645/si.v5i2.908. cortês neto, ed, dantas, mmc, maia, rs, araújo filho, i, &maia, emc. (2020). “the resilience of adolescent participants in social projects for sport”. ciência & saúde coletiva 25(3): 901–8. doi: 10.1590/141381232020253.18362018. cortês-neto, ed, alchieri, jc, miranda, hf, & dantas-cavalcanti, fi. (2010). “elaboração de indicadores de sucesso em programas de saúde pública com foco sócio-esportivo”. revista de salud pública 12(2):208– 19. doi: 10.1590/s0124-00642010000200004. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 1; january-febuary 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 16 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe de martini ugolotti, nicola. (2017). “„we are rolling andvaulting tonight‟: sport programmes, urbanregenerationandthepoliticsofparkour in turin, italy”. international journal of sport policy and politics 9(1):25–40. doi: 10.1080/19406940.2016.1263234. declaração do rio de janeiro. (1992). estudos avançados, v. 6, n. 15, p. 153–159, ago. https://doi.org/10.1590/s0103-40141992000200013. journal of physical education and sports management, vol. 8(2), december 2021 haudenhuyse, r,hayton, j,parnell, d,verkooijen, k &delheye, p. (2020). boundaryspanning in sport for development: openingtransdisciplinaryandintersectoral perspectives. social inclusion, v. 8, n. 3, p. 123– 128, 17 ago. https://doi.org/10.17645/si.v8i3.3531. hermens, n, super, s,verkooijen, k &koelen, m. (2015). intersectoral action to enhance the social inclusion of socially vulnerable youth through sport: na exploration of the elements of successful partnerships between youth work organisations and local sports clubs. social inclusion, v. 3, n. 3, p. 98–107, 25 jun. https://doi.org/10.17645/si.v3i3.139. hills, s, walker, m & barry, ae. (2019). “sport as a vehicle for health promotion: a sharedvalueexampleof corporate social responsibility”. sport management review 22(1):126–41. doi: 10.1016/j.smr.2018.10.001. johns, a,grossman, m & mcdonald, k. (2014). “more than a game”: the impactof sport-based youth mentoring schemesondevelopingresiliencetowardviolentextremism. social inclusion, v. 2, n. 2, p. 57– 70, 20 ago. https://doi.org/10.17645/si.v2i2.167. kravchychyn, c & oliveira, aab. (2015). projetos e programas sociais esportivos no brasil: uma revisão sistemática. movimento (esefid/ufrgs), v. 21, n. 4, p. 1051, 24 ago. https://doi.org/10.22456/19828918.54017. moreira, mr,kastrup, e, ribeiro, jm, carvalho, ai & braga, ap. (2019). o brasil rumo a 2030? percepções de especialistas brasileiros(as) em saúde sobre o potencial de o país cumprir os ods brazilheadingto 2030. saúde em debate, v. 43, n. spe7, p. 22–35. https://doi.org/10.1590/0103-11042019s702. medeiros, um, & vianna, ja. (2021). motivos para o ingresso, a permanência e a evasão de meninas em projetos de inclusão social por meio do esporte. revista cocar, 15(32): 1-18. https://periodicos.uepa.br/index.php/cocar/article/view/3996 mailto:topacademicjournals@gmail.com https://periodicos.uepa.br/index.php/cocar/article/view/3996 american journal of medical and physical education vol.6, issue 1; january-febuary 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 17 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe nols, z,haudenhuyse, r &theeboom, m. (2017). urban sport-for-developmentinitiativesand young people in sociallyvulnerablesituations: investigatingthe „deficit model‟. social inclusion, v. 5, n. 2, p. 210–222, 29 jun. https://doi.org/10.17645/si.v5i2.881. pike, ecj, page, a &vinas, v. (2018). “playing out: a movement for movement?” frontiers in sociology 3:32. doi: 10.3389/fsoc.2018.00032. schaillée, h, theeboom, m &cauwenberg, jv. (2015). “what makes a difference for disadvantaged girls? investigatingtheinterplaybetweengroupcompositionand positive youth development in sport”. social inclusion 3(3):51–66. doi: 10.17645/si.v3i3.285. shetty, s. (2005). declaração e objetivos de desenvolvimento do milênio: oportunidades para os direitos humanos. sur. revista internacional de direitos humanos, v. 2, n. 2, p. 6–21. https://doi.org/10.1590/s180664452005000100001. souza, mt, silva, md, carvalho, r., souza, mt, silva, md, & carvalho, r. (2010). revisão integrativa: o que é e como fazer. einstein (são paulo), v. 8, n. 1, p. 102–106, mar. https://doi.org/10.1590/s1679-45082010rw1134. super, s,wentink, cq,verkooijen, kt, & koelen, ma. (2017). exploringthe sports experiences of socially vulnerable youth. social inclusion, v. 5, n. 2, p. 198–209, 29 jun. https://doi.org/10.17645/si.v5i2.864. undp. (2017).movimento é vida atividades físicas e esportivas para todas as pessoas. [s. l.: s. n.]. http://hdr.undp.org/en/content/national-human-development-report-2017-brazil. vianna, ja, &lovisolo, hr. (2011). a inclusão social através do esporte: a percepção dos educadores. revista brasileira de educação física e esporte, v. 25, n. 2, p. 285–296, jun. https://doi.org/10.1590/s1807-55092011000200010. vianna, ja, &lovisolo, hr. (2009). projetos de inclusão social através do esporte: notas sobre a avaliação. movimento (esefid/ufrgs), v. 15, n. 3, p. 145–162, 16 fev. https://doi.org/10.22456/1982-8918.5190. vianna, ja, &lovisolo, hr. (2018). sports: the expectationofchildrenand young practitioners in the favela. journalofphysicaleducationand sports management, v. 5, n. 1, p. 8. viñas, f, casas, f, abreu dp, alcantara, sc & montserrat, c. (2019). social disadvantage, subjectivewellbeingandcopingstragies in childhood: the casofnortheasternbrazil. children na youth services review, v. 97, p. 14-21.https://doi.org/10.1016/j.childyouth.2017.06.012get rights and content votre, sj et al (2011). gênero e atividade física.rio de janeiro: mauad x: faperj. whittemore, r&knafl, k. (2005). the integrative review: updatedmethodology. journalofadvancednursing, v. 52, n. 5, p. 546–553, dez. https://doi.org/10.1111/j.1365-2648.2005.03621.x. mailto:topacademicjournals@gmail.com https://doi.org/10.1016/j.childyouth.2017.06.012 https://doi.org/10.1016/j.childyouth.2017.06.012 american journal of medical and physical education vol.10, issue 4; july-august 2025; issn: 2994-0524 impact factor: 7.06 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ ajmpe; mail: topacademicjournals@gmail.com 1 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ ajmpe prevalence of hepatitis b surface antigen among students of kwara state college of health technology, offa, nigeria: a cross-sectional study college of health technology, offa *dr raufu alabi aliyu1, and mathew folaranmi olaniyan2 1department of medical laboratory science, kwara state college of health technology, offa, nigeria. 2department of medical laboratory science, kwara state college of health technology, offa, nigeria. email: aliyurauf@yahoo.com/ doi: https://doi.org/10.5281/zenodo.16793004 abstract background: hepatitis b virus (hbv) infection remains a significant global public health concern, particularly in sub-saharan africa where it is endemic. this study aimed to determine the prevalence of hepatitis b surface antigen (hbsag) among students of kwara state college of health technology, offa, nigeria. methods: a cross-sectional study was conducted between july and august 2016 involving 100 randomly selected students from various departments of the college. blood samples were collected and screened for hbsag using a rapid chromatographic immunoassay. data on age, sex, and department were recorded and analyzed using descriptive statistics. results: the overall seroprevalence of hbsag was 7% (n=7). females showed a higher prevalence (8.2%) compared to males (5.13%). students aged 18-21 years had a higher prevalence rate (12.5%) than those aged 22-25 years (4%). no hbsag positivity was detected in students above 26 years. analysis by department revealed the highest prevalence in environmental health department (27.1%), followed by public health and community health departments (9.1% each), with dental health and nutrition departments each showing 8.3% prevalence. conclusion: this study demonstrates a concerning prevalence of hbsag among college students, particularly in younger females and students of environmental health. the findings highlight the need for targeted hbv screening, vaccination programs, and education about preventive measures within tertiary institutions in nigeria. keywords: hepatitis b virus, hbsag, prevalence, students, nigeria introduction hepatitis b virus (hbv) infection represents a major global health challenge, affecting approximately 2 billion people worldwide, with 350 million suffering from chronic infection (who, 2022). the world health mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.10, issue 4; july-august 2025; issn: 2994-0524 impact factor: 7.06 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ ajmpe; mail: topacademicjournals@gmail.com 2 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ ajmpe organization considers hbv second only to tobacco among liver carcinogens. in sub-saharan africa and east asia, approximately 10% of the population is chronically infected with hbv, with significant risk of developing complications such as liver cirrhosis and hepatocellular carcinoma (spearman et al., 2017). hbv is a dna virus belonging to the hepadnaviridae family that can cause both acute and chronic liver infections. transmission occurs through contact with infected blood or body fluids, with perinatal, horizontal, and sexual transmission being the predominant routes (ott et al., 2012). in africa, epidemiological studies have shown that hbv infection commonly occurs during childhood, resulting in an increased tendency toward chronicity (lemoine et al., 2013). the clinical manifestations of hbv infection range from asymptomatic carrier state to fulminant hepatitis. after an incubation period, patients typically present with prodromal symptoms including chills, headache, nausea, and vomiting, which may precede jaundice. while most acute hbv infections resolve spontaneously, chronically infected individuals have elevated risks of developing cirrhosis and hepatocellular carcinoma (trépo et al., 2014). diagnosis of hbv infection is primarily confirmed through serological testing, with hbsag being the most important marker. hbsag appears during the incubation period and persists during acute disease, disappearing after one to two months following jaundice in resolving infections. persistence of hbsag for more than 6 months indicates a carrier state and risk for chronic hepatitis (liaw & chu, 2009). despite the availability of an effective vaccine against hbv since 1982, and its integration into the expanded programme on immunization (epi) in many countries, hbv infection continues to be a significant public health issue in nigeria. various studies have reported prevalence rates ranging from 2.4% to 18.4% across different population groups in nigeria (musa et al., 2015). college students represent a demographic group that may be at higher risk for hbv infection due to lifestyle factors including potential unsafe sexual practices, sharing of personal items, and participation in activities with risk of blood exposure. understanding the epidemiology of hbv infection among this population is crucial for developing targeted preventive strategies (eni et al., 2018). the present study aimed to determine the prevalence of hbsag among students of kwara state college of health technology, offa, nigeria, and to identify demographic factors associated with hbv infection in this population. materials and methods study design and population a cross-sectional study was conducted between july and august 2016 at kwara state college of health technology, offa, nigeria. the college is located in offa, the second largest town in kwara state with a population of approximately 90,000 inhabitants. the college has about ten departments with approximately 10,000 students. a total of 100 students were randomly selected from various departments of the college. the study population comprised 39 males and 61 females, with ages ranging from 18 to 28 years. the distribution of participants mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.10, issue 4; july-august 2025; issn: 2994-0524 impact factor: 7.06 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ ajmpe; mail: topacademicjournals@gmail.com 3 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ ajmpe across departments was as follows: medical laboratory science (n=11), public health (n=11), dental health (n=12), community health (n=11), health education (n=11), environmental health (n=11), pharmacy (n=10), human nutrition (n=12), and health information (n=11). ethical considerations ethical approval was obtained from the institutional review board of kwara state college of health technology. informed consent was obtained from all participants prior to sample collection. confidentiality of all personal and medical information was maintained throughout the study. sample collection and processing venous blood samples (approximately 3ml) were collected using standard venipuncture technique. blood samples were collected in plain bottles and allowed to clot. sera were separated by centrifugation and stored appropriately until analysis. laboratory analysis serum samples were screened for hbsag using a commercially available rapid chromatographic immunoassay kit according to the manufacturer's instructions. the principle of the test is based on the reaction between specimen and colloidal gold particles labeled with specific antibodies against hbsag. a positive result is indicated by the development of a pink-colored band in the test region in addition to the control band, while a negative result shows only the control band. quality control measures included checking expiration dates of test kits, ensuring water-free conditions, avoiding sample mix-ups, and running positive and negative controls with each batch of tests. data analysis data were analyzed using simple descriptive statistics. the prevalence of hbsag was calculated as the percentage of positive cases among the total number of students tested. stratified analysis was performed to determine the distribution of hbsag positivity by age, sex, and department. results overall prevalence of hbsag of the 100 students screened, 7 tested positive for hbsag, giving an overall seroprevalence of 7%. prevalence of hbsag by sex among the 39 males screened, 2 (5.13%) were positive for hbsag, while 5 of the 61 females (8.2%) tested positive (figure 1). the data indicated a higher seroprevalence among female students compared to their male counterparts. prevalence of hbsag by age group the age-specific distribution of hbsag showed that students in the age group 18-21 years had the highest prevalence rate of 12.5% (5/40), followed by those in the age group 22-25 years with a prevalence of 4% (2/50). no positive cases were detected among students aged 26 years and above (0/10) (figure 2). prevalence of hbsag by department mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.10, issue 4; july-august 2025; issn: 2994-0524 impact factor: 7.06 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ ajmpe; mail: topacademicjournals@gmail.com 4 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ ajmpe the departmental distribution of hbsag positivity revealed that students from the environmental health department had the highest prevalence at 27.1% (3/11), followed by public health and community health departments, each with 9.1% (1/11). dental health and nutrition departments each had a prevalence of 8.3% (1/12). no positive cases were detected among students from medical laboratory science, health education, pharmacy, and health information departments (figure 3). discussion this study reports an overall hbsag seroprevalence of 7% among students of kwara state college of health technology, offa, nigeria. this finding falls within the range of hbsag prevalence reported in previous studies conducted in nigeria, which varies between 2% and 20% depending on the population and geographical region (musa et al., 2015; eke et al., 2011). according to the world health organization classification of hbv endemicity, a prevalence of 7% places this population in the intermediate-high endemicity category (5-7%), which is consistent with the general classification of nigeria as an hbv endemic country (who, 2022). the result is comparable to findings from similar studies among college students in nigeria, such as the 6.2% prevalence reported by oluboyo et al. (2014) among students in ekiti state and 8.3% reported by ndako et al. (2013) among students in ibadan. the higher prevalence of hbsag among female students (8.2%) compared to male students (5.13%) observed in this study contrasts with several previous studies that reported higher prevalence among males (eke et al., 2011; ndako et al., 2013). this unusual finding may be attributed to the unequal distribution of participants by sex in our study (61 females vs. 39 males) or could reflect local epidemiological patterns. potential factors contributing to higher female prevalence might include higher rates of body enhancement procedures such as manicure/pedicure with shared instruments, or other gender-specific risk behaviors not assessed in this study. the age-specific analysis revealed that younger students (18-21 years) had a higher prevalence (12.5%) of hbsag compared to older students (4% in the 22-25 age group and 0% in those >26 years). this finding aligns with other studies that have reported higher hbv infection rates among younger adults in nigeria (musa et al., 2015). this could be attributed to lower vaccination coverage among younger students, as the national hbv vaccination program in nigeria has faced implementation challenges, or to behavioral factors such as higher engagement in risk behaviors among younger students. the departmental distribution of hbsag positivity showed marked variation, with the environmental health department having the highest prevalence (27.1%). this striking difference might be related to specific exposures during practical training, such as handling waste materials or engagement in community-based fieldwork where students might be exposed to contaminated materials. the absence of positive cases in departments such as medical laboratory science, despite potential occupational exposure to blood and body fluids, might suggest better awareness and adherence to standard precautions among these students due to their specialized training. several limitations should be considered when interpreting the results of this study. the relatively small sample size (n=100) may not be fully representative of the entire student population of approximately 10,000. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.10, issue 4; july-august 2025; issn: 2994-0524 impact factor: 7.06 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ ajmpe; mail: topacademicjournals@gmail.com 5 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ ajmpe additionally, the study relied solely on hbsag detection without assessing other serological markers of hbv infection such as anti-hbc, anti-hbs, or hbeag, which would have provided a more comprehensive understanding of the infection status. furthermore, the study did not evaluate risk factors associated with hbv infection, limiting our ability to explain the observed prevalence patterns. despite these limitations, our findings highlight a significant prevalence of hbsag among college students, particularly among younger females and students in specific departments, warranting targeted interventions. conclusion this study revealed a 7% prevalence of hbsag among students of kwara state college of health technology, offa, nigeria, with higher rates observed among females, younger students (18-21 years), and students in the environmental health department. these findings underscore the need for comprehensive prevention strategies, including screening, vaccination, and education programs specifically targeting high-risk groups within the college population. recommendations based on the findings of this study, we recommend: 1. implementation of routine hbv screening for all new and continuing students in tertiary institutions in nigeria to identify infected individuals for appropriate management and to prevent transmission. 2. strengthening of hbv vaccination programs within educational institutions, with particular focus on departments with higher prevalence rates. 3. development of educational campaigns to increase awareness about hbv transmission, prevention, and the importance of vaccination, especially targeting younger students and departments with higher prevalence. 4. enhancement of infection control practices during practical training sessions, particularly for students in environmental health and other departments with potential exposure to blood and body fluids. 5. conducting larger, multi-center studies with more comprehensive serological testing and risk factor assessment to better understand the epidemiology of hbv infection among nigerian college students. acknowledgments the authors thank the management and students of kwara state college of health technology, offa, for their cooperation and participation in this study. conflicts of interest the authors declare no conflicts of interest. references eke, a. c., eke, u. a., okafor, c. i., ezebialu, i. u., &ogbuagu, c. (2011). prevalence, correlates and pattern of hepatitis b surface antigen in a low resource setting. virology journal, 8, 12. https://doi.org/10.1186/1743-422x-8-12 mailto:topacademicjournals@gmail.com https://doi.org/10.1186/1743-422x-8-12 american journal of medical and physical education vol.10, issue 4; july-august 2025; issn: 2994-0524 impact factor: 7.06 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ ajmpe; mail: topacademicjournals@gmail.com 6 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ ajmpe eni, a. o., soluade, m. g., oshamika, o. o., efekemo, o. p., igwe, t. t., &onile, o. s. (2018). seroprevalence of hepatitis b virus and hiv among healthy young adults in south-west nigeria. the pan african medical journal, 30, 69. https://doi.org/10.11604/pamj.2018.30.69.14579 lemoine, m., nayagam, s., &thursz, m. (2013). viral hepatitis in resource-limited countries and access to antiviral therapies: current and future challenges. future virology, 8(4), 371-380. https://doi.org/10.2217/fvl.13.11 liaw, y. f., & chu, c. m. (2009). hepatitis b virus infection. the lancet, 373(9663), 582-592. https://doi.org/10.1016/s0140-6736(09)60207-5 musa, b. m., bussell, s., borodo, m. m., samaila, a. a., & femi, o. l. (2015). prevalence of hepatitis b virus infection in nigeria, 2000-2013: a systematic review and meta-analysis. nigerian journal of clinical practice, 18(2), 163-172. https://doi.org/10.4103/1119-3077.151035 ndako, j. a., nwankiti, o. o., echeonwu, g. o., junaid, s. a., anaele, o., & anthony, t. j. (2013). studies on prevalence and risk factors for hepatitis b surface antigen among secondary school students in northcentral, nigeria. sierra leone journal of biomedical research, 5(1), 5-12. oluboyo, b. o., enitan, s. s., adeleke, g., &oluboyo, a. o. (2014). prevalence of hepatitis b and c viral infections among medical students in ekiti state university, ado-ekiti, nigeria. international journal of current microbiology and applied sciences, 3(10), 834-845. ott, j. j., stevens, g. a., groeger, j., & wiersma, s. t. (2012). global epidemiology of hepatitis b virus infection: new estimates of age-specific hbsag seroprevalence and endemicity. vaccine, 30(12), 22122219. https://doi.org/10.1016/j.vaccine.2011.12.116 spearman, c. w., afihene, m., ally, r., apica, b., awuku, y., cunha, l., dusheiko, g., gogela, n., kassianides, c., kew, m., lam, p., lesi, o., lohouès-kouacou, m. j., mbaye, p. s., musabeyezu, e., musau, b., ojo, o., rwegasha, j., scholz, b., ... gastroenterology and hepatology association of subsaharan africa (ghassa). (2017). hepatitis b in sub-saharan africa: strategies to achieve the 2030 elimination targets. the lancet gastroenterology & hepatology, 2(12), 900-909. https://doi.org/10.1016/s2468-1253(17)30295-9 trépo, c., chan, h. l., & lok, a. (2014). hepatitis b virus infection. the lancet, 384(9959), 2053-2063. https://doi.org/10.1016/s0140-6736(14)60220-8 mailto:topacademicjournals@gmail.com https://doi.org/10.11604/pamj.2018.30.69.14579 https://doi.org/10.2217/fvl.13.11 https://doi.org/10.1016/s0140-6736(09)60207-5 https://doi.org/10.4103/1119-3077.151035 https://doi.org/10.1016/j.vaccine.2011.12.116 https://doi.org/10.1016/s2468-1253(17)30295-9 https://doi.org/10.1016/s0140-6736(14)60220-8 american journal of medical and physical education vol.10, issue 4; july-august 2025; issn: 2994-0524 impact factor: 7.06 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ ajmpe; mail: topacademicjournals@gmail.com 7 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ ajmpe world health organization. (2022). hepatitis b. https://www.who.int/news-room/fact-sheets/detail/hepatitis-b mailto:topacademicjournals@gmail.com https://www.who.int/news-room/fact-sheets/detail/hepatitis-b american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 48 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe examining the factor structure and reliability of the revised self-leadership questionnaire in a greek sample maria chatzichristodoulou kingston university united kingdom abstract: the revised self-leadership questionnaire (rslq) is a psychometric instrument that measures selfleadership, a process by which individuals control their own behaviors, create influence, and lead themselves using specific behavioral and cognitive strategies. the rslq has been translated into several languages, including chinese, portuguese, turkish, hebrew, and german. the translated versions of the rslq have shown good reliability and construct validity, providing evidence of the measure's cross-cultural validity. however, more research is needed to assess the measurement properties of the rslq in new cultural contexts. keywords: self-leadership, rslq, psychometrics, cross-cultural validity introduction the measurement of persons’ socio-behavioral characteristics, that is, skills that can lead to better selfmanagement of behaviors, is a rather attractive subject to researchers. such an interest is due to the belief that knowledge of persons’ skills, such as self (self-leadership), can contribute to the design and implementation of programs aimed at the cover needs for self-direction and self-motivation to shape their behaviors in positive ways to enhance their overall performance (houghton, dawley, &diliello, 2012). self-leadership has been described as a process by which a person controls his/her own behaviors, creates influence and leads oneself using specific behavioral and cognitive strategies (manz, 1986, 2015; manz& neck, 2004; manz& sims, 2001). self-leadership strategies include three different dimensions: behavior-focused strategies, natural reward strategies and constructive thought pattern strategies (anderson & prussia, 1997; houghton & neck, 2002; manz& neck, 2004; manz& sims, 2001; neck & houghton, 2006; prussia, anderson, &manz, 1998). the selfleadership construct has been measured by means of the revised self-leadership questionnaire (rslq; houghton & neck, 2002). the rslq consists 35 items in 9 subscales, representing three self-leadership dimensions: the behaviorfocused which consists five subscales (self-goal setting; self-reward; selfpunishment; self-observation and self-cueing), the natural reward which consists only one subscale, and the constructive thought which consists three subscales (visualizing successful performance; self-talk; and evaluating beliefs and assumptions. the rslq has indicated relative a good reliability and construct validity in several studies (e.g., carmeli, meitar, & weisberg, 2006; curral& marquesquinteiro, 2009; houghton, bonham, neck, & singh, 2004; houghton & jinkerson, 2007). the rslq, except for its use in english language (e.g., houghton & neck, 2002; usa, and mahembe, engelbrecht, & de kock, 2013, and nel & zyl, 2015; south africa), it has been translated in another languages, as chinese (ho & nesbit, 2009; neubert & wu, 2006), portuguese (curral& marques-quinteiro, 2009; marquesquinteiro, curral, &passos, 2012), turkish (dogan &sahin, 2008), hebrew (carmeli et al., 2006), and german (andressen&konradt, 2007). the translated versions of the rslq further confirm the original findings by houghton and neck (2002) and give additional evidence of the measure’s cross-cultural validity (houghton et al., 2012). despite the fact that rslq has been used enough in self-leadership research, is support that more research is needed to assess the measurement properties of the rslq (houghton & neck, 2002), especially when it is applied in new cultural contexts (houghton et al., 2012). mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 49 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe the significance of the current investigation lies in the examination of the factor structure of rslq in the greek culture. moreover, an examination of the rslq measure with that sample can contribute to the research on selfleadership skills in a different achievement domain, such as of physical activities. to date, self-leadership has been examined in concepts, such as spirituality in the workplace (neck & milliman, 1994), performance appraisals (neck, stewart, &manz, 1995), organizational change (neck, 1996), entrepreneurship (neck, neck, & manz,1997), diversity management (neck, smith, & godwin, 1997), job satisfaction (houghton & jinkerson, 2007; robert &foti, 1998), non-profit management (neck, ashcraft, &vansandt, 1998), goal setting/goal performance (godwin, neck, & houghton, 1999; neck, nouri, & godwin, 2003), team performance (stewart & barrick, 2000), team sustainability (houghton, neck, &manz, 2003), succession planning (hardy, 2004) and ethics (vansandt& neck, 2003). finally, this instrument can help to identify individuals with poor self-leadership skills in physical activities contexts. by doing so, support can be provided to such individuals to improve their self-influencing (self-leadership) skills which, in turn, could help them to perform more effectively. hence, the purpose of the present study is to test the factor structure of the rlsq instrument in a greek sample. 2. method 2.1 participants the study used undergraduate students from a greek university (department physical education and sport science), 385 questionnaires were distributed to participants and 373 completed questionnaires were returned. the resulting response rate was very high (96.9%) because research questionnaires were administered in class, with voluntary participation. the sample consisted of 197 male (52.8%) and 176 female (47.2%) participants. the majority (95%) fell in the age category between 18 and 24 years. 2.2 instrument self-leadership. self-leadership was measured with the revised self-leadership questionnaire (rslq) development by houghton and neck (2002). there are 35 item statements in the self-leadership scale measuring behavior-focused, natural reward, and cognitive thought strategies. self-leadership strategies were scored using a 5point likert scale ranging from 1 = “totally disagree” to 5 = “totally agree”. there are nine subscales in the rslq. behavior-focused self-leadership can be measured with five subscales identified as self-goal setting (5 items; α = 0.84), self-reward (3 items; α = 0.93), self-punishment (4 items; α = 0.86), self-observation (4 items; α = 0.82), and selfcueing (2 items; α = 0.91). natural reward self-leadership is measured with a single 5-item scale (α = 0.74). constructive thought self-leadership is measured with three subscales, including visualizing successful performance (5 items; α = 0.85), self-talk (3 items; α = 0.92), and evaluating beliefs and assumptions (4 items; α = 0.78). 2.3 procedure prior institutional permission was granted before conducting the research. data were collected from undergraduate physical education classes after permission granted by the competent professors and after the participants were informed of the nature of the study. participation was voluntary, and no incentives were provided. 2.4 data analysis preliminary analyses for violations of statistical assumptions were conducted. then factor analyses (confirmatory and exploratory) were used to investigate the factor structure of the items from the nine rslq scales described above. both analyses were used because the theoretical foundation of self-leadership is built upon in many theories. exploratory factor analysis (efa) is generally thought of as more of a theory-generating procedure, while the confirmatory factor analysis (cfa) is a theory-testing model (stevens, 1996). three procedures were used. first, all 35 items were forced to a nine-factor solution and cfa was used to assess the fit of original model of nine-factor 35item in greek language. second, exploratory factor analyses were used because the correlation between the observed and latent variables was found to be uncertain (byrne, 2001). specifically, efa were used mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 50 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe to determine the extent to which the item measurement (the observed variables) were related to the nine latent constructs. next, cfa was used to tested fit of the 8-factor 25-item model, based on the results of the efa. the models (9-factor, 32-item and 8factor, 25-item) were tested using cfa with maximum likelihood (ml) parameter estimates in amos 22.0. the ml algorithm was selected because it resulted in accurate fit indexes with orderedcategorical data that violate the assumption of multivariate normality (hutchinson & olmos, 1998; olsson, foss, troye, & howell, 2000). the sample size in the present study was adequate to estimate the various models based on two criteria: (a) the total sample size was larger than 300, and (b) the ratio of the total sample size to the number of freely estimated parameters should be greater than 10:1 (kline, 2005). several criteria were used to test the hypothesized factor structure of the rslq. the traditional measure of fit for cfas models is the x2 goodness-of-fit test (statistic). non-significant values suggest a good fit, since they indicate only a minor discrepancy between the observed and the estimated covariance matrix. however, now it is generally agreed that the x2 statistic is sensitive to sample size and violations of multivariate normality (bollen& long, 1992). the goodness-of-fit index (gfi) represents the relative amount of variances reproduced by the specified model as compared to the saturated model. fit indices exceeding .90 are considered evidence of adequate model fit (e.g., bollen, 1989; fan, thompson, & wang, 1999), although hu and bentler (1999) have proposed more conservative criteria, in which gfi at .95 or higher is deemed a good model fit. the comparative fit index (cfi) is an index in which values greater than .90 may indicate reasonably good fit of the data to the model (hu &bentler, 1999). finally, the root mean square error of approximation (rmsea) is an index least affected by the sample size (fan et al., 1999). the rmsea ≤ .05 indicates close approximate fit; values between .05 and .08 suggest reasonable error of approximation and rmsea ≥ .10 suggests poor fit (brown &cudeck, 1993). these fit indices were selected as the best indices, acknowledging that there is not a single fit index that is considered to be the definitive marker of optimum model fit (hu &bentler, 1999; byrne, 2001). to efa two criteria were used to determine the factor structure: (a) retain items with a factor loading equal to or greater than .40, and (b) exclude items with double loadings. 3. results preliminary analyses prior to analyses, data were examined for the presence of univariate and multivariate outliers (tabachnick&fidell, 2007), which might attenuate the results. the former was analyzed through standardized scores (z ≥ 3.30) and the latter thought mahalanobis distance (p< .001) and studentized deleted residual (greater than ± 4.00). few univariate outliers were identified as having high z scores while no multivariate outliers were found. also, the normality of each of the 35 items was investigated in terms of its skewness (-1.10 to 0.23, m = 0.85) and kurtosis (-.97 to 2.25, m = 1.52). these values were all within the level recommended for a cfa with maximum-likelihood estimation (skew > 2, kurtosis > 7; west, finch, & curran, 1995), supporting the normality assumption for all variables. for this, no cases were deleted. factor analyses initially, a confirmatory factor analysis was applied because the rslq was developed based on theoretical grounds, specific hypotheses regarding which items should load significantly on which scale were suitable for confirmatory factor analysis (stevens, 1996). based on content validity the factorial structure of the rslq was tested making use a confirmatory factor analysis (9-factor correlated model) (table 1). results from the cfa analysis indicated lack-of-fit of the hypothesized model (chi-square = 1176.44, df = 526, p< .001, cfi = 834, gfi = .844, rmsea = .058). the next step in the analysis was to perform exploratory factor analysis (efa) because the original factor structure could not be confirmed. the factor structure of the preliminary 35-item rslq was identified using efa with principal component analysis as the extraction method. the varimax with kaiser normalization method was used for rotation because the factors were thought to be uncorrelated. the kaiser–meyer–olkin’s measure (kmo) of mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 51 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe sampling adequacy (acceptable level >.50; kaiser, 1970) and bartlett’s test of sphericity (bartlett, 1950) were calculated to verify the appropriateness of an efa. the number of factors was determined using parallel analysis (pa) performed with spss syntax developed by o’connor (2000). only items with a strong loading (.40 or higher) on one factor and <.30 on any other factors were retained to form latent variables because large loadings on factors other than the primary factor could result in serious flaws in the factor structure (costello & osborne, 2005). however, these views vary slight within literature. for example, tabachnick&fidell (2007) suggest that the secondary loading (or cross-loading) should be no greater than .32. costello and osborne (2005) suggest that a loading of .50 is enough to be considered “strong,” while guadagnoli and velicer (1988) state that the loading should be .60 or greater. the efa with data from the 35-item rslq indicated that the sample and correlation matrix were appropriate for factor analysis (kmo index = .800 and bartlett’s test of sphericity was significant [x2(595, n = 373) = 4,367.10, p< .001]). ten factors were extracted based on pa analysis that cumulatively accounted for 61.74% of the total variance. however, several items were found to have a poor loading (<.40) on all factors or had crossed loadings (loading ≥.30 in two or more factors). these items were then dropped and a repeated efa was conducted with remaining items using the same method. this procedure was replicated until all retained items met the criteria. the excluded items were: item 34: “i write specific goals for my own performance”; item: 8: “i focus written notes to remind myself of what i need to accomplish”; item 17: “i try to surround myself with the objects and the people that bring out my desirable behaviors”; item 26: “when i have a choice, i try to do my work in ways that i enjoy rather than just trying to get it over with”; item 1: “i use my imagination to picture myself performing well on important tasks”; and item 23: “i openly articulate and evaluate my own assumptions when i have a disagreement with someone else”. the sub dimension of “self-observation” was also discarded given all items saturated in more than one factor. finally, a 25-item scale was generated with all items having a strong loading on the primary factor but not on the other factors (table 2). the appropriateness of the efa for the revised 25-item rslq was again justified, kmo = .787; bartlett’s test: x2(300, n = 373) = 3.279,21, p< .001. the number of factors was change on a repeated pa (table 1). a clear 8factor solution emerged. the initial eigenvalues of eight factors were 5.52, 2.32, 2.07, 1.82, 1.47, 1.34, 1.16, and 1.04. these latent variables explained 22.07%, 9.27%, 8.26%, 7.28%, 5.89%, 5.35%, 4.64%, and 4.17% of variance, respectively, and together 66.93% of the total variance. after carefully examining of the items, it was found that all items of the self-observation factor were excluded. to examine the stability of the 8-factor solution derived from exploratory factor analyses, we conducted a cfa on the 25-item modified rlsq using the same sample. as model postulated an 8-factor 25-item correlated latent factors structure, in which each item was constrained to load on its respective latent variable. results indicated good model fit (x2 = 462,36, df = 247, p< .001, gfi = .91, cfi = .93 and rmsea = .048 (table 1). table 1fit indices for models model description x2 df gfi cfi rmsea 9-factor 1176,44 526 .844 .834 .058 8-factor 432,36 247 .910 .930 .048 for the assessing of reliability internal consistency methods and cronbach’s alpha were used (anastasi &ubrina, 1997; cortina, 1993). internal consistency method that used here was correlations with item-to-scale (average item-total correlation) (devellis, 2003). the results of the inter-total correlation indicated low to good relation among items (see table 2). an average inter-item correlation of .30 or higher indicates acceptable reliability (robinson, shaver, &wrightsman, 1991). tabachnick and fidell (2007) suggest that correlations exceeding .30 provide enough evidence to indicate that there is enough commonality to justify comprising factors. values for an item-total correlation (point-biserial) between 0 and .19 may indicate that the question is not mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 52 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe discriminating well, values between .20 and .39 indicate good discrimination and values .40 and above indicate very good discrimination. in item analysis, in order to protect the sumability aspect of the scale, it has to be higher than .30 (kline, 1993), or at least .40 (gliem&gliem, 2003). table 2factor loadings (if), communalities (h2) and reliability characteristics [cronbach alpha (α), and item-total correlations (itc) of the rslq-25 variable if h2 itc self-goal setting (α = .74) sl02 .71 .55 .50 sl11 .70 .59 .56 sl20 .77 .64 .59 sl28 .57 .50 .49 self-reward (α = .84) sl04 .77 .65 .61 sl13 .88 .80 .73 sl22 .91 .85 .79 self-punishment (α = .64) sl06 .61 .54 .33 sl15 .76 .65 .49 sl24 .77 .60 .47 sl30 .58 .48 .40 self-cue (α = .78) sl09 .88 .81 .64 sl18 .85 .80 .64 nature reward (α = .62) sl32 .80 .72 .44 sl35 .81 .75 .44 visualization (α = .77) sl10 .79 .71 .65 sl19 .86 .79 .71 sl27 .72 .59 .56 sl33 .48 .45 .41 self-talk (α = .88) sl03 .86 .78 .74 sl12 .89 .83 .80 sl21 .88 .81 .78 beliefs (α = .65) mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 53 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe sl05 .81 .72 .52 sl14 .71 .60 .42 sl29 .57 .55 .46 cronbach’s index of internal consistency ranged from 0.62 to 0.88 (see table 2), with five subscales showing acceptable alpha coefficient (α > 0.70; kline, 2005) and three subscales showing moderately low alpha coefficient (0.61 < α < 0.70; kline, 2005). however, since alpha coefficient is affected by the number of items (cortina, 1993), it is maintained that when the number of items is small, the measure should be considered reliable (schmitt, 1996). in the present study, the three factors which exhibited alpha values below the acceptable limit comprised four, three and two items, respectively. according to ntoumanis (2001) and pallant (2010) the values 0.62, 0.64 and 0.65 of factors present in this study, can be considered satisfactory, since these factors comprise less than ten items (four, three and two items, respectively). 4. discussion the present study was designed to translate into greek and to examine the construct validity of the greek version of the rslq. results showed that a 25-item instrument had adequate psychometric properties for measuring eight dimensions of self-leadership using greek sample that participated on physical activities. this instrument can to represents a first step towards the development of an individual self-leadership measure in the greek physical activity contexts and for that several recommendations for future research are presented. the results the current study is not provided support for the hypothesized nine-factor 35-item of original version of the rslq (houghton & neck, 2002). factorial analysis has suggested that several items should be reviewed, as factorial structure showed that several of them simultaneously had low scores in more than one factor. this was the case of self-observation. similar finding has been reported by marques-quinteiro et al. (2012), who examined the factorial structure of rslq in portuguese context. results imply that may be some systematic differences in the way the members separate cultures respond to and interpret item on the rslq, and it seems likely that these differences may reflect cultural differences relative to the u.s. sample of original instrument (houghton, carnes, & ellison, 2014). results other studies were suggested the exist important differences in selfleadership across cultures (georgianna, 2007; neubert & wu, 2006). based on of the existing cross-cultural selfleadership research suggests, we do expect that cultural differences may be reflected in the operationalization and measurement of the construct (houghton et al., 2014). this study has some limitations. first, it should be noted that the assessment of self-leadership dimensions was based on self-reports. second, the findings cannot be generalized to the broader population that participate in physical activities without further replication and another ages, because the sample that was used consisted of mostly young (18-24 years). it would be of interest to examine whether the present measure could be generalized to other ages, and in other greek population working adults. a systematic future research is necessary. 4.1 conclusions in conclusion, the current study failed to support the full nine-factor 35-item model. the psychometric evaluation of new factor model of the rslq-gr indicates good reliability and factorial validity. therefore, this study makes an important contribution in advancing physical activity self-leadership research. overall, the results of this study are in line with international research regarding the psychometric properties of the rslq. the rslq-gr may prove to be an effective self-leadership measure with much potential to facilitate empirical self-leadership research and practice. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 54 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 5. references anastasi, a., & urbina, s. (1997). psychological testing (7th ed.). upper saddle river, nj: prentice-hall international. andressen, p., &konradt, u. (2007). measuring self-leadership: psychometric test of the german version of the revised self-leadership questionnaire. zeitschrift fur personalpsychologie, 6, 117-128. http://dx.doi.org/10.1026/1617-6391.6.3.117 anderson, j. s., & prussia, g. e. (1997). the self-leadership questionnaire: preliminary assessment of construct validity. the journal of leadership studies, 4(2), 119–143. https://doi.org/10.1177/107179199700400212 bartlett, m. s. (1950). tests of significance in factor analysis. british journal of psychology, 3, 77-85. https://doi.org/10.1111/j.2044-8317.1950.tb00285.x bollen, k. a. (1989). structural equations with latent variables. new york: wiley. https://doi.org/10.1002/9781118619179 bollen, k. a., & long, j. s. (1992). tests for structural equation models. sociological methods and research, 21, 123-131. https://doi.org/10.1177/0049124192021002001 brown, m. w., &cudeck, r. (1993). alternative ways of assessing model fit. in k. a. bollen& j. s. long (eds.), testing structural equation models (pp. 136-162). newbury park, ca: sage publication, inc. byrne, b. m. (2001). structural equation modeling with amos. basic concepts, applications, and programming. mahwah, nj: erlbaum. carmeli, a., meitar, r., & weisberg, j. (2006). self-leadership skills and innovative behavior at work. international journal of manpower, 27(1), 75-90. doi:10.1108/01437720610652853 cortina, j. m. (1993). what is coefficient alpha? an examination of theory and applications. journal of applied psychology, 78, 98–104. doi:10.1037/0021-9010.78.1.98 costello, a. b., & osborne, j. w. (2005). best practices in exploratory factor analysis: four recommendations for getting the most from your analysis. practical assessment research & evaluation, 10, 1-7. retrieved from https://pareonline.net/pdf/v10n7.pdf curral, l., & marques-quinteiro, p. (2009). self-leadership and work role innovation: testing a mediation model with goal orientation and work motivation. revista de psicologia del trabajo y de las organizaciones, 25, 165-176. doi:10.4321/s1576-59622009000200006 devellis, r. f. (2003). scale development: theory and applications (2nd ed.). thousand oaks, ca: sage. dogan, s., &sahin, f. (2008). a study of reliability, validity and adaptation of revised self-leadership questionnairerslq to turkish context. journal of economics and administrative sciences, 26, 139-164. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 55 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe fan, x. b., thompson, b., & wang, l. (1999). effects of sample size, estimation method, and model specification on structural equation modeling fit indices. structural equation modeling: a multidisciplinary journal, 6, 56–83.https://doi.org/10.1080/10705519909540119 georgianna, s. (2007). self-leadership: a cross-cultural perspective. journal of managerial psychology, 22(6), 569–589. https://doi.org/10.1108/02683940710778440 gliem, j. a., &gliem, r. r. (2003). calculating, interpreting, and reporting cronbach’s alpha reliability coefficient for likert-type scales. midwest research to practice conference in adult, continuing, and community education. accessed january 10, 2008. http://www.alumniosu.org/midwest/midwest%20papers/gliem%20&%20gliem-done.pdf godwin, j. l., neck, c. p., & houghton, j. d. (1999). the impact of thought self-leadership on individual goal performance: a cognitive perspective. the journal of management development, 18(2), 153–169. https://doi.org/10.1108/02621719910257738 guadagnoli, e., &velicer, w. f. (1988). relation of sample-size to the stability of component patterns. psychological bulletin, 103(2), 265-275. http://dx.doi.org/10.1037/0033-2909.103.2.265 hardy, k. (2004). self-leadership as a tool in management succession planning. the public manager, 33, 41–44. ho, j., & nesbit, p. l. (2009). a refinement and extension of the self-leadership scale for the chinese context. journal of managerial psychology, 24, 450-476. doi:10.1108/02683940910959771 houghton, j. d., & jinkerson, d. l. (2007). constructive thought strategies and job satisfaction: a preliminary examination. journal of business and psychology, 22(1), 45–53. http://dx.doi.org/10.1007/s10869-0079046-9 houghton, j. d., & neck, c. p. (2002). the revised self-leadership questionnaire: testing a hierarchical factor structure for self-leadership. journal of managerial psychology, 17(8), 672–692 https://doi.org/10.1108/02683940210450484 houghton, j. d., bonham, t. w., neck, c. p., & singh, k. (2004). the relationship between self-leadership and personality: a comparison of hierarchical factor structures. journal of managerial psychology, 19, 427441. https://doi.org/10.1108/02683940410537963 houghton, j. d., carnes, a., & ellison, c. n. (2014). a cross-cultural examination of self-leadership: testing for measurement invariance across four cultures. journal of leadership & organizational studies, 21(4), 414–430. doi:10.1177/1548051813515753 houghton, j. d., dawley, m., &diliello, t. c. (2012). the abbreviated self-leadership questionnaire (aslq): a more concise measure of self-leadership. international journal of leadership studies, 7(2), 216–232. houghton, j. d., neck, c. p., &manz, c. c. (2003). we think we can, we think we can, we think we can: the impact of thinking patterns and self-efficacy on work team sustainability. team performance management, 9, 31–41. https://doi.org/10.1108/13527590310468042 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 56 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe hu, l., &bentler, p. m. (1999). cutoff criteria for fit indexes in covariances structure analysis: conventional criteria versus new alternatives. structural equation modeling, 6, 1-55. doi:10.1080/10705519909540118 hutchinson, s. r., & olmos, a. (1998). behavior of descriptive fit indices on confirmatory factor analysis using ordered categorical data. structural equation modeling, 5, 344–364. https://doi.org/10.1080/10705519809540111 kaiser, h. f. (1974). an index of factorial simplicity. psychometrika, 39, 31-36. kline, p. (1993). the handbook of psychological testing. london: routledge. kline, r. b. (2005). principles and practice of structural equation modeling (2nd ed.) new york: the guilford press. mahembe, b., engelbrecht, a. s., & de kock, f. s. (2013). a confirmatory factor analytic study of a selfleadership measure in south africa. sa journal of human resource management, 11(1), 10 pages. http://dx.doi.org/10.4102/sajhrm.v11i1.520 manz, c. c. (1986). self-leadership: toward an expanded theory of self-influence processes in organizations. academy of management review, 11(3), 585–600. https://www.jstor.org/stable/258312 manz, c. c. (2015). taking the self-leadership high road: smooth surface or potholes ahead? the academy of management perspectives, 29(1), 132–151. https://doi.org/10.5465/amp.2013.0060 manz, c. c., & neck, c. p. (2004). mastering self-leadership: empowering yourself for personal excellence. upper saddle river, nj: pearson prentice-hall. manz, c. c., & sims, h. p. (2001). the new super leadership: leading others to lead themselves. oakland, ca: berrett-koehler. marques-quinteiro, p., curral, l. a., &passos, a. m. (2012). adapting the revised self-leadership questionnaire to the portuguese context. social indicators research, 108, 553-564. doi:10.1007/s11205011-9893-7 neck, c. p. (1996). thought self-leadership: a self-regulatory approach to overcoming resistance to organizational change. international journal of organizational analysis, 4, 202–216. neck, c. p., & houghton, j. d. (2006). two decades of self-leadership theory and research past developments, present trends, and future possibilities. journal of managerial psychology, 21(4), 270–295. https://doi.org/10.1108/02683940610663097 neck, c. p., & milliman, j. f. (1994). thought self-leadership: finding spiritual fulfilment in organizational life. journal of managerial psychology, 9, 9–16. https://doi.org/10.1108/02683949410070151 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 57 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe neck, c. p., ashcraft, r., &vansandt, c. (1998). employee self-leadership: enhancing the effectiveness of nonprofits. international journal of organization theory and behavior, 1, 521–552. https://doi.org/10.1108/ijotb-01-041998-b006 neck, c. p., neck, h. m., &manz, c. c. (1997). thought self-leadership: mind management for entrepreneurs. journal of developmental entrepreneurship, 2, 25-36. neck, c. p., nouri, h., & godwin, j. l. (2003). how self-leadership affects the goal-setting process. human resource management review, 13, 691–707. doi:10.1016/j.hrmr.2003.11.009 neck, c. p., smith, w., & godwin, j. (1997). thought self-leadership: a self-regulatory approach to diversity management. journal of managerial psychology, 12, 190-203. neck, c. p., stewart, g., &manz, c. c. (1995). thought self-leadership as a framework for enhancing the performance of performance appraisers. journal of applied behavioral science, 31, 278–302. https://doi.org/10.1177/0021886395313004 nel, p., & van zyl, e. (2015). assessing the psychometric properties of the revised and abbreviated selfleadership questionnaires. sa journal of human resource management/sa tydskrifvirmenslikehulpbronbestuur, 13, 1–8. doi:10.4102/sajhrm.v13i1.661 neubert, m. j., & wu, j. c. (2006). an investigation of the generalizability of the revised self-leadership questionnaire to a chinese context. journal of managerial psychology, 21, 360-73. ntoumanis, n. (2001). a step-by-step guide to spss for sport and exercise studies. london and new york: routledge. o’connor, b. p. (2000). spss and sas programs for determining the number of components using parallel analysis and velicer’s map test. behavior research methods, instruments, & computers, 32, 396–402. olsson, u. h., foss, t., troye, s. v., & howell, r. d. (2000). the performance of ml, gls, and wls estimation in structural equation modeling under conditions of misspecification and nonnormality. structural equation modeling, 7, 557–595. https://doi.org/10.1207/s15328007sem0704_3 pallant, j. (2010). spss survival manual: a step by step guide to data analysis using spss for windows (4th ed.). maidenhead, berkshire: open university press. prussia, g. e., anderson, j. s., &manz, c. c. (1998). self-leadership and performance outcomes: the mediating influence of self-efficacy. journal of organizational behavior, 19(5), 523–538. robert, h. e., &foti, r. s. (1998). evaluating the interaction between self-leadership and work structure in predicting job satisfaction. journal of business and psychology, 12(3), 257–267. robinson, j. p., shaver, p. r., &wrightsman, l. s. (1991). measures of personality and social psychological attitudes. san diego, ca: academic press. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 58 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe schmitt, n. (1996). uses and abuses of coefficient alpha. psychological assessment, 8(4), 350–353. doi:10.1037/10403590.8.4.350. stevens, j. (1996). applied multivariate statistics for the social sciences. mahwah, nj: lawrence erlbaum. stewart, g. l., & barrick, m. r. (2000). team structure and performance: assessing the mediating role of intrateam process and the moderating role of task type. academy of management journal, 43, 135–49. doi:10.2307/1556372 tabashnick, l. s., &fidell, b. g. (2007). using multivariate statistics (5th ed.). new york, ny: pearson. vansandt, c. v., & neck, c. p. (2003). bridging ethics and self-leadership: overcoming ethical discrepancies between employee and organizational standards. journal of business ethics, 43, 363–387. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 59 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe diplomatic fallout: the risks of hosting international sporting events kemal can katkat brooklyn, new york, united states abstract: sports organizations play an important role in society, from promoting physical fitness and healthy living to fostering international cooperation and understanding. they can also be a major source of economic activity and tourism. this paper provides an overview of the history, types, and objectives of sports organizations. it also discusses the challenges and opportunities facing these organizations in the 21st century. keywords: sports organizations, history, types, objectives, challenges, opportunities 1. introduction in today's world, sports activities are seen as an opportunity for effective advertising and promotion. all sports activities focus on an impeccable organization and completion of the event from the beginning to the end. hence, failure within this process will affect the overall activity and cause loss of brand and image (demirci, 1986), because the dynamic and variable structured management of sports organizations may have negative impacts on the delegations of the visiting countries when any potential disruptions during the organization process occur (sunay, 2010). in this context, sports organizations should be considered as a concept with a rational structure and operating system acting as a social personality or organization within relatively clear boundaries of the sports industry and according to the framework of specific objectives (slack, 1997). the history of sporting events goes back to sports, music and poetry competitions organized for gods in the aegean and especially on the island of crete. it is also known that car races, boxing, wrestling, and running games were exhibited even at funerary ceremonies in the first centuries of the middle ages. sports organizations have a wide range from the most basic activities such as physical education classes to the most comprehensive activities such as the international olympic committee. although some of these organizations are voluntary and some are mandatory, they were all established for certain purposes. there are a few fundamental differences that distinguish sports organizations from other events. these can be listed as the area covered and the density, participation, aesthetics, and excitement displayed simultaneously (sunay, 2010). sports organizations have specific objectives as well as general objectives. the general objectives of sports organizations determined by international sports organizations are; the organization of sports in different countries with the principles of peace, friendship and brotherhood in mind, the training of successful athletes and sports officials, the competitiveness of country and club athletes under equal conditions, the introduction and dissemination of various sports to the masses. the aims and expectations of the countries hosting the sports organizations are to contribute to the friendship and peace, to make the country's propaganda through political superiority (ayan, 2009) and to gain financial benefits (tascıoglu, 2016). therefore, sports organizations are an important means for the promotion of the host country to the world public (doğar, 1997). moreover, the success of the countries in sports organizations is seen equivalent to their success in diplomacy or political fields. briefly, the prestige of the organizing country or the city organizing the event is the main issue in an international sports organization. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 60 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe in sporting events organized at the national level, it is an important goal to offer the best to the public and attract more people to the sports fields by encouraging sports (cankalp, 2002). the aim of sports organizations as a public service has general purposes such as the contribution to the development of a healthy society (balcı, 1999), providing equal opportunities for all citizens through sports (demirci, 1986), promoting sports branches throughout the country, ensuring the spread of sports, training successful athletes and special purposes such as creating images through advertising (sunay, 2010). it is observed that the opening-closing ceremonies have become a very significant show in major sports events held in recent years. the basis of all international multi-branch sports games such as the olympics, mediterranean games, universidad, asian games and martial games is the olympic charter. in other words, great sports games are being organized by taking the model of the olympics. in addition to the central body for the sports events, each field has its own regulations. these regulations include the general provisions concerning the preparation, beginning, ending of the sports events, as well as the provisions and rules on what could be the cultural content during the events (ioc, 2018). the most important elements in these games are opening-closing ceremonies and medal ceremonies. thanks to live broadcasting, these ceremonies are followed by the entire world with curiosity, are of great importance for the image, advertising, and prestige of the hosting country. a small mistake could cast a shadow on the image and prestige of the country and create a diplomatic crisis between countries. in this regard, ceremonies carry a kind of diplomatic importance. the display of the south korean flag on the stadium screens instead of the north korean flag at the beginning of the football match in london 2012 olympics (aa, 2018) or the inability of the london philharmonic orchestra to play the hungarian national anthem with the appropriate synchronism created small-scale crises, and cast a shadow over the success of the host organization (eurosport, 2018a). in this study, the logos and mascot of the games, presentation of country names, country flags, athletic courts, seating arrangement of the delegations, national anthems of the countries, game village and accommodation, accreditation, vip and sitting arrangements and cultural programs were highlighted, and recommendations were developed. this study is deemed important for increasing the quality of future international sports organizations by noting diplomatic crises of the past and predicting possible future crises. 1. methods: this study included mega sport organizations such as the olympics, mediterranean games, universidad, asian games, martial games, world and continental championships. in this study, the country names presented during these sport events, national flags, national anthems of the countries, logos and mascots, the athletic cortege, the seating arrangement of the delegations, the athlete village, accommodation, accreditation, vip services and cultural show programs were observed and described with the case analysis method. 2. risks and evaluations: 3.1 games logo and mascot: each sports organization must have a symbolic logo and a mascot. this logo and mascot having attractive, memorable, and guiding characteristics regarding their marketing capabilities is determined by the host country and submitted to the approval of the international committee. the logo and mascot may be determined by a referendum in the host country or by the proposal of the local organizing committee. however, presenting to the public vote in the context of public relations before the organization is a more effective method. the local organizing committee should predict factors that symbolize the semantic that may occur during the design and selection of the logo and mascot. a shape, a symbol or a color can be a symbol with negative connotation for the visiting countries. gathering information through a research is essential in order to avoid such cases. the best method is to use symbols, colors, and fables that bring global values to the forefront. it is possible to prevent semantic risks accordingly. after the logo and mascot are determined, it is presented to the approval of the mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 61 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe international committee and announced to the participating countries and broadcasters. the use of the correct logo is essential during the broadcasting. as a matter of fact, during the 2014 sochi olympics, a tv channel received an international reaction by accidentally using a logo that protested the sochi olympics (eurosport, 2018-b). 3.1 presentation of country names: the names of the participating countries are repeatedly announced during the opening-closing ceremonies or medal ceremonies. the names of the participating countries must be accurately announced in accordance with the international diplomatic recognition format. otherwise, the mistake of the host country due to a wrong presentation may be deemed incontrovertible, or it can be touted as a deliberate act of humiliation against the said country. in this case, there may be a diplomatic crisis between the organizing committee, the host country state and the states of the visiting countries. for example; errors such as announcing “russian federation” (ministy of foreign affairs, 2018) as russia, “czechia” (un, 2018) as the czech republic, or the presentation of “cyprus” as the turkish republic of northern cyprus carries diplomatic risks. the local organizing committee should be aware of the fact that the official names of the countries according to the international diplomatic recognition criteria may be different from the generally known names. to prevent the possibility of facing such a situation and crises the host organizing committee may receive information from its foreign departments or through consultancy by appointing a staff member. however, in case of any change in official names due to rapidly changing global conjuncture, receiving confirmation from the visiting country may eliminate these risks completely. the country, with the official name "the former yugoslav republic of macedonia" (un, 2018) since 1993, requested to change its name to "republika severna makedonija" (eu, 2018) in 2018, is a good example of a rapid change. 2.1. official flags of the countries: country flags are used both in flagpoles and in online/offline broadcasts for the opening-closing ceremony, medal ceremonies, and other ceremonies. country flags consist of different colors, scales, directions, and meanings. there are also flags in several different versions of countries. for example, the uk, austria, hungary, serbia flags are available on or without a royal symbol (united falgs, 2018). hanging the switzerland and vatican flags (eu, 2018) being in a square form on the poles with the standard sizes and the presentations made by the organizing committee was observed as some of the common mistakes. although they are of the same color and pattern (united falgs, 2018), the flags of monaco and indonesia are also examples of other flags with different scales. due to the fact that the different visuals on the front and back of the country flag of paraguay, it is a critical detail to decide on which side should come forward. in this respect, the approval of the relevant authorities will prevent the potential problems. although the flags of romania and chad are identical, the fact that there is only a minor color difference is another example for the organizing committee to be careful. the flags of ireland and the ivory coast are two flags that are the same color but the opposite of each other. during the presentation, the utmost attention should be paid to the detail in which way the flag should be hanged. when hanged on the green edge, the flag represents ireland. if hanged from its red edge, the flag represents the ivory coast (united falgs, 2018). north koreans reacted when they saw the flag of south korea instead of their own flag on the stadium screens at the start of the football match in the london 2012 olympics (aa, 2018). then the british prime minister apologized to north korea and hampered the growth of the diplomatic crisis (dw, 2018). if the local organizing committee makes a plan based on the wrong information, it may cause a diplomatic crisis because of the wrong flag use. the committee may prevent the possible crisis by keeping in contact with the national olympic committee of each participating country during the preparation stage and by checking the official flag image and scales. 2.2. national anthems of the countries: mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 62 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe the national anthem is a march reflecting the love of a nation to their homeland and flag, to freedom, independence, and their passion for modernity (türkçe bilgi, 2018). the anthems are the most important sound and music effects that represent the countries during both opening-closing ceremonies, and medal ceremonies. konrad lorens described the olympics as the only place where a country's anthem was played and the feelings of hostility towards other nations were not awakened (konrad, 1967). the countries' marches have different versions such as symphonic or acoustic, short or long and fast or slow. special short versions (e.g. 24 sec or 30 sec) may be requested from countries to be used in medal ceremonies as required by the charter. the host organizing committee has no authority to edit these versions. for instance, the bulgarian delegation sent an official protest letter to the greek authorities for the wrong arrangement of the organizing committee at the 2004 athens olympics and the misuse of the bulgarian anthem (haber vitrini, 2018). a similar example took place in the 2012 london olympics. the failure of the london philharmonic orchestra to play the hungarian national anthem properly led to the reaction of the hungarian delegation and caused a small crisis between the two countries (eurosport, 2018-a). the presentation of an anthem received from wrong or informal channels may create a diplomatic problem between the host country and the represented country. in order not to end up in similar mistakes, local committees should keep in continuous contact with the national olympic committees (noc) of the countries during the organization preparations to ensure which version of the official national anthems is required to avoid such potential problems. if necessary they may ask for the correct version in written and certified form. 2.3. delegation cortege: athletes, technical and administrative delegations representing the countries in the games, must walk in the form of a cortege in the opening-closing ceremonies. they march in turns and according to a specific order, passing in front of the spectators and live-broadcasting cameras.. the clothing to be worn by the athletes at the cortege depends on the initiative of the related country. however, these clothes should not use the symbols of religion, language, and race to harm the philosophy of the games (ioc, 2018). although the host organizing committee has no duties defined in the charter, it is important to pay attention to every situation to avoid overshadowing the success of the organization. the order of the walk at the cortege is clearly stated in the charter of the games. this order can usually be performed in an alphabetical order of country names as well as in other specific orders. for example, the cortege is performed in an alphabetical order in the olympics, where the greece (hellas) delegation is in front of the cortege (ioc, 2018). country names are also important. when a country name is presented incorrectly in the alphabetical order, it will cause a crisis. it is important to provide information to the participants and viewers about the cortege layout. in addition, some country delegations may not want to walk side by side with delegations of some other countries in the cortege due to some special reasons. the host organizing committee may not be aware of such a sensitive situation. the organizers should be ready for such possible crisis, and the plans should be in a modular changeable structure. 2.4. delegation’s seating areas at the ceremonies: delegations are directed to the tribunes reserved for them to watch the cortege in the opening ceremony and the cultural program after the official program. the organizing committee should reserve sections for delegations. even though fair play actions are encouraged without discriminations of religion, language, and race in the olympic philosophy, there may be special and ongoing problems among some countries (ioc, 2018). the local organizing committee may ignore such situations. in this case, it may be objectionable for the delegations of the relevant country to sit close to each other. these risks will be minimized if the organizing committee creates a mixed and voluntary seating arrangement with the idea of friendship-fraternity by being aware of these risks and with the approval of the international committee. according to the olympic charter, a sufficient number of seats should be reserved in the sports facilities for mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 63 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe the delegations and accredited protocol (ioc, 2018). the organizing committee may also apply the abovementioned method for these seats. 2.5. olympic village. at all olympic events, athletes and delegation members must stay in rooms assigned to them in the game village (ioc, 2018). the game village is a private, intimate area reserved for athletes and administrators isolated from the external environment. therefore, a special accreditation and security protocol should be applied in this field. the host organizing committee shall announce at which block and rooms the delegations will be accommodated. despite being isolated from the outside, there may be problems between athletes or delegations staying. a german athlete who participated in the 2012 london olympics had a connection with an extreme right-wing political party; therefore he was excluded from the game village. a swiss sportsman and a greek athlete who shared threatening and racist messages via social networks were also excluded from the olympic village (dw, 2018-b). the organizing committee should make room layout plans by evaluating the possibility of problems between delegations since some countries may not want to stay on the same floor with some other country delegations. 2.6. accreditation: accreditation is a security module that classifies all the authorities in sports organizations according to their responsibilities and determines which facilities and which departments they can enter (ioc, 2018). the accreditation protocol for delegations, officials and important persons (vips) should be planned in a sensitive manner. the entryexit of the guests and staff who can use the vip areas should be considered in accordance with the principles of welcome-hospitality and security. if the local organizing committee authorizes uncontrolled access to unrelated people, it may cause unpleasant situations. the freedom can turn into a troubled state. the possibility of encountering such situations should be considered in advance. the rules of accreditation should be carried out in a determined manner, and initiatives should not be used. 2.7. vip zones & services: the number of seats to be allocated to the international committee in the vip stands in sports organizations is determined by the relevant unit of the committee, approved and cannot be changed later (ioc, 2018). even though the games are hosted by a country, it is the international committee that is the real host of the organization. the local hosting committee should be aware of this fact and apply the rules of the international protocol determined by the games charter rather than the rules of the local protocol. the seats reserved for vip guests should be determined according to their status. it will be useful to get help from an experienced protocol specialist to minimize the risks in this regard. however, there may be people who will try to disrupt or bypass the protocol implemented. therefore, it is important to include official and private security personnel in planning. in this way, the problems will be prevented in advance. on the other hand, international sports organizations can have guests such as commercial, political, artistic or sports people who will be invited from abroad for both opening and closing ceremonies and other events. precise planning should be carried out to meet and accommodate these guests and provide all necessary services. hosting non-governmental organizations should also be included in the planning according to the interests of the guests. for example, the support of the local businessmen associations and the chambers of industry can be obtained to establish positive dialogues among guests in the field of commerce. similarly, the support of local art associations can be obtained for artist guests. the cooperation of the local organizing committee with the protocol departments of the state, non-governmental organizations and universities can increase the quality and success of the games and may also contribute to the realization of the objectives of the games. 2.8. cultural show programs: the hosting country exhibits a cultural show to be watched by many people during the opening-closing ceremonies through tv broadcasting (draper & maheshwari, 2018). the opening ceremony of the 2016 rio olympics is reported to have been watched by nearly 3 billion people (eurosport, 2018-c). cultural music, plays, mailto:topacademicjournals@gmail.com https://www.nytimes.com/by/kevin-draper http://www.nytimes.com/by/sapna-maheshwari american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 64 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe dances, and theatrical shows are exhibited in this section with the aim to make cultural marketing to the whole world. on the other hand, these shows cannot contain political messages, actions, music or rhetoric to offend other countries, and cannot include any national political message (ioc, 2018). these sensitivities should be shared with the art director of the show and the possibility of making mistakes should be eliminated during the rehearsals of the show. otherwise, it may lead to a diplomatic crisis that cannot be repaired. during the opening ceremonies of the 1936 berlin olympics, the inclusion of many racist and unethical political messages and actions gave rise to the problems that are still debated today (un, 2018). 3. conclusion and recommendations: diplomacy is a set of agreements covering all kinds of international relations. international sports organizations include competitions between countries, establishing superiority, promotions, interactions and political relationships. sports games are important organizations in which countries represent national values. national values are sensitive values and possess important social and cultural elements as the pride of a nation. sports games are important organizations where countries represent national values. therefore, it is very acceptable for countries to try to uphold these values and be defensive against abuse. in this context, countries and organizing committees hosting sports organizations should be aware of the sensitivities and take maximum care. diplomatic crises can be experienced during the advertising, public relations, and marketing activities prior to the games, during and after the games. since these organizations reach millions of people around the world through broadcasting channels, the impact will also be in a broad-scale. a small negativity can create a disastrous effect in the world. with the power of internet-based social networking sites, the impact can be exponentially incurable. planning should be made carefully for sports organizations to eliminate such risky cases at the points where diplomatic sensitivity is required. a simple method should be used to obtain approval from countries about the country flags, national anthems, clothes, and visual and audio elements. for example; there is a computer software program called game management system (gms) where the countries participating in the organizations can upload registration, accreditation, accommodation, volunteer and delegation lists, rosters and transportation information (gms, 2018). in addition to standard information, a module must be developed and added to the system in which the countries can upload and approve data regarding national flags, national anthems, clothes and their special requests and sensitivities that may be of particular importance from the diplomatic point of view. as a conclusion, the country-city and organization committees that host sports organizations should not consider games as a sporting event but rather as a broad diplomacy display. it will be possible to establish and develop good international relations and contribute to the promotion and recognition of the host country by leaving a good image for the visiting countries. acknowledgement: this academic work was linguistically supported by the mersin technology transfer office academic writing center of mersin university. 4. rerefences anatolian agency, (aa, 2018). „olimpiyatlarda bayrak krizi flag crisis at olimpics , 25 july 2012, https://www.aa.com.tr/tr/ spor/olimpiyatlarda-bayrak-krizi/352636, (accessed 17 nov 2018). ayan s., (2009). „evaluation of the reasons behind the city of istanbul‟s failure to win the right to hold the olympic games by students studying at higher education of physical education and sports‟, journal of selcuk university physical education and spor sciences 11 no.1, 24-31. mailto:topacademicjournals@gmail.com https://www.aa.com.tr/tr/%20spor/olimpiyatlarda-bayrak-krizi/352636 american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 65 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe balci v., (1999). spor etkinliklerinin planlanması ve yönetimi sports events planning and management , bagirgan publishing ltd, ankara-turkey. cankalp m., (2002). sporda yönetim ve organizasyon management and organization at sport , nobel publishing&distribution, ankara-turkey. demirci n., (1986). sporda yönetim-teşkilatlanma ve organizasyonlar management at sport-governance and organizations , ministry of education publishing, ankara-turkey. doğar y., (1997). türkiye'de spor yönetimi sport management at turkey , oz akdeniz publishing ltd, malatyaturkey. draper k., maheshwari s., (2018). „how many people are watching the olympics?‟, newyork times, https://www.nytimes.com/2018/02/13/sports/olympics/olympics-nbc-viewers-digital. html, (accessed 13 dec 2018). deutsche welle, (dw, 2018a). editorial, 26 july 2012, https://p.dw.com/p/15emg, (accessed 14 nov 2018). deutsche welle, (dw, 2018b). editorial, https://p.dw.com/p/15lab-07 agu 2012 (accessed 11 nov 2018). eurosport, (2018a). „macaristan milli marşı hungarian national anthem ‟, 30 july 2012, https://tr.eurosport.com/olimpiyat-oyunlari/macaristan-milli-mars_sto3367757/story.shtml, (accessed 18 nov 2018). eurosport, (2018b). „trt çerkeslerin logosunu kullandı trt used circassians' logo ‟, 07 feb 2014, https://tr.eurosport.com/ olimpiyat-oyunlari/soci/2014/trt-cerkezlerin-logosunukullandi_sto4125886/story.shtml, (accessed 17 nov 2018). eurosport, (2018c). „üç milyar kişi i̇zledi three billion people watched ‟, 06 agu 2016, https://tr.eurosport.com/olimpiyat-oyunlari/rio/2016/uc-milyar-kisi-izledi_sto5709435 /story.shtml, (accessed 18 nov 2018) european union, (eu, 2018). „countries‟, https://europa.eu/europeanunion/index_en, official web site (accessed 13 dec 2018). game management system, (gms, 2018). „sport event information management system user guide‟, http://www.sporteventsolutions.com/games-management-system.html, (accessed 01 dec 2018). haber vitrini news screen , (2018). „atina olimpiyatlarında hangi ülkenin milli marsı yanlış çalındı? which country's national anthem was stolen wrong at the athens olympics? ‟, 26 agu 2004, http://www.habervitrini.com/spor/atina-olimpiyatlarinda-hangi-ulkenin-milli-marsi-yanlis-calindi127689, (accessed 17 nov 2018). international olympic committee, (ioc, 2018). „olympic charter‟, https://stillmed. olympic.org/documents/olympic_charter_en.pdf, september 2015, (accessed 13 feb 2018). konrad l., (1967). on aggression, bantam, new york-usa. mailto:topacademicjournals@gmail.com https://www.nytimes.com/by/kevin-draper http://www.nytimes.com/by/sapna-maheshwari https://www.nytimes.com/2018/02/13/sports/olympics/olympics-nbc-viewers-digital.%20html https://www.nytimes.com/2018/02/13/sports/olympics/olympics-nbc-viewers-digital.%20html https://p.dw.com/p/15emg https://p.dw.com/p/15lab https://tr.eurosport.com/olimpiyat-oyunlari/macaristan-milli-mars_sto3367757/story.shtml https://tr.eurosport.com/%20olimpiyat-oyunlari/soci/2014/trt-cerkezlerin-logosunu-kullandi_sto4125886/story.shtml https://tr.eurosport.com/%20olimpiyat-oyunlari/soci/2014/trt-cerkezlerin-logosunu-kullandi_sto4125886/story.shtml https://tr.eurosport.com/%20olimpiyat-oyunlari/soci/2014/trt-cerkezlerin-logosunu-kullandi_sto4125886/story.shtml https://tr.eurosport.com/olimpiyat-oyunlari/rio/2016/uc-milyar-kisi-izledi_sto5709435%20/story.shtml https://tr.eurosport.com/olimpiyat-oyunlari/rio/2016/uc-milyar-kisi-izledi_sto5709435%20/story.shtml https://europa.eu/european-union/index_en https://europa.eu/european-union/index_en http://www.sporteventsolutions.com/games-management-system.html http://www.sporteventsolutions.com/games-management-system.html http://www.habervitrini.com/spor/atina-olimpiyatlarinda-hangi-ulkenin-milli-marsi-yanlis-calindi-127689 http://www.habervitrini.com/spor/atina-olimpiyatlarinda-hangi-ulkenin-milli-marsi-yanlis-calindi-127689 american journal of medical and physical education vol.7, issue 4; july-august 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 66 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe ministry of foreign affairs official web site, (2018). „russia‟ http://www.mfa.gov.tr/rusya-kunyesi.tr.mfa, (accessed 14 dec 2018). olympic channel, (2018). https://olympicchannelservices.com/, (accessed 13 feb 2018). slack t., (1997). understanding sport organizations the application of organization theory, human kinetics book, illinoisusa. sunay h., (2010). sporda organizasyon organization at sport , gazi book store, ankara. tascioglu r., (2016). türkiye’nin uluslararası tanıtımında spor organizasyonlarının yeri locating sports organizations in turkey's international promotion , image publishing, 47-8, erzurum-turkey. türkçe bilgi turkish knowledge , (2018). „national anthem‟, https://www.turkcebilgi. com/ulusal_mar%c5%9, (accessed 14 feb 2018). united nations, (un, 2018). „member states‟, http://www.un.org/en/member-states/#gotom, official web site (accessed 12 dec 2018). united flags, (2018). „countries flags‟, https://www.unitedflags.co.uk, official web site (accessed 12 dec 2018). united states holocaust memorial museum, (2018). holocaust encyclopedia, national archives, https://encyclopedia.ushmm.org/content/tr/film/opening-of-1936-summer-olympic-games, (accessed 24 oct 2018). mailto:topacademicjournals@gmail.com http://www.mfa.gov.tr/rusya-kunyesi.tr.mfa https://olympicchannelservices.com/ http://www.un.org/en/member-states/#gotom https://www.unitedflags.co.uk/ https://encyclopedia.ushmm.org/content/tr/film/opening-of-1936-summer-olympic-games american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 28 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe personality types and wellness in pharmacy students jesse shadowen, e. sheaffe, k. mcnutt, g. hudson, and a. robert california state university abstract: the myers-briggs type indicator (mbti) is a personality assessment tool that can be used to understand how individuals handle stress and maintain wellness. prior studies have shown that certain personality traits are more adept at maintaining an overall positive wellness in their life than others. this study investigated the relationship between mbti personality type and wellness in pharmacy students. the study found that introverts had a more balanced sense of wellness than extroverts. introverts were more likely to make time for themselves and engage in activities that helped them relax and recharge. extroverts, on the other hand, were more likely to focus on emotional needs and less on personal and intellectual needs. the study also found that extroverts were more likely to participate in wellness-based activities, such as exercise, than introverts. however, introverts who did participate in these activities were just as likely to benefit from them as extroverts. keywords: myers-briggs type indicator (mbti), personality type, wellness, pharmacy students, stress, introvert, extrovert, exercise, well-being introduction the myers-briggs type indicator (mbti) is an assessment tool that is used to categorize individuals by personality traits and overall psychological types11. the assessment is made up of over one hundred questions that the participant swiftly answers with the first thought that comes to mind. once the participant completes the assessment, they are assigned the following traits: introvert (i) or extrovert (e), sensing (s) or intuition (n), thinking (t) or feeling (f), and judging (j) or perceiving (p). after the participant is assigned their traits and types (four traits combined), inferences can be made about their personality and how they handle situations as well as their daily lives. this assessment is primarily used to analyze how people interact with and understand each other, especially in the workplace. prior studies1 have used these personality traits to outline how individuals handle stress and maintain wellness. wellness is defined as the balance-point between an individual’s resources and the challenges he or she faces2,10. however, a person can be in a state of “well-being” but not “wellness” because they are only at a balance point and not in a true state of overall wellness. in pharmacy school, students are faced with balancing multiple academic tasks and assignments along with their personal life. this can be difficult for students because it may be the first time they are living on their own or faced with adversity of this magnitude. certain personality traits are more adept at maintaining an overall positive wellness in their life while others struggle4. their actions and daily activities can be related back to mbti types based on their behavior. a very notable difference in how individuals may approach their own wellness is in their personality trait of “introverted” or “extroverted”. extraverts are much more sociable and include group activities as a major part of their own wellness because it is their preferred outlet from stress and a source of happiness. introverts on the other hand, typically prefer isolation or time away from others to recharge and escape outside stressors. current studies6 show introverts to have a more balanced sense of wellness because they always make time for themselves, whereas extroverts have a more slanted wellness based primarily on emotional needs and less towards personal mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 29 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe and intellectual needs. however, some studies have shown an extraverted personality type to include more wellness-based activities such as exercise in their daily lifestyle because of social interactions. contrastingly, introverts who may not practice certain wellness activities, such as exercise, were less likely to complete those activities in the studies6. people with a “sensing” personality trait rely primarily on concrete facts and their five senses. these individuals have shown to be more likely to reach out to their support system (friends, family, etc.), while people with an “intuition” personality trait are less likely. this is presumed because people with an intuition personality type would rather resolve problems themselves and are more likely to remember patterns than facts. this means if an intuitive individual has dealt with significant adversity before they are more likely to use past experiences (patterns) to help them through the process as opposed to a sensing individual who would reach out immediately because of what they are feeling in that moment2. because of this, more intuitive individuals predominately scored lower on scales assessing wellness, regardless of being an introvert or extrovert9. “feelers” are defined as people who are concerned with values and what is best for all those involved. “thinkers” are defined as people who stay true to basic principles and make logical decisions based on pros and cons. feelers were shown to have more extreme differences in wellness, while thinkers maintained a relatively consistent sense of wellness6. in general, thinkers have a better overall wellness because they do not experience such extreme highs and lows6. this is likely due to thinkers staying relatively consistent in situations based on their principles, whereas feelers may make extreme sacrifices for others in certain situations, resulting in feelingsof depression or anxiousness. the authors did not locate any studies published on pharmacy students’ personality traits and their overall wellness. pharmacy school is one of many graduate programs that provide a unique challenge and stressful experience for students; many studies suggest that students develop psychological disorders such as anxiety or depression as a result2. being able to identify personality traits that are more susceptible to these trends and have a lower state of wellness can be a key factor in improving student mental health and productivity in pharmacy school and other graduate programs. 2. methods a cross-sectional qualtrics online survey was designed to collect data to assess the stress and wellness of mcwhorter school of pharmacy students. the survey included seven multiple choice demographic questions and 53 questions of varying options that assessed personality traits, stress, and wellness (as well as other factors assessed by other investigators). the questions were sent to the institutional review board at samford university and received exempt status. the survey was then sent out via an email link to full-time students enrolled in the graduating classes of 2021 to 2023 at mcwhorter school of pharmacy to participate in the survey. the survey was open for four weeks, with three reminders. the responses were collected anonymously through the “anonymize response” feature in qualtrics. demographic questions such as age and gender were included to ensure the responses were representative of the student population, as well as provide data that could be used for analyses. the personality questions contained in the survey were based on the mbti and were piloted in advance: they appear to accurately determine an individual’s personality type/traits. subsequent questions—on wellness, depression, resilience, and gallup strengths—were developed based on general principles in the literature for the other investigators’ research questions. those questions also were piloted. the survey was voluntary but was incentivized by a drawing for one of five $20 amazon.com gift cards or a hand sanitizer gift set. once participants completed the survey, they were linked to a separate survey to enter an optional drawing for the gifts. access to the second survey data was restricted to the faculty investigator to protect the anonymity of the participant list. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 30 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe the results of the primary survey were provided to the investigators. an initial review was conducted in qualtrics to eliminate incomplete responses. the complete responses were then exported to microsoft excel and ibm’s statistical package for the social sciences (spss) for further analysis. a total of 179 students completed the survey, which was approximately 50% of the target population. tests used for data analysis included sample ttests and chi-square tests to determine significance, independence, and p-values. 3. results there were 179 total responses to the survey consisting of 122 females and 57 males. there were 24 students age 18-21, 104 students age 22-25, 28 students age 26-29, and 17 students 30 years and older. of the 179 responses, the recorded wellness scores ranged from 25 to 41 and the average wellness score was 32.72, which would be categorized as a c wellness rating. of the total 179 responses, 32 were categorized as extroverts and 147 were categorized as introverts. extroverts’ wellness rating ranged from a to c and introverts’ wellness rating ranged from b to d. the frequency of wellness ratings for introverts/extroverts is listed in table 1 below. table 1: frequency of reported wellness ratings of introverts/extroverts in samford university mcwhorter school of pharmacy students wellness rating personality trait a b c d extroversion 0.5% (1) 7.8% (14) 9.5% (17) 0.0% (0) introversion 0.0% (0) 35.8% (64) 41.9% (75) 4.5% (8) total 0.5% (1) 43.6% (78) 51.4% (92) 4.5% (8) a = wellness score of 41 or greater b = wellness score of 34-40 c = wellness score of 27-33 d = wellness score of 20-26 of the total 179 responses, 76 were categorized as having a “sensing” personality trait and 103 were categorized as having an “intuitive” personality trait (these are dichotomous traits). sensing individuals had a wellness rating that ranged from a to d and intuitive individuals had a wellness rating that ranged from b to d. the frequency of wellness ratings for sensing/intuitive personality traits are listed below in table 2. table 2: frequency of reported wellness ratings of sensing/intuitive individuals in samford university mcwhorter school of pharmacy students wellness rating personality trait a b c d sensing 0.5% (1) 19.0% (34) 22.3% (40) 0.5% (1) intuition 0.0% (0) 24.6% (44) 29.1% (52) 4.0% (7) total 0.5% (1) 43.6% (78) 51.4% (92) 4.5% (8) a = wellness score of 41 or greater b = wellness score of 34-40 c = wellness score of 27-33 d = wellness score of 20-26 of the total 179 responses, 106 were categorized as having a “feeling” personality trait and 73 were categorizes as having a “thinking” personality trait. feeling individuals had a wellness rating that ranged from a to d and mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 31 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe thinking individuals had a wellness rating that ranged from b to d. the frequency of wellness ratings for sensing/intuitive personality traits are listed below in table 3. table 3: frequency of reported wellness ratings of feeling/thinking individuals in samford university mcwhorter school of pharmacy students wellness rating personality trait a b c d feeling 0.5% (1) 24.6% (44) 31.3% (56) 2.8% (5) thinking 0.0% (0) 19.0% (34) 20.1% (36) 1.7% (3) total 0.5% (1) 43.6% (78) 51.4% (92) 4.5% (8) a = wellness score of 41 or greater b = wellness score of 34-40 c = wellness score of 27-33 d = wellness score of 20-26 of the total 179 responses, 23 were categorized as living with a parent(s) or guardian(s), 121 were categorized as “living with a roommate(s) &/or spouse”, and 35 were categorized as “alone or as a single parent”. both “individuals living with a parent(s) or guardian(s)” or “alone or as a single parent” had a wellness rating that ranged from a b to a d and “individuals living with a roommate(s) &/or spouse” had a wellness rating that ranged from an a to a d. the frequency of wellness ratings based on current living arrangements is listed below in table 4. table 4: frequency of reported wellness ratings based on current living arrangements in samford university mcwhorter school of pharmacy students wellness rating living arrangements a b c d with parent(s) or guardian(s) 0.0% (0) 3.4% (06) 8.4% (15) 1.1% (2) with roommate(s) &/or spouse 0.5% (1) 31.8% (57) 33.0% (59) 2.3% (4) alone or as a single parent 0.0% (0) 8.4% (15) 10.0% (18) 1.1% (2) total 0.5% (1) 43.6% (78) 51.4% (92) 4.5% (8) a = wellness score of 41 or greater b = wellness score of 34-40 c = wellness score of 27-33 d = wellness score of 20-26 of all the comparisons, none yielded a statistically significant result when conducting a chi-square test. the closest p-value was from the comparison between introverts and extroverts seen below in table 5. the value did not reach the target goal of 0.05 and therefore is not statistically significant. table 5: statistical analysis of wellness ratings comparing introverts/extroverts in samford university mcwhorter school of pharmacy students. test type p-value* pearson chi-square test (2-sided) 0.095 likelihood ratio (2-sided) 0.085 n=179 4. discussion one hundred and forty-seven of the 179 responders were categorized as introverts and only 32 were categorized as extroverts. based on previous studies, it is hypothesized that while introverts have a more consistent sense of mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 32 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe wellness, they are more likely to have a lower overall wellness rating due to their lack of interactions with a support system. this hypothesis is supported by the data provided in table 1. though there were fewer extraverts in the study, they had a higher average wellness rating and did not have a rating recorded lower than a c. opposingly, the results showed that introverts had a lower average wellness rating and did not have a single rating that was recorded higher than a b. the data was heavily skewed towards introverts and it is unclear if there was a misinterpretation of the e/i questions or if the results were affected by the covid-19 stayat-home orders in place during the survey. when comparing sensing to intuitive personality traits, this was the most balanced category in terms of results, with 46% of sensing individuals and 42.7% of intuitive individuals having a wellness rating of a b or higher. this result was surprising because, based on previous studies8, intuitive individuals scored significantly lower than their sensing counterparts. this was believed to be due to sensing individuals being more aware of their own stress and likely to reach out to their support system and intuitive individuals being more likely to work through their own problems. however, this was not the case in this study. the results for feelers versus thinkers were also similar. roughly 42.5% of feelers had a wellness rating of a b or higher and 46.6% of thinkers had a wellness rating of a b or higher. feelers had a lower overall average wellness rating but did not completely follow the trends outlined by prior studies. previous studies6 suggest that feelers think more of how an action impacts another individual than themselves and it results in a more extreme variance in wellness, compared to a thinker who makes primarily logical decisions, regardless of those impacted. feelers did have more a and d wellness ratings, but it was hypothesized that thinkers would only have b or c ratings since they are typically more consistent. most participants categorized themselves as “living with a roommate(s) &/or spouse”, accounting for 67.6% of the total number of participants. this group had the greatest percent of members with a wellness rating of b or higher at 47.9% and the group categorized as “living with a parent(s) or guardian(s)” had the lowest percent of members with a wellness rating of b or higher at 26.1%. the group categorized as “living alone or as a single parent” had 42.8% of participants with a wellness rating of a b or higher. these results show that even if a support system is available through someone you live with, it does not guarantee a higher wellness rating. the study had enough participants to make reasonable conclusions based on the results, which was a strength. the survey was online and easily accessible for the participants because it was not limited by location. the window to complete the survey was open four weeks, which gave responders adequate time to respond even if they were on a clinical rotation. the length of the survey made it manageable for the survey to be completed in a reasonable amount of time and was incentivized to help promote full completion and response to the survey. one weakness in this study was the response bias. when looking at the results it is apparent that the data is heavily skewed towards females and students between the ages of 22-25. however, this is likely because that demographic is representative of students enrolled in pharmacy schools3,5. while this data may not be as applicable to other professions or demographics, it is representative of most pharmacy schools. if a future study were conducted, it would be important to have a more diverse demographic subject group and conducted at other pharmacy schools or healthcare divisions if possible so more inferences and applications could be made in using the study. another weakness in the study was the lack of statistical significance. while there were trends present or inferences that could be made when looking at the results of the survey, none of the research questions yielded a p-value 0.05 when conducting a chi-square test. only one of the comparisons yielded a value near the target goal, which was comparing introverts versus extroverts. studies have shown a strong link between the two mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 33 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe personality traits and wellness. however, from a statistical perspective the null hypothesis was accepted in each case, meaning there is no difference between any of the groups outlined in the research questions. a potential weakness was the wording and number of questions used to assess personality traits. while the questions were based on mbti questions, the results received from the survey were divergent from pharmacy students’ aggregate official mbti assessment results over the last several years. as previously mentioned, there was a heavy bias towards introverts rather than extroverts we did not expect. one potential cause could have been the covid-19 environment students were in (largely online classes at home). students’responses may have been atypical as compared to pre-covid conditions. the isolated and stressful environment likely lowered the respondents’ wellness ratings and may have caused them to either adapt or change their daily routine and activities. a larger sample size of both categories in an environment without a pandemic should help further illuminate and support this expected trend. 5. conclusion wellness represents an important component in mental health and observing it has led to improvements in individual’s productivity and outlook in the workplace in previous studies3,7,9. while this study was not able to provide statistical justification to assertions made between personality and wellness, it did provide insight on what trends to expect when looking at traits such as extroversion versus introversion. more studies need to be conducted to further assess the connection between personality traits and wellness to further assess the potential implications on learning, productivity, and mental health. this data could be used to adjust curriculum in pharmacy schools or anticipate potential stressors for individuals based on their personality traits or type. 6. references abdullahi, a.m., orji, r., rabiu, a.m., &kawu, a.a. (2020). personality and subjective well-being: towards personalized persuasive interventions for health and well-being. online journal of public health informatics, 12(1). doi:10.5210/ojphi.v12i1.10335 bart, r., ishak, w.w., ganjian, s., et al. (2018). the assessment and measurement of wellness in the clinical medical setting: a systematic review. innovations in clinical neuroscience, 15(9-10), 14-23. boult, m. j. l., thompson, r. c., & schaubhut, n. a. (2017). well-being and mbti personality type in the workplace: an international comparison. retrieved on february 23, 2021 from https://ap.themyersbriggs.com/content/ research%20and%20white%20papers/mbti/white_paper_well-being_and_mbti_personality_type_ in_the_workplace.pdf ferguson, e. (2013). personality is of central concern to understand health: towards a theoretical model for health psychology. health psychology review, 7(suppl1), s32. doi:10.1080/17437199.2010.547985 grabenstein, j. d. (2016). trends in the numbers of u.s. colleges of pharmacy and their graduates, 1900 to 2014. american journal of pharmaceutical education, 80(2). doi:10.5688/ajpe80225 jinkerson, j., masilla, a., & hawkins, r.c. (2015). can mbti dimensions predict therapy outcome: differences in the thinking-feeling function pair in cbt. research in psychotherapy: psychopathology, process, and outcome, 18(1). doi:10.4081/ripppo.2015.167 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 34 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe löckenhoff, c.e., duberstein, p.r., friedman, b., & costa, p.t. (2011). five-factor personality traits and subjective health among caregivers: the role of caregiver strain and self-efficacy. psychology and aging, 26(3), 592-604. doi:10.1037/a0022209 schommer, j., tieger, p., olson, a., & brown, l. (2017). applying personality type theory to develop individualized wellness plans for reducing chronic diseases. innovations in pharmacy, 8(1). doi:10.24926/21550417.1328 sperandeo, r., messina, g., iennaco, d., et al. (2020). what does personality mean in the context of mental health? a topic modeling approach based on abstracts published in pubmed over the last 5 years. frontiers in psychiatry, 10, 1. doi:10.3389/fpsyt.2019.00938 srivastava, k., & das, r. (2015). personality and health: road to well-being. industrial psychiatry journal, 24(1):1. doi:10.4103/0972-6748.160905 storm, susan (2015, august 5). how each myers-briggs® type reacts to stress (and how to help!). retrieved on march 16, 2020 from https://www.psychologyjunkie.com/2015/08/02/how-each-mbti-type-reacts-tostress-andhow-to-help/ mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 35 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe persistence and personality in doctor of pharmacy students: an analysis of correlations gregory hudson, emily sheaffe, ashley robert, jesse shadowen, and kimberly mcnutt dallas, texas, united states abstract: the myers-briggs type indicator (mbti) is a personality assessment tool that can be used to understand how individuals view the world and make decisions. the mbti divides individuals into four dichotomies: introversion or extraversion, sensing or intuition, feeling or thinking, and judging or perceiving. persistence is the ability to take action in spite of difficulty or opposition. it is a key trait for success in pharmacy school, which is a challenging and demanding program. individuals with high levels of persistence are able to overcome setbacks, failures, and other obstacles. they are also able to adapt to change and stay focused on their goals. keywords: myers-briggs type indicator (mbti), persistence, pharmacy school, success, personality, decisionmaking, stress, coping introduction the myers-briggs type indicator (mbti) is an assessment tool that allows individuals to answer questions using introspection about psychological preferences in how they view the world around them13.after completion of the questionnaire, the individual is placed into dichotomies. the dichotomies include introversion or extraversion, sensing or intuition, feeling or thinking, and judging or perceiving. extraverts are action-oriented and are energized by frequent social interactions. introverts tend to be thought-oriented and feel recharged after spending time alone. sensing individuals tend to live in the moment and enjoy facts and details. intuitives enjoy thinking of all the possibilities, fantasizing about the future and abstract concepts. feelers are those who tend to make decision based on emotions, concerned about keeping harmony and may be seen as indirect. thinkers tend to make decisions based on logic, enjoy technical and scientific fields and believe telling the truth is more important than being tactful. judgers are individuals who prefer to have things planned out and orderly, appear to be taskoriented and like to make lists of things to do. perceivers are spontaneous and flexible, appear to be loose and casual, work in bursts of energy, and are able to go with the flow13.persistence is being able to take action in spite of difficulty or opposition14.an individual may need a high level of persistence to overcome the immense workload that pharmacy school casts upon students. every student will face failures, setbacks, unstable moods, and overwhelming obstacles, not only in the classroom but outside. studies have found that individuals with high levels of persistence tend to be more successful8.they understand that failure is a part of the process. instead of becoming emotionally frustrated, they calmly reflect on the event, logically analyze their mistakes, and learn to correct those mistakes. mentally tough individuals will then develop a plan for how they will overcome their failure—even if they know that it could result in another failed experience—because they understand that it will only benefit them in the future. mentally vigorous individuals understand that things will not go as planned mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 36 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe and will have to adapt to the ever-changing environment2. overall, there is a multitude of traits that persistent individuals may use to help them overcome the obstacles in pharmacy school and become a successful student. there have been similar studies comparing pharmacy students and mbti tests12, as well as pharmacy students and persistence levels9but those studies have not examined the combination of all three variables. with that being stated, the previous studies have found that students with higher levels of persistence have a strong correlation with higher gpa’s in pharmacy school6,9.one source indicates that the most suitable mbti for pharmacy has been found to be entj5.by conducting the research study on personality and persistence, the investigators hoped to find new statistical evidence about the correlation between mcwhorter school of pharmacy students’ personality traits and persistence levels. by analyzing the results and discovering correlations, the school could potentially develop early intervention strategies for future students who may need additional encouragement to overcome the program’s difficulty. pharmacy school is a challenging experience for many students who enter this professional degree program. with the challenges presented by the level of education, each student will have varying ways of dealing with obstacles. some students will enter the program already having anxiety, depression, and other psychological disorders. studies have found that a percentage of students will develop psychological disorders brought on by the stress of pharmacy school7.it is important to learn how to effectively cope with the added stress that pharmacy school brings. being able to have adequate self-care and time management reduces the likelihood of developing depression. another important factor is persistence levels. students need a certain level of persistence to be able to push through the immense workload. if a student is unable to keep up and starts getting behind, stress levels will likely increase. if the study’s outcomes indicate trends, it would be beneficial to identify those who may need assistance based on certain personality traits. this could help increase students’ overall well-being and prevent the development of avoidable mental health disorders and course failures. 2. methods a cross-sectional qualtrics online survey was designed to collect data, categorize personality traits, and analyze persistence levels of mcwhorter school of pharmacy students. the survey included 10 multiple choice demographic questions and 53 questions on various topics to be assessed. the study was approved by the institutional review board at samford university. the survey was sent via an email link to eligible students, which were full-time students in the pharmacy graduating classes of 2021-2023. the survey was open for four weeks, with three reminders for completion. the results were recorded anonymously through the “anonymize response” feature in qualtrics. survey respondents first answered the demographic questions, which consisted of questions such as gender, age, and previous education. the personality questions contained in the survey were based on the mbti and were piloted for accurately. subsequent questions on wellness, phq-9, persistence, and gallup clifton strengths® were developed based on general principles in the literature. these questions were also piloted. the voluntary survey allowed students to enter a to drawing with the chance of winning one of five $20 amazon.com gift cards or a hand sanitizer gift set. these items were used as an incentive to obtain an adequate number of student responses. the investigators were not allowed electronic access to the second survey to protect to anonymity of the participants. after the primary results were provided to the student investigators, qualtrics was used to eliminate incomplete responses. once the incomplete responses were eliminated from the data set, the investigators exported the final response set to microsoft excel and ibm’s statistical package for the social sciences for further analysis. a total of 179 students completed the survey. descriptive data analysis was used to identify similarities and trends. the investigators primarily utilized the chi-square test and the fisher exact test to determine statistical significance, independence, percentages, and p-value. 3. results mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 37 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe a total of 179 survey responses were recorded. of these, there were 57 males and 122 females. in addition, there were 24 students age 18-21, 104 students ages 22-25, 28 students age 26-29, and 17 students 30 years and older. the persistence scores ranged from a minimum of 19 to a maximum of 35. of the 179 responses, the mean score was 27.58, which was categorized as an “inconsistent” persistence rating. out of the 179 responses, there were 147 categorized as the introvert (i) trait and 32 categorized as the extravert (e) trait. the introvert and extravert trait both had results in all ratings of persistence. frequency of i/e persistence rating can be found in table 1. table 1: frequency of reported wellness ratings of introverts/extraverts in doctor of pharmacy students at mcwhorter school of pharmacy personality traits persistence rating* introvert (n) extravert (n) very good 1.4% (2) 3.1% (1) good 42.2% (62) 40.6% (13) inconsistent 51.7% (76) 53.1% (17) poor 4.8% (7) 3.1% (1) total 100.0% (147) 100.0% (32) * persistence ratings: very good = 35-40 good = 24-29 inconsistent = 23-28 poor = 17-22 very poor = 00-16 the next set of data analyzed was the sensing (s) and (n) traits. there were103 categorized as sensing and 76 categorized as intuitive. again, both traits covered all persistence ratings. the frequency of s/n persistence ratings can be found in table 2. table 2: frequency of persistence ratings of sensing/intuition in doctor of pharmacy students at mcwhorter school of pharmacy personality trait persistence rating* sensing (n) intuition (n) very good 1.0% (1) 2.6% (2) good 37.9% (39) 47.4% (36) inconsistent 54.4% (56) 48.7% (37) poor 6.8% (7) 1.3% (1) total 100.0% (103) 100.0% (76) * persistence ratings: very good = 3540 good = 2429 inconsistent = 2328 poor = 1722 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 38 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe very poor = 0016 one hundred six (106) responses were categorized as the feeling(f) trait and 73 were categorized as the thinking(t) trait. overall, both traits covered all the rating levels. as with i/e and s/n, the most common rating was “inconsistent”. the frequency of f/t persistence ratings can be found in table 3. table 3: frequency of persistence ratings of feeler/thinker in doctor of pharmacy students at mcwhorter school of pharmacy personality trait persistence rating* feeling (n) thinking (n) very good 1.4% (1) 1.9% (2) good 43.8% (32) 40.6% (43) inconsistent 53.4% (39) 50.9% (54) poor 1.4% (1) 6.6% (7) total 100.0% (73) 100.0% (106) * persistence ratings: very good = 3540 good = 2429 inconsistent = 2328 poor = 1722 very poor = 0016 of the 179 responses, 136 were categorized as the judging (j) trait and 43 as the perceiving (p) trait. judging individuals reflected all persistence rating levels. however, none of the perceiving individuals scored in the “very good” persistence level. the frequency of j/p persistence ratings are listed in table 4. table 4: frequency of persistence ratings of judging/thinking in doctor of pharmacy students at mcwhorter school of pharmacy personality trait persistence rating* judging(n) perceiving (n) very good 2.2% (3) 0.0% (0) good 41.2% (56) 44.2% (19) inconsistent 52.9% (72) 48.8% (21) poor 3.7% (5) 7.0% (3) total 100.0% (136) 100.0% (43) * persistence ratings: very good = 3540 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 39 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe good = 2429 inconsistent = 2328 poor = 1722 very poor = 0016 of the total 179 responses, 58 were male and 121 were female. results showed that both male and females covered every level of persistence, but the majority of males scored with “good” persistence, whereas the majority of females scored with “inconsistent” persistence. the frequency of male and female persistence rating can be found in table 5. table 5: frequency of persistence ratings per gender in doctor of pharmacy students at mcwhorter school of pharmacy gender persistence rating* male (n) female (n) very good 1.7% (1) 1.7% (2) good 55.2% (32) 35.5% (43) inconsistent 37.9% (22) 58.7% (71) poor 5.2% (3) 4.1% (5) total 100.0% (58) 100.0% (121) * persistence ratings: very good = 3540 good = 2429 inconsistent = 2328 poor = 1722 very poor = 0016 4. discussion the results indicated that 147 of the 179 response were introverts. this was more than expected. it could indicate a problem with the e/i personality trait questions and/or that survey responses were impacted by the statewide covid-19 quarantine. during quarantine, many students who would normally classify as extraverts temporarily became more introverted because of the restricted social interactions. other studies conclude that extraverts and introverts are equal when it comes to persistence levels, with extraverts having a little more persistence, possibly due to possibly having a stronger support system5,10. the results from this survey coincide with the studies suggesting that introverts and extraverts are equally persistent. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 40 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe next, the lead investigator hypothesized that intuitives would have a higher persistence level than the sensors. intuitive focus on the future, while sensors focus on the present. the results reflected the investigator’s hypothesis: a greater percentage of intuitive than sensors scored as “very persistent”. when comparing feeling versus thinking trait, the results were fairly even across the board. the investigators hypothesis was that thinkers would have a higher level of persistence than feelers because they would be able to set aside their feelings and make decisions based on logic. this did was not the case with the results with feelers actually having a slightly higher percentage than thinkers. for the judging versus perceiving trait, the results showed more people scored as judgers than perceivers. this is reflective of the general population. judging individuals had ratings in all levels of persistence, while perceivers did not have any ratings of “very good” persistence. while examining the biological genders, male and female results came back with an interesting find. there were more females than males in the study because that reflects the pharmacy school’s (and all pharmacy schools’) population. results showed that males have a slightly higher persistence level than females, with males having a 55.2% “good” persistence rating and females having a 35.5% “good” persistence rating. this was further concluded with males having a 37.9% “inconsistent” persistence rating and females having a 58.7%“inconsistent” persistence rating. the p-value on this comparison was 0.073, so unfortunately it cannot be concluded as statistically significant. while some studies support these results of men having higher persistence than women, others do not11. there are more studies pointing towards women being better at handling adversity than men1,3,4. a strength of the study was the accessibility. the survey was easily accessed online which was a great attribute during quarantine. this contributed to a strong response rate, which was assisted by survey reminders and an incentive (drawing) for completion. the number of responses allowed for adequate data to interpret conclusions. the study can be generalized to young college students in professional or graduate programs. a limitation of this study was that results indicated a disproportionate number of introverts over extraverts. another limitation of the study was the lack of statistical significance; there was no correlation p-value of statistical significance, meaning that the null hypothesis was accepted in every case. in a future study, the survey should be administered in a time without quarantine, which may more accurately reflect typical personalities. 5. conclusion pharmacy school is a challenging experience for all students who are enrolled. persistence is a key trait in overcoming the obstacles faced with in pharmacy school, workplace, and everyday life. this study was beneficial in allowing the investigators to see trends and relationships between the personality traits and persistence levels. studies need to be more conclusive before developing early intervention techniques related to personality and persistence. although, there was no statistical significance in these comparisons, this study was a good starting point for future studies. 6. references alnuwieri, t. (2018, january 11). women are more resilient than men, study shows. well+good. retrieved on november 29, 2020 from https://www.wellandgood.com/women-more-resilient-than-men-lifeexpectancy/ barker, e. (2019, june 5). a navy seal explains 8 secrets to grit and resilience. ladders.com. retrieved on november 21, 2020 from https://www.theladders.com/career-advice/a-navy-seal-explains-8-secrets-togrit-andresilience mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 41 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe boardman, j.d., blalock, c.l., & button, t.m. (2008). sex differences in the heritability of resilience. twin research and human genetics, 11(1), 12-27. doi:10.1375/twin.11.1.12 browning, f. (2015, april 29). survival secrets: what is it about women that makes them more resilient than men? cal alumni association, california magazine. retrieved on november 29, 2020 from https://alumni.berkeley.edu/ california-magazine/just-in/2015-04-30/survival-secrets-what-it-aboutwomen-makes-them-more career assessment site. (n.d.). myers-briggs® test entj personality type pharmacist career. retrieved on november 29, 2020 from https://careerassessmentsite.com/myers-briggs-test/mbti-personalitytypes/entj/careers/ pharmacist/myers-briggs-entj-career/ choi, a. n., curran, g. m., morris, e. j., salem, a. m., curry, b. d., &flowers, s. k. (2019). pharmacy students' lived experiences of academic difficulty and tinto's theory of student departure. american journal of pharmaceutical education, 83(10), 7447. doi:10.5688/ajpe7447 fischbein, r, &bonfine, n. (2019). pharmacy and medical students' mental health symptoms, experiences, attitudes and help-seeking behaviors. american journal of pharmaceutical education, 83(10), 7558. doi:10.5688/ajpe7558 kelly, j. (2018, september 7). habits of mentally strong people, and how they can help you succeed. forbes.com. retrieved on november 29, 2020 from https://www.forbes.com/sites/jackkelly/2018/09/07/habits-ofmentallystrong-people-and-how-they-can-help-you-succeed/?sh=1a5a04411ac1 pate, a.n., payakachat, n., harrell, t.k., pate, k.a., caldwell, d.j., &franks, a.m. (2017). measurement of grit and correlation to student pharmacist academic performance. american journal of pharmaceutical education, 81(6), 105. doi:10.5688/ajpe816105 peasland, p. (2017, september 4). extroverts, introverts and practising resilience. retrieved on november 29, 2020 from https://philippa-peasland.medium.com/extroverts-introverts-and-practising-resilience4511d1b288e9 sambu, l.j., &mhongo, s. (2019). age and gender in relation to resilience after the experience of trauma among internally displaced persons (idps) in kiambaa village, eldoret east sub-county, kenya. journal of psychology and behavioral science, 7(1), 31-40. doi.org/10.15640/jpbs.v7n1a4 shuck, a. a.,& phillips, c. r. (1999). assessing pharmacy students’ learning styles and personality types: a tenyear analysis. american journal of pharmaceutical education, 63(1), 27-33. doi:aj630104.pdf the myers & briggs foundation. (n.d.). mbti® basics. retrieved on november 29, 2020 from https://www.myersbriggs.org/my-mbti-personality-type/mbti-basics/ vocabulary.com. (n.d.). persistence – dictionary definition. retrieved on november 29, 2020 from https://www.vocabulary.com/dictionary/persistence mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 3; may-june 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 17 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe anthropometrics and physiological determinants as predictors of military specifi skills 1horst michael stocker, 2thomas johann huber, 3andreas peter hofer 1american philosopher, marjorie guttag professor of ethics and political philosophy at syracuse university 2ph.d. physics, gustavus adolphus college, university of wyoming 3universität konstanz abstract: the military has undergone significant changes in recent years, and these changes have had an impact on the selection process for new recruits. in particular, there is now less tolerance for poor physical fitness, as weak fitness can lead to sickness absence and overuse injuries. to identify recruits with the appropriate potential for a military career, common fitness tests are used, but the relationship between these tests and job performance is not always clear. this study investigated the correlations between common fitness tests and simulated basic military tasks. keywords: military fitness, common fitness tests, simulated basic military tasks job performance, physical fitness, sickness, absence, overuse injuries introduction many changes in the society have had major effects on the role of the military of today. new health standards, changes of motoric and physiological capabilities of children and young adults [22] have impact on the selection process of required personnel [9]. in the course of history, different criteria have been used to determine who would be selected to enter military as professional soldier. as a consequence, there is less tolerance for poor performance in strength, coordination and endurance [16] for a further military career [20]. weak physical fitness in case of overweight and inactivity has influence on sickness absence [1]and overuse injuries [13] during training [23]. to identify the appropriate potential for a cadre function common fitness tests were used but relationship to job performance was not always clear. in previous researches [21] several tasks were defined which are common for all soldiers as basic skills to perform [10]. according to nato research manual movement of equipment along a surface, repeated lifting equipment on/ off ground or vehicle, carry various equipment items over distances, move fastwith or without change of direction for short distances, crawl in high and low techniques and march with load were considered as military basic tasks in this research study[17]. the aim of the study was to investigate the correlations between common fitness tests and simulated basic military tasks. 1. material & methods 53 male officer cadets were recruited for this study. each of them attends a three-year academic military leadership degree program at the theresian military academy in wiener neustadt, austria. in this educational program daily physical fitness and activities are of great importance in order to ensure adequate fitness for military tasks/operations as well as for a healthy and balanced lifestyle. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 3; may-june 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 18 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe the evaluation and assessment of a standardized physical testing battery is approached since multiple years. this testing procedure involves: • 2400m running test • one repetition maximum test • loaded military march • military specific test 2400m running test the selected distance was applied to the cooper test concept which is an often-used method to quantify aerobic fitness in military research. the test was performed on a 400m running track, with a 15min individual warm up program. the officer cadets were registered with a bib number in order to ensure accurate lap count and timing. the subjects were sent off in a 5 second countdown and each of them was asked to perform maximum exertion at each stage of the test. in order to exclude a learning effect, participants performed two recognitional trials prior to the intervention. one repetition maximum test one repetition maximum one repetition maximum (1rm) was assessed on a machine based multi rowing machine (see figure 1 below). leg press (lp), seated bench press (sbp) and seated bench pull (sr) were the selected exercises. figure 1: concept 2 dyno see concept 2 training guide loaded march and military specific test military specific skills involved a 3.200m march in full military equipment (battle dress with weapon aug77 ) carrying 25kg load. the goal was to finish the 3.200m on selective terrain in the fastest possible time for each individual. the second part is the military specific test (mst), which includes four sections (see figure below). total time as well as split times were recorded. section a: moving in selective terrain includes change in direction, speed and position over a total distance of 140m including 10m of crawling. section b: load pulling of 50kg over a total distance of 40m section c: load carrying of 2x18kg over a total distance of 100m.(exercise farmer’s walk) section d: load lifting / releasing of 5x24kg on a 125cm high box (exercise dead lift) mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 3; may-june 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 19 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe figure 2: military specific test 2.1. data analysis split times of military basic tasks, 2400m running test and loaded march were recorded with a manual timing system (hanhart modul 3, hanhart 1882 gmbh, gütenbach, germany). one repetition maximum (1rm) for leg press (lb), seated bench press (sbp) and seated bench pull (sr) were performed on a machine based multi rowing machine (concept 2 dyno, concept 2 ltd, uk). in a further step second by second data and 1rm values were prepared in microsoft excel (windows 10, microsoft windows, washington, us) for statistical calculations. relative o2max values were derived from the 2400m distance running time using following equation according to the cooper test [4]. 3.5 + a further formula derived o2max from 2400m running time was applied to compare the original cooper based results with the new approach. however, the new approach indicated a higher standard deviation and coefficient of variation compared to the traditional method [13], so the cooper formula was selected for o2max estimation. 2.2. statistics using shapiro wilk (p>0.05). correlation and multi regression analyses were conducted to compare the relationship between strength and endurance parameters on the soldier’s occupational tasks. all statistical analyses were generated using the spss statistics 20 software package (ibm corporation, armonk, new york). mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 3; may-june 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 20 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 3.results 3.1. subjects the officer cadets (n = 53, age: 24.6 ± 4.6 years) average of maximum oxygen consumption ( o2max) of 53.74 ml min-1 kg-1 during the 2400m distance running test to maximal exertion. the subject’s anthropometric and physiological characteristics are listed in the table below. table 1: descriptive statistics of the physiological and anthropometric profile (mean ± sd; 95 % ci confidence interval). age [years] 24.6 ± 4.6 23.3 – 25.9 height [m] 1.80 ± 0.6 1.78 – 1.81 body mass [kg] 77.2 ± 9.3 74.6 – 79.8 bmi = body mass index, v̇o2 = maximum oxygen consumption 3.2. physical performance tests for cardiorespiratory fitness a standardized 2400m running test was performed on a track to assess endurance performance. regarding strength testing push-ups, leg press, bench press and bench pull were performed on a concept. in table 2 physical performance parameters are presented. table 2:descriptive statistics of the physical performance tests (mean ± sd; 95 % confidence interval). variables mean ± sd n = 53 95 % ci n = 53 2400m test [mm:ss] 09:37 ± 34 [s] 09:26 – 09:46 military specific test [mm:ss] 02:15 ± 35 [s] 02:04 – 02:25 military march [mm:ss] 19:40 ± 02:02 19:04 – 20:16 push-up [reps] 40 ± 9 37 – 43 leg press [kg] 264 ± 41 251 – 277 seated bench press [kg] 98 ± 16 93 – 104 seated bench pull [kg] 103 ± 17 97 – 109 3.2.military specific test military basic skills were assessed with a military specific test as described above. participants had to complete all four sections in one run (see table below). table 3: descriptive statistics of the occupational tasks (mean ± sd; 95 % confidence interval). variables mean ± sd n = 53 95 % ci n = 53 total [mm:ss] 02:15 ± 35 [s] 02:04 – 02:25 station a [s] 55.7 ± 4.7 54.38 – 57.07 station b [s] 24.4 ± 3.7 23.3 – 25.4 station c [s] 45.3 ± 7.0 43.3 – 47.3 variables mean ± sd n = 53 95 % ci n = 53 bmi 24.1 ± 2.2 23.4 – 24.7 relative v o max 2 ml [ min 1 kg 1 ] 53.74 ± 3.0 52.8 – 54.5 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 3; may-june 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 21 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe station d [s] 15.1 ± 10.1 – 18.0 3.3 .influence of anthropometrics on physical performance pearson’s linear correlation was used to investigate the effects of anthropometric parameters height, body mass and body mass index (bmi) on the 2400m running test (see table 4). no significant relationship was found between height (r = -0.199, p = 0.142), body mass (r = -0.008, p = 0.548) and bmi (r = 0.057, p = 0.677) on 2400 m running time. derived o2max of the 2400m running test however significantly correlated with bmi (r = -0.285, p = 0.033). regarding strength parameters lp, sbp, and sr no significant relationship was found for body mass (p > 0.05). bmi significantly influenced lp (r = 0.389, p = 0.004), sbp (r = 0.710, p = 0.001) and sr (r = 0.570, p = 0.001). in addition, height significantly correlated with the lp (r = 0.349, p = 0.010). a multi linear regression analysis compared the influence of anthropometrics on strength parameters and showed a significant influence on the lp (f(3,49) = 6.173, p = 0.001) with a r2 of 25.3% explained variance. height (p = 0.004) and bmi (p = 0.001) demonstrated a significant influence on the lp. table 4: pearson correlation coefficient on anthropometrics and physiological determinants leg press [kg] -0.70 0.621 0.34 0.010* 0.38 0.004 0.12 0.360 seated bench press [kg] -0.43 0.762 0.19 0.157 0.71 0.001* -0.05 0.969 seated bench pull [kg] -0.22 0.887 0.13 0.376 0.57 0.001* -0.00 0.969 2400m running [mm:ss] -0.00 0.952 0.19 0.142 0.57 0.677 -0.22 0.104 military march [mm:ss] -0.21 0.114 0.45 0.743 0.53 0.699 -0.42 0.001* military specific test -0.25 0.61 -0.14 0.287 0.10 0.941 -0.34 0.010* [mm:ss] bm = body mass, bmi = body mass index, o2max = relative maximum oxygen uptake, *significant relationship 3.4. influence of physical performance on military specific skills linear correlation according to pearson compared the influence of physical performance parameters including 2400m running test, lp, sbp and sr on bm [kg] height [cm] bmi o max 2 ] ml/min/kg [ r p r p r p r p mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 3; may-june 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 22 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe the soldier cadet’s military specific skills including the mst and as the results of this study indicate aerobic performance is a strong determinant of military specific skills. in contrary 1rm of lp, sbp and sr did not show a statistically significant relationship with the mst and military walk. the subjects in this study were classified as moderately trained according to the aerobic determinants [15] with small variations in weight and bmi. these findings are in contrast to other studies in military research, where large effects have been reported in the relationship of anthropometric and physical determinants [18]. in addition, the influence of anthropometrics on physical performance is often associated to lean body mass [19] predominantly in studies with large heterogeneity. the collective homogeneity in this study is probably due to pre selection criteria for officer cadets while other research is mainly based on cross sectional data from soldiers in military basic training to special forces [6]. muscular strength has shown to be related to military specific skills in the literatur. especially muscular endurance ability has been named frequently as a greater predictor for military fitness than 1rm [3]. these findings are in line to our observations, as 1rm of upper and lower extremities did not show a significant relationship to neither general physical performance nor military specific skills. cardiorespiratory fitness in general and military population is known to be an important aspect for both, health and performance. due to that reason, many military fitness test batteries consist of minimum one cardiorespiratory fitness assessment. the most commonly used methods in the literature are capacity tests in form of fixed distance or duration among 1.5-3km or 8-12min in order to reach o2max [8]. as an alternative, shuttle runs can be performed depending on the available material and group size. the approach in this study for assessing cardiorespiratory fitness was based on current military research recommendations. in this study, a close military march (see table 4). strength para meters did not correlate significantly with the mst and military march (p > in 0.005) . however as shown table 4 below, o max 2 derived from the 2400 m running test showed a significant relationship with total time in the mst (r = = 0.010 0.340 , p as well as all split times (p < 0.05). furthermore ) o 2 max was found to have a significant effect on the military march (r = 0.428 , p = 0.001) see figure 2 . figure 2 : relationship of o 2 max and military walk 4 . discussion mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 3; may-june 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 23 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe interaction of 2400m running performance to military specific skills as well as to the military march can be confirmed. these findings support that aerobic performance might have a larger influence on military performance than 1rm, which is also confirmed by other research findings [11]. one limitation of this study is that o2max values of the 2400m running test have not been measured directly with a breath-by-breath spiro-ergometry system. this could lead to underor overestimation of real o2max for an individual [2]. nevertheless, applying the cooper formula in large cohorts [5] like the military has been a frequently used method, which was one of the reasons why o2max in this study was derived from 2400m running time [12]. 5. conclusions the results indicate that the endurance determinants predominantly influence the military specific skills more than the 1rm. in addition, these findings underpin the importance of a high level of muscular endurance for mst and the military march [13]. anthropometric characteristics have demonstrated to influence both strength [18] and endurance components [5]. we recommend further research in this direction to get a better understanding for requirements for military specific skills. references: anderson, m. k., grier, t., hauschild, v., & jones, b. h. (2015). injury rates, limited duty days, medically not ready rates, and injury risk factors in an army chemical brigade (no. usaphc-tr-s. 0032423.315). army public health center (provisional) aberdeen proving ground md. batista, m. b., romanzini, c. l. p., castro-piñero, j., & ronque, e. r. v. (2017). validity of field tests to estimate cardiorespiratory fitness in children and adolescents: a systematic review. revista paulista de pediatria, 35(2), 222-233 colmenero, m. h., vicente, g. f., & ruíz, j. r. (2014). assessment of physical fitness in military and security forces: a systematic review. european journal of human movement, (32), 3-28. cooper, k. h. (1968). a means of assessing maximal oxygen intake: correlation between field and treadmill testing. jama, 203(3), 201-204. drinkard, b., mcduffie, j., mccann, s., uwaifo, g. i., nicholson, j., & yanovski, j. a. (2001). relationships between walk/run performance and cardiorespiratory fitness in adolescents who are overweight. physical therapy, 81(12), 1889-1896. farina, e. k., taylor, j. c., means, g. e., williams, k. w., murphy, n. e., margolis, l. m., ... & mcclung, j. p. (2017). effects of combat deployment on anthropometrics and physiological status of us army special operations forces soldiers. military medicine, 182(3-4), e1659-e1668. friedl, k. e., knapik, j. j., häkkinen, k., baumgartner, n., groeller, h., taylor, n. a., ... & nindl, b. c. (2015). perspectives on aerobic and strength influences on military physical readiness: report of an international military physiology roundtable. the journal of strength & conditioning research, 29, s10-s23. grant, s., corbett, k., amjad, a. m., wilson, j., & aitchison, t. (1995). a comparison of methods of predicting maximum oxygen uptake. british journal of sports medicine, 29(3), 147-152. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 3; may-june 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 24 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe hansen, b. h., anderssen, s. a., andersen, l. b., hildebrand, m., kolle, e., steene-johannessen, j., ... & sardinha, l. b. (2018). cross-sectional associations of reallocating time between sedentary and active behaviours on cardiometabolic risk factors in young people: an international children’s accelerometry database (icad) analysis. sports medicine, 48(10), 2401-2412. hauschild, v. d., degroot, d. w., hall, s. m., grier, t. l., deaver, k. d., hauret, k. g., & jones, b. h. (2017). fitness tests and occupational tasks of military interest: a systematic review of correlations. occup environ med, 74(2), 144-153. knapik, j., daniels, w., murphy, m., fitzgerald, p., drews, f., & vogel, j. (1990). physiological factors in infantry operations. european journal of applied physiology and occupational physiology, 60(3), 233-238. kuipers, h., verstappen, f. t. j., keizer, h. a., geurten, p., & van kranenburg, g. (1985). variability of aerobic performance in the laboratory and its physiologic correlates. international journal of sports medicine, 6(04), 197-201. kyröläinen, h., häkkinen, k., kautiainen, h., santtila, m., pihlainen, k., & häkkinen, a. (2008). physical fitness, bmi and sickness absence in male military personnel. occupational medicine, 58(4), 251-256. leamon, s. m., & nevola, v. r. (2003). a review of health-related physical fitness and ist application within the uk armed forces. qinetiq. ki/chs/pub030167. qinetiq group plc, farnborough. mcardle, w. d., katch, f. i., & katch, v. l. (1991). exercise physiology: energy, nutrition, and human performance. nindl, b. c., beals, k., witchalls, j., & friedl, k. e. (2017). military human performance optimization and injury prevention: strategies for the 21st century warfighter. journal of science and medicine in sport, 20, s1-s2. optimizing operational physical fitness. final report of task group 019, nato. research and technology organisation, 2009. pierce, j. r., degroot, d. w., grier, t. l., hauret, k. g., nindl, b. c., east, w. b., & jones, b. h. (2017). body mass index predicts selected physical fitness attributes but is not associated with performance on military relevant tasks in us army soldiers. journal of science and medicine in sport, 20, s79-s84. reilly, t., spivock, m., prayal-brown, a., stockbrugger, b., & blacklock, r. (2016). the influence of anthropometrics on physical employment standard performance. occupational medicine, 66(7), 576-579. robinson, m., siddall, a., bilzon, j., thompson, d., greeves, j., izard, r., & stokes, k. (2016). low fitness, low body mass and prior injury predict injury risk during military recruit training: a prospective cohort study in the british army. bmj open sport & exercise medicine, 2(1), e000100. rohde, u., rüther, t., & leyk, d. (2017). basic military fitness tool (bmft): a reliable field uniform-test for performance prediction of strength-related common military tasks. journal of science and medicine in sport, 20, s170. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 3; may-june 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 25 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe ruiz, j. r., cavero-redondo, i., ortega, f. b., welk, g. j., andersen, l. b., & martinez-vizcaino, v. (2016). cardiorespiratory fitness cut points to avoid cardiovascular disease risk in children and adolescents; what level of fitness should raise a red flag? a systematic review and meta-analysis. br j sports med, 50(23), 14511458. taanila, h., suni, j. h., kannus, p., pihlajamäki, h., ruohola, j. p., viskari, j., & parkkari, j. (2015). risk factors of acute and overuse musculoskeletal injuries among young conscripts: a population-based cohort study. bmc musculoskeletal disorders, 16(1), 104. vaara, j. p., kyröläinen, h., niemi, j., ohrankämmen, o., häkkinen, a., kocay, s., & häkkinen, k. (2012). associations of maximal strength and muscular endurance test scores with cardiorespiratory fitness and body composition. the journal of strength & conditioning research, 26(8), 2078-2086. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 9 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe role of nanoparticles in the efficacy of antibiotics 1muhammad ukashah, 2bareera ijaz, 3muhammad a. riaz, 4muhammad k. javed 1department of biotechnology university of sargodha, sargodha 2center for agriculture biochemistry & biotechnology university of agriculture faisalabad 3center for agriculture biochemistry & biotechnology university of agriculture faisalabad 4institute of molecular biology & biotechnology bahauddin zakariya university multan abstract: now a day, the reason of greater mortality rate is due to bacterial diseases. the cure of bacterial diseases is the use of antibiotics but there is a problem that bacteria have become multidrug resistant and so antibiotics can’t be used for treating bacterial diseases. a great revolution in this aspect is the use of nanoparticles. nanoparticles can be made from different metals like gold, copper, zinc etc. the mode of action of nanoparticles is that they enter into the cell membrane of pathogen and affect their molecular pathways. nanoparticles are used in combination with different drugs. the nanoparticles which have been extensively studied are silver nanoparticles. experiments were performed of check the efficiency of silver nanoparticles in gram positive and gram negative bacteria. silver nanoparticles were not used with the combination of any drug. nanoparticles are stable for long time as they are surrounded by capping layers because of which they are stable for long time. another important function of these capping layers is that they are also providing active surface area for the interaction with other biological components. shortly, we can say that nanoparticles can be used as an alternative to antibiotics and they can serve us in better way. introduction: the term antibiotic is derived from the word “antibiosis” which means (against life). when we look on the definition of antibiotics these are defined as chemical compounds that can either kill or inhibit the growth of bacteria or other pathogens. these antibiotics can be antifungal, antibacterial or antiviral. however, in general terms the term antibiotic is used for antibacterial compounds. these antibiotics are used to treat bacterial disease. their mode of action is to either interfere with dna, rna or protein of the host. the bacterial diseases are lethal as they can cause death. recently, the greater mortality rate is due to bacterial diseases as due to the rapid use of these antibiotics the bacteria has developed resistance against these antibiotics. the main reason of resistance to antibiotics is horizontal gene transfer which is by means of biofilm creation, transformation, transduction or bacterial conjugation. the complete removal of resistance is necessary in order to compete with bacterial diseases. both gram positive and gram negative bacteria can create biofilms on medical apparatus. the bacteria related to human diseases are enterococcus faecalis, staphylococcus epidermidis, e.coli and many more other bacteria. the greater revolution in this aspect is the use of nanoparticles. these nanoparticles can be effectively used in the treatment of different bacterial and infectious diseases. the nanoparticles are metallic in nature and the metals used are gold, silver or zinc etc. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 10 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe in order to inhibit the growth of pathogenic microbes the ions used are copper and cobalt. the complexes of metals are also used to inhibit growth of pathogens that can cause diseases. the nanoparticles are used in combination with the different drugs in order to cure bacterial and other infectious diseases. the nanoparticles that are extensively studied are silver nanoparticles. in this review article we will study how nanoparticles are used in the treatment of different diseases as an alternative to antibiotics. antibiotic resistance: antibiotics were first discovered by sir alexander fleming in 1928. at that time the antibiotics were the only possible solution to treat different diseases. the first antibiotic discovered was “penicillin”. later on, these drugs were extensively used and because of their extensive use the bacteria developed resistance to these drugs leading to higher mortality rate. resistance genes were transferred to progeny in order to transfer resistance to next progeny. this type of resistance is known as “acquired resistance”. another type of resistance is “intrinsic resistance”. in this type of resistance the genetic traits don’t depend on the exposure to antibiotic that was previously done. resistance is the development of different molecules that are utilized when pathogen is exposed to any drug. as the bacteria have developed multidrug resistance the pharmaceutical companies are not focusing greatly on the development of new antibiotics. those bacteria that are multidrug resistant meaning when they are exposed to different antibiotics they show resistance and be killed, the bacteria of this type are known as “super bugs”. more than 35000 people are subjected to death every year because of the multi drug resistant bacteria. this is an alarming situation as we have never won war against microorganisms. if we want to eliminate this situation we have to do something as soon as possible. the alternative to this alarming situation is the use of nanoparticles which can effectively eliminate this situation. mechanisms of antibiotic resistance: here we will discuss some of the mechanisms of antibiotic resistance. these mechanisms are divided into following categories.  enzymatic inhibition: this type of inhibition happens when the antibiotics that are used are being neutralized by bacteria before these drugs can perform their action. the antibiotics beta lactam is targeted at transpeptidase enzymes which are playing their role in the synthesis of cell walls by the breakage of amide bonds of the four members[1-3]. in case of gram negative bacteria the genes of beta lactamase are present inside the periplasmic space but in case of gram positive bacteria in them beta lactamase is excreted [4]. the genes of beta lactamase are present in transposons or plasmids that result in swift movement and the genetic material is conveyance to alternative bacteria. the additional changes to these genes of beta lactamase result in the systems that are for multidrug resistance that consist of sulphonamides, macrolides, aminoglycosides and chloramphenicol. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 11 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe  target site alteration: the alteration of target site occurs when the product of target gene of antibiotics is changed and the interaction between the bacteria and drug is avoided. there are both 30s and 50s ribosomes which are the target for antibiotic [7-8]. both of these ribosomes permit the changes and because of these changes permit the cells of bacteria of the maintain their homeostasis even during the presence of any antibiotic [10].  alteration of a metabolic pathway: sulphonamides are the example of inhibition which occurs in dihydropteroate synthase present in folic acid. folic acid and nucleic acid can be synthesized by using paba which confirms resistance in sulphonamide bacteria [12]. the antibacterial activity of antibiotic can be inhibited by activating paba [14-15]  membrane permeability shifts: the membrane of bacteria is made up of transport proteins, phospholipids and lipopolysaccharides. the hydrophobic antibiotics penetrate the membrane and then enters into the cell [15, 16]. when we change the penetrability of the membrane the arrangement of lipopolysaccharides is changed. if there is the expression of entire length of polysaccharides than the strains of bacteria show resistance to antibiotic [17, 15]. these strains which are resistant to antibiotic limit the penetration of the hydrophobic antibiotics. experimental: the alternative to antibiotics is the use of metallic nanoparticles. here we will discuss the preparation of nanoparticles through some examples.  preparation of citrate capped gold nanoparticles: take boiling solution of the haucl4.6h2o, distilled water and trisodium citrate because of this addition the color of solution gold chloride that was yellow than turned into wine red and show absorbance at 518nm at uv spectrum. the diameter of these nanoparticles is 12-15 nm.  preparation of antibiotic coated gold nanoparticles: in the preparation of drug coated nanoparticles following steps are performed. the stabilized 0.1 mm citrate gold nanoparticles were mixed with 5cm3 of 3mm drugs in water and then stir them for 2h. two different concentrations of gold particles 0.3mm and 0.5mm were prepared.  preparation of co nanoparticles: in order to prepare cobalt nanoparticles reduce a cobalt (2) salt by using a reducing agent hydrazine hydrate. take 10 gram of cobalt chloride and dissolve it into 150ml of ethylene glycol and water and then stir the solution until it is dissolved completely. adjust the ph of the solution to 12 by adding naoh solution. than treat the solution of cobalt chloride with 50% of hydrazine hydrate. after that centrifugation of reaction mixture is carried out. than collect the black particles and wash it with water in order to remove chloride, sodium and hydrazine. than dry the final product in oven at 60c. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 12 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe  preparation of silver nanoparticles: take 1.2% of metallic silver and than stabilize it with 18.8% of pvp (polyvinyl chloride) in water. when observed on uv spectrum they show absorbance at 400nm. the shape of silver nanoparticles is sphere and diameter is 35 -15nm.  preparation of zno nanoparticles: take 0.2 gram of the ctab and than add it into the bi-distilled water in a flask. take 10ml of the zn(ch3coo)2.2h2o was added into the solution. than stir the solution at different conditions. add naoh drop wise and after that the solution turns milky. than retain the solution for half hour and cool it, than centrifuge and dry it at room temperature and thanwash with methanol and water.  bismuth based nanoparticles: bismuth is a brittle and crystalline metal, and when we freeze this metal it expands. its thermal conductivity is low than any other metal. this method of preparation of nanoparticles is cost effective and can be employed on industrial scale. these bismuth based nanoparticles are used in the treatment against different pathogens.  gold based nanoparticles: the gold combinations can be used in the treatment of different diseases like juvenile arthritis, palindromic rheumatism, rheumatic diseases [84]. apparently gold nanoparticles have no antibacterial activity, vidya et al .[85] synthesized and than functionalized in a process in which antibiotics of third generation are used and also of second generation. nanoparticles as antimicrobial agents: the number of first line antibiotics is decreasing and the number of last line antibiotics is increasing in order to treat infectious diseases thus, decreasing the options of treatment for patients. nanoparticles can be used in combination with the different antibiotic drugs. for example, silver nanoparticles used in combination with drugs can be used to overcome bacterial resistance. when we observed the effect of silver nanoparticles used in combination with antibiotics like vancomycin, amoxicillin and erythromycin showed that this combination is effective only against gram positive bacteria [34]. deng showed that when silver nanoparticles alone were used they resulted in antibacterial activity against salmonella typhinium. when the complex of tetracycline-silver nanoparticles were used it showed elevated drug action because of the accumulation of silver outside the cell and this inhibited the action of bacteria. banoee and his colleagues when used zinc oxide it showed increased antibacterial activity against s.aureus and e.coli [36]. it was observed that if we use zinc oxide nanoparticles combined with nitrofurantoin and amoxicillin than antibacterial activity was decreased against s.aureus and e.coli. this combination with drugs not all the times the antibacterial activity is increased it can also be decreased depending on the drug and nanoparticles [36].  mechanisms of drug resistance to antimicrobials: these mechanisms are as follows:  decreased uptake: when drugs uptake is decreased than it does not allow the storage of drugs in cells to such level that is not effective for the killing of cells. bacteria contain the resistance genes against specific antibiotics. for example, mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 13 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe gram negative and gram positive bacteria possesses genes for tetracycline tetk, tetb, teta. under native conditions the teta gene is repressed by its repressor gene tetr. when tetracycline binds to tetr and then inactivates it and teta is expressed. the teta gene than flushes out tetracycline making the bacteria resistant to tetracycline. other such examples of resistance are resistance against fluoroquinolones in gram negative bacteria and also the resistance against macrolide in gram positive bacteria [5]. examples of less uptake of drugs include resistance against aminoglycoside in gram negative bacteria.  alteration of antimicrobial target: in bacteria, resistance is also developed by expressing genes that codes for alternative version for antibiotic target. the wild type versions have more binding affinity than altered substrates so altered substrates can decrease the activity of antibiotics. for example, staphylococcus aureus is resistant to methicillin. in case of pbp2a and pbp the beta lactam has low binding affinity and mcca confers resistance against beta lactams [5,38,39]. the resistance against glycopeptides is conferred by gene vana which is involved in the expression of enzyme known as d-alanine d-lactate ligase. the peptidoglycan precursor d-ala-d-ala is converted into d-aladlactate by this enzyme. the wild type version of this precursor is 1000 times greater than this modified precursor and thus showing resistance towards vancomycin [5 , 40]. other examples are sulfonamide resistance in e.coli, resistance in gram positive and gram negative bacteria against quinolones [5, 41].  modification of antimicrobial drugs: bacteria also has resistance genes that code for enzymes that modify antibiotic. for example, the acetylation of nh2 group of aminoglycoside is catalyzed by act n-acetyltransferase, the phosphorylation of oh group of aminoglycoside catalyzed by aph o-phosphotransferase, the adenylation of oh group of aminoglycoside catalyzed by ant o-adenyltransferase. in all these cases it is observed that due to modification the affinity of antibiotics is reduced, the antimicrobial activity is also reduced by 30s ribosomal subunit. the development of chloramphenicol resistance is done by inactivation of chloramphenicol by acetyltransferases.  production of competitive inhibitor: a competitive inhibitor is also produced to develop antibiotic resistance. for example, species like s.aureus and n.meningitides both produce enhanced concentration of paba that is involved in competition with sulfonamide for its target that is dihydropteroate synthetase and thus developing resistance against sulfonamide drugs.  persister cells: when small number of bacteria slow down their metabolic activity when they express toxin-antitoxin and then they become more tolerant towards antimicrobial drug. such type of cells is known as persister cells. when bacterial population is exposed to antibiotics than most of the bacteria are killed leaving behind the persisters. when the metabolic activity of persisters is resumed than the chances of reoccurrence of infection are there [5, 36].  biofilm formation: mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 14 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe when the bacterial cells attach to medical implants and human tissues than they immobilize themselves. due to the presence of extracellular polymeric substance around the bacterial cells the treatment of infections that are associated with biofilm are difficult to treat. this eps matrix is resistant towards many antibiotics thus causing chronic infections in humans [5, 43]. the barrier between bacterial cells and antibiotics is caused by this eps matrix. the molecules that have greater size than a certain size, also including antibiotics, are unable to pass through this eps matrix. in case of antibiotics because of their negative charge they are also trapped into eps matrix. in eps matrix certain enzymes are present that reduces the affinity of antibiotics. if the concentration of antibiotics below their mic value than eps matrix also develops resistance in bacteria [5, 44].  swarming: in case of bacteria the multicellularity observed is known as swarming. this situation occurs when on semisolid surfaces the swarm cells come together as a single unit. in case of planktonic cells they are elongated and then develop multiple flagella. the swarm cells migrate with each other like raft. these swarm cells are resistant towards several antibiotics. when we culture the swarm cells in a liquid media they restore their susceptibility towards antibiotics [5, 38].  intracellular microbes: as the drugs have limited affinity to enter into the bacterial cells so, when the intracellular microbes are inside the host cells they are protected [5].  factors which affect antimicrobial activity: size: the size of nanoparticles is important in this aspect that this determine the degree of penetration of nanoparticles in the bacterial cell wall. this has direct correlation with the degree to which the nanoparticles penetrate into the cell wall. the mechanism of action through which the nanoparticles adhere to the surface of cell wall also depends on the type of nanoparticles being used. the nanoparticles of size 50nm can penetrate beyond the cell wall and can also target the dna that is present inside the cell. morones and his colleagues observed that the silver nanoparticles having the size 10nm have the ability to penetrate bacteria and showed antimicrobial action [66]. hsueh and his colleagues reported the activity of silver nanoparticles against bacillus subtilis [51]. besides the size, the morphology of nanoparticles is also important in their affectivity. sadeghi and his reporters showed the activity of silver nanoparticles against s.aureus and e.coli [67]. they also observed that regardless of shape the activity of nanoparticles can be achieved. so, this one showing that morphology is not playing an important role in the activity of nanoparticles [67]. zeta potential: zeta potential is also important in the antimicrobial activity of nanoparticles. zeta potential determines the interaction of nanoparticles with the surface of bacterial cell wall [68]. zeta potential also determines that how nanoparticles can be used as drug carriers. this zeta potential also determines the pharmacokinetic behavior of the nanoparticles, it is important because of the ph changes that occur inside the body that can affect the charge of nanoparticles. in case of bacteria, this zeta potential determines that how much associations and repulsions occur between the bacterial cell and the nanoparticles [69]. in case of gram positive bacteria teichoic acid is present on the mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 15 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe cell surface and inn case of gram negative bacteria, lipopolysaccharides are present on the cell surface [9]. these components present on the surface of cell affect the stability of nanoparticles. as in case gram negative bacteria most of the cell surface is covered with lps which gives negative charge to the surface. this negative charge explains that why nanoparticles rather than penetrating the prokaryotic cell they accumulate on their surface [71]. in case of bacteria that are susceptible to antibiotic the antibiotics like aminoglycosides which are lipid soluble they can easily penetrate. in case of mdr bacteria the composition of cell wall is changed in order to prevent the entry of antibiotics inside the cell wall [73]. due to opposite charges the nanoparticles remain on the surface of cell wall [75]. pharmacokinetic and pharmacodynamic characteristics of nanoparticles: the pharmacokinetics of nanoparticles depend on different factors like surface charge, size, surface coating, exposure route, animal species and dose. their comprehensive study of these factors is important for biosafety and risk assessment in clinical practice [lin et al, 20150]. most of the nanoparticles are distributed into spleen and liver but silver nanoparticles can be modified to enhance the distribution of these nanoparticles towards the specific organ [lin et al, 2015].  dose optimization: the optimum dose is very important for treating any disease and minimizing the toxic effects of the drugs [khan et al., 2016; hua et al., 2018]. the dose of nanoparticles to kill the cell is very high and we can’t apply this higher dose to humans. the data that we collect from animal studies cannot be applied directly to humans [khan et al., 2016; hua et al., 2018]. experiments are being applied on adult volunteers to observe which dose is effective in treatment and these studies are continue.  clearance and elimination; nanoparticles can be long term accumulated in the spleen and liver [lin et al, 2015]. nanoparticles are not biodegradable and they can accumulate into tissues for long time [zaidi et al., 2017]. a greater accumulation of nanoparticles has been observed in the kidneys but the reason for this accumulation was that less number of large nanoparticles were present as their greater concentration was accumulated in liver and spleen [hoshyar et al., 2016].  toxicity: in terms of toxicity the nanoparticles themselves and their degradation products cause toxicity as they cause hemolysis and also interfere with coagulation pathways of blood [kandi and kandi., 2015]. the toxic complications that are caused by nanoparticles, their exact mechanism is unknown but it is observed that large size of nanoparticles is the cause of toxicity [dos santos et al., 2014]. when the toxicity of nanoparticles is studied, the extensive study is performed on silver nanoparticles and these nanoparticles have proven to be more toxic against cells [bondarenko et al., 2013; lvask et al., 2014]. the accumulation of silver nanoparticles in lungs, liver and spleen and in other organs result in the damage of organs and their loss of function [hemeg, 2017]. these nanoparticles can also be accumulated in bone marrow, lymphatic system, liver and spleen [hagens et al., 2007] and also their inhalation may cause cytotoxicity in the organs like lungs [leucuta, 2013]. no life threatening toxicity is caused by nanoparticles [pfurtscheller et al, 2014; sengupta et al, 2014; wei et al, 2015; mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 16 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe zazo et al, 2016].the evaluation of toxicity is important for clinical practices and in order to check any therapeutic effect [khan et al, 2016].  targeted antibiotic therapies: the infection site of bacteria is rich in molecular and physiological cues that are useful in the release of drug and also support the attachment of nanoparticles to bacteria. there are three ways for targeted drug delivery which are physical-chemical gradients, passive targeting and active targeting. 71,72in case of passive targeting there is dysfunctional lymphatic drainage and also enhanced permeability and these changes occur at infection site. at the surface of gram negative bacteria, the negative charge is present and that negative charge can be used to affect target site but some bacteria can resist this by secreting acetic acid and lactic acid.82 in order to overcome this problem, many groups have developed micelles in order to switch charge and also the nanoparticles that affect the cell wall that has negative charge.83,84 a ph sensitive polymer that is zwitterion is used that can slow down the growth of s.aureus and e.coli at low ph.85 in order to synthesize nanoparticles and the micelles that can switch the charge this includes betaamino ester,86 poly-l-histidine,84 and many other chemical functionalities.87 nanoparticles can be used to treat bacterial infections in stomach but the challenge in this aspect is that to develop nanoparticles that can work at various ph values in gastrointestinal tract. in addition to problems of ph gradients and negative charge, the bacteria can also secrete several virulence factors like collagen adhesions, toxins, fibronectin and many enzymes.97 the simplest way to target the infection site is to dope the surface of delivery vehicle with antibody. if the bacteria either facultative or obligate escapes the site of infection than the chances of reoccurrence of this infection increases. it is now observed that bacteria can escape by hiding in the phagocytic cells, osteoblasts and erythrocytes.9 the role of these pathogens is that they disrupt the microbicidal mechanism of phagocytic cells by interfering with the fusion of phagosomes with lysosomes thus increasing the duration of their survival.102 many of the pathogenic bacteria have been discovered who can perform this function and their examples are b.pseuomallei. s.aureus, m.tubercolosis.10 the cytoplasm of mammalian cells is used by the pathogens to exchange resistance and virulent genes.103 when a macrophage is infected, than in next step the intracellular pathogen is targeted. xiong et al,20 the optimum activity of any antibiotic against any cell which is infected by bacteria is dependent on the quantity of active drug inside the subcellular compartments, which in turn depends on the activity, subcellular distribution and cellular retention. one method to achieve this is to distribute this antibiotic to infection site or to cell should be through biodegradable vehicle. many biodegradable delivery systems consist of synthetic or natural polymers like cs78 and albumin can be used for this purpose. the major infection site is found in liver and spleen. outside the liver and spleen the macrophages that are infected by bacteria are also present in pulmonary cavities.112 the intake of antibiotic by infected macrophages depends on concentration and size of delivery vehicles and the amount of macrophages present at the site of infection.  vaccination vehicles: mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 17 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe the large surface area of nanoparticles can be used for the killing of bacteria and also capturing bacterial toxins. a simple solution for the removal of active toxins is to use nanosponges and erythrocyte membrane coated polymer nanoparticles. gold nanoparticles have adjuvant activities and can be used for the development of antibacterial vaccines. gold nanoparticles also have the ability to distribute bacterial antigens. however, now a days such investigations can be conducted by using cheaper biodegradable polymer nanoparticles. adjuvants can be used incorporation with polymer nanoparticle. such ways have proven successful in the treatment tb. bcg vaccination is also used for tb and anti-tb protectin is inferior to bcg.166 a single dose of antigen vaccine is not sufficient for the treatment of tb. for example, there are three mycobacterial antigens which are ag85b, mpt-64 and mpt-83 were placed onto plga nanoparticles and then introduced into mice through injection. after this injection the increased humoral and cellular responses were produced. conclusion: this review article is aimed to provide detailed study on the role of nanoparticles in the efficacy of antibiotics. as bacteria are widely available on earth and they are available in different life forms. bacterial population is important for our survival as they are involved in many processes and at the same time they are lethal for us as they can cause harm to us by causing many diseases. for centuries, thousands of humans have been died due to epidemics. than studies lead to the discovery of antibiotics and first antibiotic was discovered by alexender fleming known as penicillin. the antibiotics saved human life for many years but due to increased and repeated use of antibiotics the bacteria developed resistance towards these antibiotics. in the treatment of bacterial diseases the antibiotics are of no more use as bacteria are tolerant towards several antibiotics. in this situation when bacterial diseases are common and their sole treatment antibiotics are not effective than we require an alternative and the revolution in this aspect is nanoparticles. the nanoparticles are small metal particles that are tested to be effective in the treatment of many microbial infections. we have provided detailed study on the use of nanoparticles in the efficacy of nanoparticles and in future these nanoparticles will serve more functions and their efficiency will be enhanced soon.  data availability: the data that is used in this review article is provided by the relevant authors on request. references lin, j.; nishino, k.; roberts, m. c.; tolmasky, m.; aminov, r. i.; zhang, l.: mechanisms of antibiotic resistance. frontiers in microbiology 2015, 6. semenitz, e.: [mechanism of action of beta-lactam antibiotics and problems concerning the development of resistance in antibacterial chemotherapy]. wiener klinische wochenschrift. supplementum1982, 142, 7-11. owens, r. c.; lautenbach, e.antimicrobial resistance: problem pathogens and clinical countermeasures; crc press, 2007. kohanski, m. a.; dwyer, d. j.; collins, j. j.: how antibiotics kill bacteria: from targets to networks. nature reviews microbiology 2010, 8, 423-435. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 18 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe menninger, j. r.; otto, d.: erythromycin, carbomycin, and spiramycin inhibit protein synthesis by stimulating the dissociation of peptidyl-trna from ribosomes. antimicrobial agents and chemotherapy 1982, 21, 811-818. poole, k.: mechanisms of bacterial biocide and antibiotic resistance. journal of applied microbiology 2002, 92. chopra, i.; roberts, m.: tetracycline antibiotics: mode of action,applications, molecular biology, and epidemiology of bacterial resistance. microbiology and molecular biology reviews 2001, 65,232-260. ahmed, m.; brode, e.; brown, t.; eltoweissy, s.; gross, s.; markowitz, s.; mccutchen, m.; portney, r.; reinhart, j.; salgado, c.: effects of gallium desferrioxamine compounds on bacteria. 2015. bockstael, k.; van aerschot, a. antimicrobial resistance in bacteria. cent eur j med 2009, 4, 141-155. 331339. spink, w.w.; wright, l.d.; vivino, j.j.; skeggs, h.r. paraaminobenzoicacid production by staphylococci. j exp med 1944, 79. deck, d.h.; winston, l.g. sulfonamides, trimethoprim, & quinolones, in:b. katzung, s. masters, a. trevor (eds.), in: basic and clinical pharmacology,12th ed, 2012, pp. 831-838. iliades, p.; meshnick, s.r.; macreadie, i.g. dihydropteroate synthase mutations in pneumocystis jiroveci can affect sulfamethoxazole resistance in a saccharomyces cerevisiae model. antimicrob agents ch 2004, 48, 2617-2623. nikaido, h.: molecular basis of bacterial outer membrane permeability revisited. microbiology and molecular biology reviews 2003, 67, 593-656. ruiz, n.; kahne, d.; silhavy, t. j.: advances in understanding bacterial outer-membrane biogenesis. nature reviews microbiology 2006, 4, 57-66. delcour, a. h.: outer membrane permeability and antibiotic resistance. biochimica et biophysica acta (bba)-proteins and proteomics 2009, 1794, 808-816. jakobsen, t. h.; van gennip, m.; phipps, r. k.; shanmugham, m.s.; christensen, l. d.; alhede, m.; skindersoe, m. e.; rasmussen,t. b.; friedrich, k.; uthe, f.: ajoene, a sulfur-rich molecule fromgarlic, inhibits genes controlled by quorum sensing. antimicrobial agents and chemotherapy 2012, 56, 23142325. vidya, s.; mutalik, s.; bhat, k. u.; huilgol, p.; avadhani, k. :preparation of gold nanoparticles by novel bacterial exopolysaccharide for antibiotic delivery. life sciences 2016, 153, 171-179. yoon e-j, courvalin p, grillot-courvalin c (2013) rnd-type efflux pumps in multidrug-resistant clinical isolates of acinetobacter baumannii: major role for adeabc over expression and aders mutations. antimicrobial agents chemother 57(7):2989–2995. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 19 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe li x-z, nikaido h (2004) efflux-mediated drug resistance in bacteria. drugs 64(2):159–204 fernando d, kumar a (2013) resistance-nodulation-division multidrug efflux pumps in gram-negative bacteria: role in virulence. antibiotics 2(1):163–181 piddock ljv (2006) multidrug-resistance efflux pumps? not just for resistance. nat rev microbiol 4:629 schweizer hp (2003) efflux as a mechanism of resistance to antimicrobials in pseudomonas aeruginosa and related bacteria: unanswered questions. genet mol res 2(1):48–62 murakami s et al (2004) extra membrane central pore of multidrug exporter acrb in escherichia coli plays an important role in drug transport. j biol chem 279(5):3743–3748. r. djalali, y. chen, h. matsui, j. am. chem. soc. 124 (2002) 13660. h. li, y.y. luk, m. mrkvsich, langmuir 15 (1999) 4957. p. maincent, r. le verge, p. sade, p. couvreur, j.p. devissaguet, j. pharm. sci. 75 (1986) 955. j. y. cheon, s. j. kim, y. h. rhee, o. h. kwon, and w. h. park, “shape-dependent antimicrobial activities of silver nanoparticles,” international journal of nanomedicine,vol. 14, pp. 2773–2780, 2019. l. wang, c. hu, and l. shao, “the antimicrobial activity of nanoparticles: present situation and prospects for the future,” international journal of nanomedicine, vol. 12, pp. 1227–1249, 2017. a. d. bangham, “surrogate cells or trojan horses. the discovery of liposomes,” bioessays, vol. 17, no. 12, pp. 1081–1088, 1995. y. n. slavin, j. asnis, u. o. häfeli, and h. bach, “metal nanoparticles: understanding the mechanisms behind antibacterial activity,” journal of nanobiotechnology, vol. 15, no. 1, p. 65, 2017. b. luan, t. huynh, and r. zhou, “complete wetting of grapheme by biological lipids,” nanoscale, vol. 8, no. 10, pp. 5750–5754, 2016. h. li, q. chen, j. zhao, and k. urmila, “enhancing the antimicrobial activity of natural extraction using the synthetic ultrasmall metal nanoparticles,” scientific reports, vol. 5, no. 1, p. 11033, 2015. i. armentano, c. r. arciola, e. fortunati et al., “the interaction of bacteria with engineered nanostructured polymeric materials: a review,” the scientific world journal, vol. 2014, article id 410423, 18 pages, 2014. w. gao, s. thamphiwatana, p. angsantikul, and l. zhang, “nanoparticle approaches against bacterial infections,” wiley interdisciplinary reviews: nanomedicine and nanobiotechnology, vol. 6, pp. 532– 547, 2014. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 20 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe s. m. dizaj, f. lotfipour, m. barzegar-jalali, m. h. zarrintan, and k. adibkia, “antimicrobial activity of the metals and metal oxide nanoparticles,” materials science and engineering c, vol. 44, pp. 278– 284, 2014. tsao, l. h., hsin, c. y., liu, h.y.,chuang, h. c., chen, l. y., and lee, y. j. (2018). risk factors for healthcare-associated infection caused by carbapenem-resistant pseudomonas aeruginosa. j. microbiol. immunol. infect. 51, 359–366. 10.1016/j.jmii.2017.08.015 vandebriel, r. j., and de jong, w. h. (2012). a review of mammalian toxicity of zno nanoparticles. nanotechnol. sci. appl. 5, 61–71. doi:10.2147/nsa. s23932 vlachou, e., chipp, e., shale, e., wilson, y. t., papini, r., and moiemen, n. s. (2007). the safety of nanocrystalline silver dressings on burns: a study of systemic silver absorption. burns 33, 979– 985. doi:10.1016/j. burns.2007.07.014 wang, l., hu, c., and shao, l. (2017). the antimicrobial activity of nanoparticles: present situation and prospects for the future. int. j. nanomed. 12, 1227–1249. doi:10.2147/ijn.s121956 wei, l., lu, j., xu, h., patel, a., chen, z. s., and chen, g. (2015). silver nanoparticles: synthesis, properties, and therapeutic applications. drug discov. today 20, 595–601. doi: 0.1016/j.drudis.2014.11.014 wu, b., huang, r., sahu, m., feng, x., biswas, p., and tang, y. j. (2010). bacterial responses to cudoped tio(2) nanoparticles. sci. zaidi, s., misba, l., and khan, a. u. (2017). nano-therapeutics: a revolution in infection control in post antibiotic era. nanomedicine 13, 2281–2301. doi:10.1016/j.nano.2017.06.015 zazo, h., colino, c. i., and lanao, j. m. (2016). current applications of nanoparticles in infectious diseases. j. control. release 224, 86–102. doi:10.1016/j.jconrel.2016.01.008 zhang, l., pornpattananangku, d., hu, c. m., and huang, c. m. (2010). development of nanoparticles for antimicrobial drug delivery. curr. med. chem. 17, 585–594. doi:10.2174/092986710790416290 zhao, y., and jiang, x. (2013). multiple strategies to activate gold nanoparticles as antibiotics. nanoscale 5, 8340–8350. doi:10.1039/c3nr01990j. mohammadd farhan khan1,2, akhter h. ansari1, m. hameedullah1, ejaz ahmad3,fohad mabood husain4,5, qamar zia6,7, umair baig8, mohd rehan zaheer2, mohammad mezbaul alam9, abu mustafa khan10, zeid a. alothman9, iqbal ahmad4, ghulam md ashraf11 & gjumrakch aliev12,13,14 vo van giau seong soo a an john hulme department of bionano technology, gachon bionano research institute, gachon university, seongnam-si, gyeonggi-do, south korea. lungu b, ricke sc, johnson mg.growth, survival, proliferation and pathogenesis of listeria monocytogenes under low oxygen or anaerobic conditions: a review. anaerobe. 2009;15(1–2):7–17. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 21 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe audoly g, fenollar f, lagier jc, lepidi h, raoult d. deglycosylation of tropheryma whipplei biofilm and discrepancies between diagnostic results during whipple’s disease progression. sci rep. 2016;6(1):23883. kim es, kim hb, kim g, et al; korea infectious diseases (kind) study group. clinical and epidemiological factors associated with methicillin resistance in community-onset invasive staphylococcus aureus infections: prospective multicenter cross-sectional study in korea. plos one. 2014;9(12):e114127. buchan bw, ledeboer na. emerging technologies for the clinical microbiology laboratory. clin microbiol rev. 2014;27(4):783–822. 14. cohen j, vincent jl, adhikari nk, et al. sepsis: a roadmap for future research. lancet infect dis. 2015;15(5):581–614. lafleur lk, bishop jd, heiniger ek, et al. a rapid, instrument-free, sample-to-result nucleic acid amplification test. lab chip. 2016;16(19):3777–3787. doyle mp, loneragan gh, scott hm, singer rs. antimicrobial resistance: challenges and perspectives. compr rev food sci food saf. 2013;12(2):234–248. winnicka k, wroblewska m, wieczorek p, sacha pt, tryniszewska ea. the effect of pamam dendrimers on the antibacterial activity of antibiotics with different water solubility. molecules. 2013; 18(7):8607– 8617. gao w, thamphiwatana s, angsantikul p, zhang l. nanoparticle approaches against bacterial infections. wiley interdiscip rev nanomed nanobiotechnol. 2014;6(6):532–547. hulme j. recent advances in the detection of methicillin resistant staphylococcus aureus (mrsa). biochip j. 2017;11(2):89–100. [59]. xiong mh, bao y, yang xz, zhu yh, wang j. delivery of antibiotics with polymeric particles. adv drug deliv rev. 2014;78:63–76. [60]. mitra rn, shome a, paul p, das pk. antimicrobial activity, biocompatibility and hydrogelation ability of dipeptide-based amphiphiles. org biomol chem. 2009;7(1):94–102. [61]. radovic-moreno af, lu tk, puscasu va, yoon cj, langer r, farokhzad oc. surface charge-switching polymeric nanoparticles for bacterial cell wall-targeted delivery of antibiotics. acs nano. 2012;6(5): 4279–4287. [62]. cao b, xiao f, xing d, hu x. polyprodrug antimicrobials: remarkable membrane damage and concurrent drug release to combat antibiotic resistance of methicillin-resistant staphylococcus aureus. small. 2018;14(41):e1802008. [63]. liu p, xu g, pranantyo d, xu lq, neoh k-g, kang e-t. ph-sensitive zwitterionic polymer as an antimicrobial agent with effective bacterial targeting. acs biomater sci eng. 2018;4(1):40–46. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 22 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe [64]. mankoci s, kaiser rl, sahai n, barton ha, joy a. bactericidal peptidomimetic polyurethanes with remarkable selectivity against escherichia coli. acs biomater sci eng. 2017;3(10):2588–2597. [65]. jadhav m, kalhapure rs, rambharose s, et al. novel lipids with three c18-fatty acid chains and an amino acid head group for ph-responsive and sustained antibiotic delivery. chem phys lipids. 2018;212:12–25. [66]. chu l, gao h, cheng t, et al. a charge-adaptive nanosystem for prolonged and enhanced in vivo antibiotic delivery. chem commun (camb). 2016;52(37):6265–6268. [67]. gillies er, fréchet jm. ph-responsive copolymer assemblies for controlled release of doxorubicin. bioconjug chem. 2005;16(2):361–368. [68]. kalhapure rs, sikwal dr, rambharose s, et al. enhancing targeted antibiotic therapy via ph responsive solid lipid nanoparticles from an acid cleavable lipid. nanomedicine. 2017;13(6):2067–2077. [69]. wang j, byrne jd, napier me, desimone jm. more effective nanomedicines through particle design. small. 2011;7(14):1919–1931. [70]. hejazi r, amiji m. stomach-specific anti-h. pylori therapy; part iii: effect of chitosan microspheres crosslinking on the gastric residence and local tetracycline concentrations in fasted gerbils. int j pharm. 2004;272(1–2):99–108. [71]. jing zw, jia yy, wan n, et al. design and evaluation of novel ph-sensitive ureido-conjugated chitosan/tpp nanoparticles targeted to helicobacter pylori. biomaterials. 2016;84:276–285. [72]. luo m, jia yy, jing zw, et al. construction and optimization of ph-sensitive nanoparticle delivery system containing plga and uccs-2 for targeted treatment of helicobacter pylori. colloids surf b biointerfaces. 2018;164:11–19. [74]. khutoryanskiy vv. beyond pegylation: alternative surface-modification of nanoparticles with mucusinert biomaterials. adv drug deliv rev. 2018;124:140–149. [75]. hayden sc, zhao g, saha k, et al. aggregation and interaction of cationic nanoparticles on bacterial surfaces. j am chem soc. 2012;134(16):6920–6923. [76]. westmeier d, posselt g, hahlbrock a, et al. nanoparticle binding attenuates the pathobiology of gastric cancer-associated helicobacter pylori. nanoscale. 2018;10(3):1453–1463. [77]. yu h, guo c, feng b, et al. triple-layered ph-responsive micelleplexes loaded with sirna and cisplatin prodrug for nf-kappa b targeted treatment of metastatic breast cancer. theranostics. 2016;6(1): 14– 27. [78]. rahme lg, stevens ej, wolfort sf, shao j, tompkins rg, ausubel fm. common virulence factors for bacterial pathogenicity in plants and animals. science. 1995;268(5219):1899–1902. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 23 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe [79]. su y, zhao l, meng f, wang q, yao y, luo j. silver nanoparticles decorated lipase-sensitive polyurethane micelles for on-demand release of silver nanoparticles. colloids surf b biointerfaces. 2017;152:238–244. [80]. chen yl, zhu s, zhang l, et al. smart conjugated polymer nanocarrier for healthy weight loss by negative feedback regulation of lipase activity. nanoscale. 2016;8(6):3368–3375. [81]xu l, he c, hui l, et al. bactericidal dendritic polycation cloaked with stealth material via lipasesensitive intersegment acquires neutral surface charge without losing membrane-disruptive activity. acs appl mater interfaces. 2015;7(50):27602–27607. [82]. yang s, han x, yang y, et al. bacteria-targeting nanoparticles with microenvironment-responsive antibiotic release to eliminate intracellular staphylococcus aureus and associated infection. acs appl mater interfaces. 2018;10(17):14299–14311. [83]. rezaee r, talebreza a, ziari k, behnod v, emampour bfs. distribution of virulence factors and antimicrobial resistance properties of uropathogenic escherichia coli isolated from diabetic and healthy males suffered from urinary tract infections. biosci biotechnol res asia. 2016;13(2):931–937. [84]. lim ym, de groof ajc, bhattacharjee mk, figurski dh, schon ea. bacterial conjugation in the cytoplasm of mouse cells. infect immun. 2008;76(11):5110–5119. [85]. marshall tg, lee re, marshall fe. common angiotensin receptor blockers may directly modulate the immune system via vdr, ppar and ccr2b. theor biol med model. 2006;3(1):1. [86]. pires-lapa m, carvalho-sousa c, cecon e, fernandes p, markus r. β-adrenoceptors trigger melatonin synthesis in phagocytes. int j mol sci. 2018;19(8):e2182. [87]. proal ad, albert pj, marshall tg, blaney gp, lindseth ia. immunostimulation in the treatment for chronic fatigue syndrome/myalgic encephalomyelitis. immunol res. 2013;56(2–3):398–412. [88]. aksungur p, demirbilek m, denkbaş eb, vandervoort j, ludwig a, unlü n. development and characterization of cyclosporine a loaded nanoparticles for ocular drug delivery: cellular toxicity, uptake, and kinetic studies. j control release. 2011;151(3):286–294. [89] mohammadi g, nokhodchi a, barzegar-jalali m, et al. physicochemical and anti-bacterial performance characterization of clarithromycin nanoparticles as colloidal drug delivery system. colloids surf b biointerfaces. 2011;88(1):39–44. [90]. giannavola c, bucolo c, maltese a, et al. influence of preparation conditions on acyclovir-loaded polyd,l-lactic acid nanospheres and effect of peg coating on ocular drug bioavailability. pharm res. 2003;20(4):584–590. [91]. couvreur p, fattal e, alphandary h, puisieux f, andremont a. intracellular targeting of antibiotics by means of biodegradable nanoparticles. j control release. 1992;19(1–3):259–267. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 24 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe [92]alka hasani1 · masoumeh madhi2 · pourya gholizadeh1 · javid shahbazi mojarrad3 · mohammad ahangarzadeh rezaee4 · gholamreza zarrini5 · hossein samadi kafil6. r. vazquez-muñozid1,2☯, a. meza-villezcas1,2☯, p. g. j. fournier2, e. soria-castro3, k. juarezmorenoid 1, a. l. gallego-herna´ndez4, n. bogdanchikova1, r. vazquez-duhalt1, a. huertasaqueroid madhuree kumari, shipra pandey, ved prakash giri, arpita bhattacharya, richa shukla, aradhana mishra, c.s. nautiyal. bizhan malaekeh-nikouei a, bibi sedigheh fazly bazzaz b,c, elaheh mirhadi a, amineh sadat tajani d, bahman khameneh . mayur kumar, anthony curtis and clare hoskins * school of pharmacy, institute of science and technology for medicine, keele university, keele, staffordshire st5 6db, uk; w2v11@students.keele.ac.uk (m.k.); a.d.m.curtis@keele.ac.uk (a.c.) palmer, j.; flint, s.; brooks, j.: bacterial cell attachment, the beginning of a biofilm. journal of industrial microbiology & biotechnology 2007, 34, 577-588. davey, m. e.; o'toole, g. a.: microbial biofilms: from ecology to molecular genetics. microbiology and molecular biology reviews 2000, 64, 847-867. donlan, r. m.: biofilm formation: a clinically relevant microbiological process. clinical infectious diseases 2001, 33, 1387-1392. arciola, c. r.; campoccia, d.; speziale, p.; montanaro, l.; costerton, j. w.: biofilm formation in staphylococcus implant infections. a review of molecular mechanisms and implications for biofilmresistant materials. biomaterials 2012, 33, 5967-5982. bogino, p. c.; oliva, m. d. l. m.; sorroche, f. g.; giordano, w.: the role of bacterial biofilms and surface components in plantbacterial associations. international journal of molecular sciences 2013, 14, 1583815859. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 3; may-june 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 1 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe empowering student-athletes: a holistic approach to mentorship john a. smith, ph.d. coppin state university, baltimore, maryland abstract: coppin state university, supported by an ncaa grant, has made significant strides in improving the academic success and graduation rates of its intercollegiate athletes. this initiative has resulted in a commendable 75% graduation rate, a notable achievement considering the historical challenges faced by athletes at historically black colleges and universities (hbcus). in addition to academic success, the university's health and health education faculty have taken a holistic approach to mentor selected intercollegiate athletes, particularly those in their first and second years. this initiative focuses on enhancing the athletes' overall well-being, recognizing that the demands on them often surpass those of their non-athletic peers. one such challenge involves countering the pervasive "dumb jock" stereotype, which can lead to negative perceptions from faculty, staff, and fellow students. this comprehensive approach aims to empower intercollegiate athletes to effectively manage the unique pressures they face during their college careers. keywords: ncaa grant, intercollegiate athletes, academic success, graduation rates, holistic mentorship, "dumb jock" stereotype introduction the national collegiate athletic association (ncaa) awarded coppin state university in baltimore, maryland a grant to accelerate academic success within the university’s athletic program. the grant was awarded in 2012 and totals $900,000 over three years. although the graduation rates of intercollegiate athletes at historically black colleges and universities (hbcus) have been as low as 49% (hosick, 2013; sander, 2007; and melendez, 2006), the current intercollegiate athlete graduation rate at coppin state university has climbed to 75% thanks to a philosophy that emphasizes graduating over remaining eligible and graduating in four years. building on the academic successes of the coppin state university athletic department, coppin state university health and health education faculty developed an initiative with selected intercollegiate athletes to holistically mentor them by focusing on aspects of their overall health and well-being, with a primary focus on first and second year intercollegiate athletes. according to stone (2012), far more demands are placed on intercollegiate athletes than are placed on their non athletic counterparts. developing a comprehensive understanding of these demands and how they play out in the mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 3; may-june 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 2 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe college classroom and then developing the means for intercollegiate athletes to effectively manage these demands will determine the success or failure of the intercollegiate athlete over the course of their college careers. stone states that one such demand with which many intercollegiate athletes must contend is the negativity of faculty, staff, and other students toward them that is characterized in the “dumb jock” stereotype. there is a very strong belief by students, faculty, and staff on college campuses that intercollegiate athletes are placed in majors that are “undemanding” and that they are placed in courses that are “dumbed down” and easy. stone suggests that intercollegiate athletes at hbcus are especially stigmatized and honestly believe the “dumb jock” label is applied to them even more so than to white intercollegiate athletes. stone cites research conducted in the 1960s in which it was revealed that these labels can result in negative relationships between intercollegiate athletes and professors and impair the intercollegiate athlete’s ability to perform well in the classroom setting. stone suggests that these types of behaviors toward intercollegiate athletes are very much reminiscent of the “stereotype threat.” the “stereotype threat” (steele and aronson, 1995), simply stated, is the anxiety one feels when they believe others have a negative opinion of them. steele and aronson suggest that this belief and the anxiety it can create can make one feel so anxious about their performance in the classroom and even the athletic arena that they will begin to perform poorly in both areas. in preparing students for the rigors of college life, gabriel (2008) cites the philosophy and teaching principles of chickering and gamson (1987). those principles include “encouraging contacts between students and faculty, developing reciprocity and cooperation among students, and communicating high expectations.” gabriel also emphasizes the need to promote “deep learning” and rigor. this is particularly important for intercollegiate athletes at hbcus. gray (2008) conducted a research study on grade inflation to find “solutions to lapses in rigor” on college campuses and found that since the 1960s grades have continued to increase while student understanding of college level subject matter has decreased. for example, gray cites denton and henson (1979) who posit that the percentage of a’s increased from 16% to 34% from the 1960s to the 1970s while the number of c grades was cut in half raising a c+ to a b. gray suggests that professors inflate grades for any number of reasons including keeping intercollegiate athletes eligible. when coupled with the fact that many intercollegiate athletes, especially at hbcus, are already unprepared for college, gabriel suggests that they lack even the basic resources to succeed in the college classroom and this lack creates a climate of stress. pfister (2004) posits that faculty mentoring programs that focus on first year intercollegiate athletes reduce the perceived stress level of the intercollegiate athlete and contribute positively to their social support systems. coppin state’s health and health education faculty began mentoring selected first and second year intercollegiate athletes in weekly sessions where a variety of concerns and issues are discussed. according to pfister, programs such as these are of great benefit to students who are attempting to transition to college life and go a long way to building and maintaining success in the classroom. pfister found that intercollegiate athletes who were mentored by faculty felt they experienced more social support than from other non-faculty sources. according to pfister, the ncaa actually encourages its member institutions to participate in its “challenging athlete’s minds for personal success” (champs) program. one of the major components of the champs program is to reduce the mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 3; may-june 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 3 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe “transitional stress” that many intercollegiate athletes experience as they transition from high school to college life. in the weekly mentoring sessions, coppin state university athletes are encouraged to create and foster better relationships with non-athletes and with athletes in different sports. this is primarily accomplished through the development of study partners. sherbume (2009) states that “little research has been conducted concerning how intercollegiate athlete’s participation in athletics affects their social development.” according to sherbume, intercollegiate athletes spend more time socializing with their teammates than with other athletes or with nonathletes and when surveyed a significant number (86.4%) of the surveyed intercollegiate athletes stated that personal relationships affected their athletic performance either negatively or positively depending on the negativity or positivity of the relationship. sherbume also noted that in classroom environments, first year intercollegiate athletes almost always sat among their teammates rather than choosing seating arrangements that foster the development of expanded social interactions. al-qaisy (2010) conducted a research study to ascertain the effects of gender and adjustment to college life among first year college students and found that while many students are excited about leaving home and attending college, they are quickly disappointed by all of the demands placed on them. many first and second year college students find that they must make many adult decisions that they are not prepared to make. al-qaisy cites a study by the national center for educational statistics that found that a third of first year college students leave college after their first year, but al-qaisy also found that first year female college students tended to adjust better to college life than did first year male college students. pfister (2004) suggests that “transitional stress” can be experienced by intercollegiate athletes when transitioning from high school to college life and this stress can sometimes lead to depression. weigard, cohen, and merenstein (2013) found significantly high levels of depression among current intercollegiate athletes when compared to former intercollegiate athletes. in their surveys, weigard et al. found that about 17% of the surveyed intercollegiate athletes exhibited many symptoms of depression. weigard et al. suggest that the added pressure of competition, training, and college level coursework can contribute to collegiate level athletic depression. another major topic of the weekly mentoring sessions focuses on sleep and sleep deprivation. dormitory and oncampus college life is not always conducive to establishing and maintaining healthy sleep patterns. a link was found between depression, stress, and sleep patterns by lund, reider, whiting, and prichard (2010) who state that between 20% to nearly 70% of the college students surveyed were kept awake all night at least once per week as a result of stress. it was further reported that 12% of these poor sleepers miss class or fall asleep in class as many as three times per month. wells and vaughn (2012) state that the solution to sleep deprivation problems should begin by promoting education and awareness of the problem on the part of educators and educational institutions. according to maas & davis (2013), although most individuals presume they are getting adequate amounts of sleep, brain wave studies suggest that nearly 70% of the population does not get the recommended daily requirement of sleep. keating (2012) postulates that just as a lack of sleep can make an intercollegiate athlete perform worst, more sleep (not just adequate sleep) can actually make an intercollegiate athlete perform better. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 3; may-june 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 4 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe keating cites research that was conducted over the course of three seasons that found that after increasing their daily rates of sleep to 10 hours per night, intercollegiate athletes in a wide variety of sports dramatically improved their athletic performance. trockel, barnes, and egget (2000) conducted a survey of college students to determine what health behaviors and variables affected grade point averages (gpa) and found that later wake-up times translated into lower gpas suggesting the benefit of earlier bedtimes. murdock (2013) reports that there is a direct link between texting and poor sleep habits. murdock states that these findings are particularly valuable given the sleep problems that first year college students already experience and according to murdock these findings also support previous research on the association of cell phone use and sleep problems. mitru, millrood, and mateika (2002) posit that although the need for quality sleep increases as one continues to age, many adolescents and young adults are not getting nearly enough sleep and this lack of sleep is affecting their ability to process information and even form and develop positive peer relationships. more than 800 college students participated in a study that included the sleep quality index and the national college health risk survey (centers for disease control) and it was found that the risk of suicide, smoking and alcohol use, and fighting are linked to poor sleep habits (vail-smith, felts, and becker, 2009). according to wells and vaughn (2012), the stop-bang questionnaire is a useful tool in screening for sleep problems. the acronym stop-bang is the abbreviation for snoring, tiredness/sleepiness/fatigue, observed apnea, and p bp (>140-90 rx or no). the “p” stands for pressure, meaning blood pressure. the bang acronym stands for body mass index, age, neck size, and gender. the stop-bang instrument was developed by chung, yegneswaran, liao, chung, vairavanathan, islam khajehdehi, and shapiro (2008). a third major topic of discussion in the weekly mentoring sessions pertains to nutrition, vitamins, and eating habits. dunn, turner, and denny (2007) suggest that while many of the intercollegiate athletes in their study had relatively good attitudes concerning nutrition and healthy eating, their overall nutritional knowledge was low. willis, peterson, and larson-meyer (2008) posit that in intercollegiate athletes as well as in the general population, there exists a “surprisingly high prevalence of vitamin d insufficiency.” willis et al. suggest that this vitamin deficiency can negatively affect an intercollegiate athlete’s sport performance. vitamin d helps the body absorb calcium and calcium is known to be an important nutrient in the development of strong bones and teeth. as a matter of fact, milk is actually fortified with vitamin d. however, at least two studies reported in the british medical journal (theodoratou, e., tzoulaki, i., zgaga, l., and loannidis, j, 2014; chowdhury, r., kunutsor, s., vitezova, a., oliver-williams, c., kiefte-de-jong, j. et al. 2014) suggest that not enough is known about vitamin d to draw any conclusions as to its beneficial qualities or lack thereof. in the first study, it was found that only about ten of the more than one hundred and thirty studies on vitamin d could conclusively link vitamin d to any healthy outcomes. hoch, papanek, szabo, widlansky, schimke and gutterman (2011) in studies of female intercollegiate athletes found that most female intercollegiate athletes lack enough vitamins in their systems to safeguard them from losses of bone density and this lack could even result in the absence of menstrual periods or an increase in mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 3; may-june 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 5 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe menstrual dysfunction. the relationship of poor eating habits, menstrual dysfunction, and low bone density in women is known as the “female triad.” only about 60% of all university athletic programs nationwide conduct comprehensive medical exams and full medical histories of their intercollegiate athletes and when they do, it is only among first year intercollegiate athletes according to hoch et al. azagba, langille, and asbridge (2014) state that energy drinks, long a staple among athletes, are actually linked to poor mental health functioning and the propensity toward substance abuse. these energy drinks can also impair sleep, can cause nervousness and nausea, and can negatively affect the cardiovascular system. according to oyebode, gordon-dseagu, walker, and mitchell (2014), eating a minimum of seven fruits and vegetables per day can reduce the risk of death by more than 40%. in a survey of more than 65,000 subjects, cancer death risks and heart disease death risks were lowered by as much as 30% as a result of a diet rich in fruits and vegetables. the study revealed that vegetables are more beneficial than fruits and fresh vegetables are more beneficial than canned or frozen. as a matter of fact, the study revealed that “canned and frozen fruit appeared to increase death rates by 17% per portion.” the study further revealed that consuming salads and snacking on fresh fruits adds another benefit and can reduce death risks by an additional 15%. in the weekly mentoring sessions, the diets and eating habits of the intercollegiate athletes are constantly evaluated and the athletes are constantly encouraged to focus on developing and maintaining good nutritional habits. in studies on subjective well-being conducted by pressman and cohen (2005) and diener and chan (2011) as well as others, it has been suggested that happier people are healthier people and healthier people are more successful and productive people. it should therefore follow that the academic/scholastic success rate of intercollegiate athletes should rise in direct correlation to increases in their overall health. references al-qaisy, l. (2010). adjustment of college freshmen: the importance of gender and place of residence. international journal of psychological studies. 2 (1). azagha, s., langille, d. and asbridge, m. (2014). an emerging adolescent health risk: caffeinated energy drink consumption patterns among high school athletes. preventive medicine, 62 (54). chickering, a. and gamson, z. (1987). the seven principles of good practice in undergraduate education. aahe bulletin. 39. 3-7. chowdhury, r., kunutsor, s., vitezova, a., oliver-williams, c., chowdhury, s., kiefte-dejong, j, et al (2014). vitamin d and risk of cause specific death: systematic review and meta-analysis of observational cohort and randomized intervention studies. british medical journal. 348 (2). chung, f., yegneswaran, b., liao, p., chung, s., vairavanathan, s., islam, s., khajehdehi, a., and shapiro, c. (2008). stop-bang questionnaire. anesthesiology. 108 (5): 812-21. denton, j. and henson, k. (1979). mastery learning and grade inflation. educational leadership. 32 (2). mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 3; may-june 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 6 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe diener, e. and chan, m. (2011). happy people live longer: subjective well-being contributes to health and longevity. health and well-being. 3 (1): 1-43. dunn, d., turner, l., and denny, g. (2007). nutrition knowledge and attitudes of college athletes. sport journal. (10) 4. gabriel, k. (2008). teaching unprepared students: strategies for promoting success and retention in higher education. stylus publishing. sterling, va. gray, h. (2008). i’m present, ‘a’ please: a case study examining grading issues in a recreation curriculum. schole: a journal of leisure studies and recreation education. 23. national recreation and park association. washington, dc. hoch, a., papanek, p., szabo, a., widlansky, m., schimke, j. and gutterman, d. (2011). association between the female athlete triad and endothelial dysfunction in dancers. clinical journal of sport medicine. 21 (2). hosick, m. (2013). ncaa.org. keating, p. (2012). sleeping giants. espn the magazine. klein, m. and pierce, j. (2009). parental care aids, but parental overprotection hinders, college adjustment. journal of college retention. 11 (2). lund, h., reider, b., whiting, a., and prichard, r. (2010). sleep patterns and predictors of disturbed sleep in a large population of college students. journal of adolescent health. 46 (2): 124-32. maas, j. & davis, h. (2013). sleep to win!: secrets to unlocking your athletic excellence in every sport. authorhouse. bloomington, in mitru, g., millrood, d., and mateika, j. (2002). the impact of sleep on learning and behavior in adolescents. teachers college record. 104 (4). murdock, k. (2013). texting while stressed: implications for students’ burnout, sleep, and well-being. psychology of popular media culture. 2 (4). oyebode, o., gordon-dseagu, v., walker, a., and mindell, j. (2014). fruit and vegetable consumption and allcause cancer and cvd mortality: analysis of health survey for england data. journal of epidemiol community health. pfister, v. (2004). effects of faculty and peer mentoring on perceived stress and social support of college students. graduate school theses dissertations. http://scholarcommons.usf.edu/etd /1195. pressman, s. and cohen, s. (2005). does positive affect influence health? psychological bulletin, 131, 925-971. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 3; may-june 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 7 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe sander, l. (2007). graduation rates of athletes outpace students at large. the chronicle of higher education. 54 (11). sherbume, s. (2009). college athletes’ perceptions about relational development, communication, and interpersonal competence. proquest dissertations and theses. steele, c. and aronson, j. (1995). stereotype threat and the intellectual test performance of african americans. journal of personal social psychology. 69 (5). stone, j. (2012). a hidden toxicity in the term “student-athlete”: stereotype threat for athletes in the college classroom. wake forest journal of law and policy. wake forest university, nc. theodoratou, e., tzoulaki, i., zgaga, l., and loannidis, j. (2014). vitamin d and multiple health outcomes: umbrella review of systematic reviews and meta-analyses of observational studies and randomized trials. british medical journal. 348 (2). trockel, m., barnes, m., and egget, d. (2000). health related variables and academic performance among firstyear college students: implications for sleep and other behaviors. journal of american college health. 49 (3). vail-smith, k., felts, w., and becker, c. (2009). relationship between sleep quality and health risk behaviors in undergraduate college students. college student journal. 43 (3). weigand, s., cohen, j., & merenstein, d. (2013). susceptibility for depression in current and retired student athletes. sports health 5 (3): 263-6. wells, m. and vaughn, b. (2012). poor sleep challenging the health of a nation. neurodiagnostic journal. 52 (3). willis, k., peterson, n., and larson-meyer, d. (2008). should we be concerned about the vitamin d status of athletes? international journal of sport nutrition and exercise metabolism. 18 (2). mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 35 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe a snapshot of sport management faculty publications and presentations in the united states and canada john david smith louisiana state university abstract: the field of sport management has seen tremendous growth over the past four decades. however, it is still considered a young discipline compared to business schools. this paper reviews the discussions of past dr. earle f. zeigler award winners on the credibility, status, legitimacy, and identity of the sport management field. the paper also discusses the concerns of past award winners and their recommendations for the future of the field. keywords: sport management, dr. earle f. zeigler award, credibility, status, legitimacy,identity 1. introduction over the past four decades, the academic field of sport management has seen tremendous growth around the world. since the inception of the first sport management master’s degree offering at ohio university in 1966 (stier, 1993), institutions that offer sport management degrees (i.e., undergraduate and/or graduate degrees) have grown from 44 programs in 1982 (lewis, 1982; parkhouse, 1987) to 211 programs in 1993 (weese, 1995), to a recent level of 462 sport management programs in the united states, 17 sport management programs in canada, 26 in europe, 18 in asia and 13 in australia (nassm, 2015a). while this growth has occurred in a short amount of time, the sport management field is still considered a young discipline compared to the likes of business schools around north america and the rest of the world (chalip, 2006; doherty, 2012; mahony & pitts, 1998). beginning in the late 1980s and continuing today, scholars used platforms such as the north american society for sport management (nassm) conference and the journal of sport management to discuss topical issues. during the nassm annual conference, the dr. earle f. zeigler award winner often offers feedback about their experiences to the nassm constituents in attendance as well as through the subsequent publication in the journal of sport management. award winners often focus their discussions on broad areas such as credibility, status, legitimacy, and identity. in addition to offering recommendations for the future of the sport management field, award winners also express their concerns. areas of concern such as the need to shift to a broad-based “domain” of sport management (slack, 1996, p. 97), and the call to examine all aspects that affect the overall credibility of the sport management field (pitts, 2001) were addressed in the past. further concerns of past award winners critically reviewed “teaching, practice and research” (frisby, 2005, p. 1) within the field in addition to the opportunities for sport management to solidify its own identity (chalip, 2006). it was pitts’ article (2001) and her zeigler award lecture that drives the current research. her primary concern was related to the “the state of the field” (p. 8). as a relatively young field, sport management has improved upon mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 36 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe its proverbial reputation (chalip, 2006; parkhouse & pitts, 2001; pitts, 2001) year after year. these improvements have not been easy as the field of sport management is interdisciplinary in its own right and does not “fit neatly” as a single discipline like sociology or law (shilbury & rentschler, 2007, p. 31). with certain identity struggles, it was pitts (2001) that suggested the need to hold those in the field of sport management accountable through areas such as assessment and to be critical of their work and future work to build upon the growth of the field. critical analysis of organizations can be the lifeblood for improvement. according to weese (1995) and cuneen and parks (1997), the nassm contingency should be continually evaluated to build upon the mission of the society to better the relationship between academics and practitioners. previous studies on the improvements of sport management programs previously focused on the assessment of topics such as sport management curriculum (desensi, kelley, blanton, & beitel, 1990; eagleman & mcnary, 2010; hardy, 1987; kelley, beitel, desensi, & blanton, 1994; parkhouse, 1987; petersen & pierce, 2009; floyd-jones, brooks, & mak, 2008) and faculty preparation and qualifications (de haan, 2011; mahony, mondello, hums, & judd, 2004; nite & singer, 2013). the purpose of the current study fills a gap in the assessment literature through the exploration of sport management faculty career profile characteristics of journal publications and conference presentations to continue the efforts of assessment within the field. a population of 479 nassm documented sport management programs in the united states and canada were reviewed for sport management faculty career profile characteristics. these characteristics were previously deemed by several scholars as necessary toward possibilities of enhancing the growth and credibility of the academic field of sport management (costa, 2005; doherty, 2012; pitts, 2001; slack, 1991, 1996). this type of assessment provides a unique look at a large component of what academics do to maintain standards institutions and faculty set for them that may translate into the field’s overall growth. therefore, the research question related to this purpose becomes what journal publications and conference presentations are represented by sport management faculty in north america? results from this type of research can prove beneficial in several ways. first, it adds to the sport management assessment literature to give a distinctive first look at where academics are in relation to their publications and conference presentations. next, sport management faculty may begin or continue to focus their efforts towards a variety of conferences or journals to broaden their own career domain. additionally, this research is beneficial for the leaders of the sport management field (i.e., nassm executive committee) as they may accumulate additional ideas for future conference and journal themes or additional partnerships with organizations not previously considered. the downside of conducting this research was there are no comparable studies related to sport management faculty career characteristics. the ability to see if the field is showing improvements and declines or make predictions compared to previous and leans on the side of futility without previous empirical evidence. this paper is organized into several parts beginning with a literature review regarding the variance of perspectives areas such as credibility have in academia. the credibility section below was deemed necessary for this research as subjective credibility discussions often stem from assessment literature but rarely review the intentions of credibility holistically. since the current research is the first of its kind, this same literature review includes an mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 37 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe overview of several forms of previous sport management field assessment research. next, the methods are discussed expanding on the data gathering and analysis procedures. this is followed by the results of sport management faculty career characteristics and discussion of these findings, concluding with limitations and recommendations for future research. 2.1 literature review several of the past and present trailblazers of the sport management field argue that assessment is critical to its growth. these same researchers often use the term credibility to describe aspects of this growth, however, credibility is difficult to measure, if at all, and at the least is a subjective term. regardless of attempting to measure credibility, (which the current research is not) recognizing areas within academia that should be assessed must be considered paramount. improving the idea of credibility (with or without measurement), as doherty (2012) suggests below, within those directly related to the field of sport management academia is necessary. “we should think outside the lines: critique what we each have done to date, and reflect on what else we might do; and, look across our respective units, faculties and universities, and consider what other disciplines and particular research projects resonate with our own.” (p. 8) the current research does not suggest that if assessment occurs and improvements are made from such an assessment, that credibility would improve. the current research simply highlights credibility as a necessary component to the assessment discussion. 2.2 credibility the concept of credibility stems from several theoretical perspectives that include legitimacy, status, and reputation. according to suchman (1995) legitimacy is “a generalized perception or assumption that the actions of an entity are desirable, proper, or appropriate within some socially constructed system of norms, values, beliefs, and definitions” (p. 574). washington and zajac (2005) suggested that status relates to the social aspects developed through relationships and those relationships develop sequential organization. deephouse and suchman (2008) defined reputation as “a generalized expectation about a firm’s future behaviour or performance based on collective perceptions (either direct or, more often, vicarious) of past behaviour or performance” (p. 5960). it is apparent here that credibility is a multi-level concept that refers to a source of reliable information (bocking, 2004), in addition to the expertise and trustworthiness of such information (hovland, janis, & kelly, 1953; metzger, 2007). it can be seen by the above definitions that through establishing credibility for an organization, concepts such as legitimacy, status, and reputation follow. “organizations that are of high quality can develop reputations for quality over time, which can then serve a useful signaling function when other forms of direct and credible information on quality are lacking” (washington & zajac, 2005, p. 283). efforts to improve credibility within the sport management field were recognized by several scholars through assessment of (i) education quality and accreditation (fielding, pitts, & miller, 1991), (ii) increased specialization in sport management (mahony & pitts, 1998), (iii) consideration of where sport management programs should be housed within a college or university (chalip, 2006), and the (iv) improvement of interdisciplinary research within the field (doherty, 2012). while these and other areas of assessment are valid towards improving perceptions of the sport management field as a whole, bridging the gap between assessment and credibility, and mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 38 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe understanding that any assessment is another step towards credibility, begins with the ambiguity of the term credibility. addressing credibility here is important, as numerous sport management researchers have used the term in the past to describe the state of the field. parkhouse (1987) referred to the term “credibility” (p. 94) with regard to the future of the industry where she expressed meaningful concerns about the quality of the sport management curricula. boucher (1998) argued that the sport management field’s credibility could be lost in academic circles through the selection of research problems that are self-serving as opposed to having purposeful applications for practicing sport managers. these views are slightly limited in nature as they each relate to only one aspect of the sport management field. cutting through the ambiguity of understanding credibility, pitts (2001) provided a holistic definition of credibility described as the “quality, accountability, and credentials” (p. 7) among the field. pitts (2001) suggested that areas in which to improve credibility lie among criteria such as guidelines, curriculum and accreditation, and faculty preparation and qualifications. she goes on to designate other areas necessary to analyze and boost credibility. pitts (2001) stated that to “attain and sustain” (p. 7) credibility, its members must measure and assess its merit in several areas including conference representation, industry literature, and scholarly association. by establishing a holistic definition rather than a varied definition of credibility assumed by previous scholars, the field of sport management can continue to assess itself with a clear level of critical analysis. this critical analysis was shown by costa (2005) through her indications of credibility enhancement using a delphi study by enlisting 17 leading sport management scholars to provide their professional opinions regarding the status and future of the field. costa further explained that improvements to sport management program’s infrastructure (e.g., journal publication acceptance) would help attain increased status. the term infrastructure can be linked to the term credibility, as costa (2005) suggested “the status of the field is related to the field’s infrastructure, particularly university programs, recognition and reward systems, and publication outlets” (p. 130). while pitts (2001) and costa (2005) called for credibility improvements among several infrastructural areas, others have proclaimed an upgrade in areas such as research design (frisby, 2005; olafson, 1990) and in an accreditation process (boucher, 1998; floydjones et al., 2008; mahoney & pitts, 1998). however, it was slack (1991, 1996) who envisioned the best intentions of success for the field by suggesting that a broadening of practitioner and researcher endeavors are necessary to be influential amongst all academics, not simply sport management academics. however, establishing ourselves as the experts in the management of sport will not only require us to broaden the range of organizations that we study, it will also necessitate a considerable change in the theoretical bases or our work, a broadening of the places we publish and present our research, a re-examination of the topics we study and the adoption of new approaches to doing research. (slack, 1996, p. 98-99) it was this quote by slack (1996) in addition to pitts’ (2001) definition of credibility that drives the current research to expand the assessment of the sport management field by studying its members. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 39 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 2.3 sport management program assessment the importance of academic program assessment is to determine whether the program has merit (cuneen, 2004). assessment in sport management previously focused on areas such as sport management curricula and the preparation for becoming a sport management faculty member. establishing quality curriculum for any academic program, including sport management, is a primary tenant for the united states department of education accreditation process. the common goal for colleges and universities must be “to ensure that education provided by institutions of higher education meets acceptable levels of quality” (us department of education, 2014, n.p.). in 1986, the national association for sports and physical activity (naspe) developed a special committee to identify and develop guidelines for college and university programs that offered sports and sport management classes. shortly thereafter, the naspe partnered with nassm to develop an accreditation process strictly for sport management programs (eagleman & mcnary, 2010). between 1990 and 2009, numerous sport management scholars suggested or directly recommended the necessity to have an accreditation body for sport management (c.f., fielding et al., 1991; mahoney et al, 2004; zakrajsek, 1993). currently, the commission on sport management accreditation (cosma) is the lone accreditation body for sport management academia. as of march 2015, cosma has accredited 42 sport management programs with 14 programs in the candidacy stages (nassm newsletter, 2015). with the nassm and cosma membership base continuing to expand, continued assessment of the sport management field is essential to properly manage such growth (amis & silk, 2005; chalip, 2006; cuneen & parks, 1997; pitts, 2001). 2.4 curriculum assessment scholars have previously indicated that studies regarding assessment of sport management curriculum are limited (eagleman & mcnary, 2010). over the course of the last several decades, however, several important studies have assessed curriculum in an investigative manner. shortly after the establishment of nassm and the journal of sport management, parkhouse (1987) analyzed the status of curricula for 83 institutions with sport management programs. data was collected in the areas of undergraduate and graduate foundational and applicable sport management subject areas. her findings suggested that many of these sport management programs did not offer a consistent base for sport management course offerings. desensi, kelly, blanton, and beitel (1990) reviewed the perspectives of sport management constituents (e.g., employers, academics, and students) in developing curricula models to aid curricula developers and determine the appropriate course for a sport management program. similarly, fielding et al. (1991) reached out to 109 sport management programs in north america to collectively determine the characteristics of a quality program. although many responses were conflicting, results suggested that characteristics necessary for a quality sport management program revolved around the education of the instructors and the coursework offered to its students. more recent assessment of sport management curricula used a distinctive approach when petersen and pierce (2009) surveyed sport industry professionals (e.g., nfl, mlb, and the nba). the results from 32 surveys evenly collected from these professional sport associations indicated that a student’s field experience was most important mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 40 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe followed by legal aspects, ethics, management and leadership, marketing, economics, budget and finance, governance, and socio-cultural aspects. shortly thereafter, and using a quantitative content analysis methodology, eagleman and mcnary (2010) examined 227 undergraduate sport management programs using cosma guidelines as a means for the analysis. results concluded that curriculum offered among the sample sport management programs in the study was inconsistent and, in fact, the course offerings varied greatly. these results showed that many sport management programs were not meeting the academic standards (i.e., curriculum) related to career preparation requested by sport industry professionals. 2.5 faculty preparation sport management academics have long been concerned about their own development as teachers, researchers, and community builders. it was weese (1995) that broke the proverbial silence and called out sport management academics to upgrade their own research agendas to meet the needs of a wider audience, such as the general business industry, rather than be limited to the sport industry. cuneen and parks (2001) added to this by suggesting that sport management faculty expand their own dialogue in relation to professional preparation. weese (2002) reiterated his own sentiments by strongly advocating the need for properly trained sport management faculty, as this need may not meet the demand of students in existing programs. he noted that sport management undergraduate and graduate programs would continue to expand with hurdles likely to follow without proper leadership. hurdles such as “under-employment” (p. 15) of students may occur without quality faculty to provide students with sound decision making skills and the ability to communicate effectively. he also referenced mondello, mahony, hums, and moorman (2002) and the importance of their study in which sport management search committee chairs were discouraged by the lack of qualified sport management candidates. weese’s previous concerns have spurred other studies related to the preparation of sport management faculty, including the mahony et al. (2004) review of 24 doctoral programs in north america. they directed their research towards gathering data on doctoral graduates produced each year, including the skills and qualities being developed during their programs. these results were then cross-referenced against sport management job qualifications advertised during the time of data collection. conclusions from this study suggested that doctoral programs place high emphasis on teaching and research; however, not all doctoral programs have sport management undergraduate programs, which limits the opportunity for doctoral candidates to hone their teaching abilities leading into their first years of academic teaching. 2.6 faculty profile research research is limited from the perspective of reviewing faculty profile characteristics. floyd-jones et al. (2008) did however provide an overview of 50 sport management programs responding to a survey consisting of infrastructure characteristics (c.f., costa, 2005) such as program profile (including program size, approval status, admittance requirements, and faculty/student ratio) and faculty profile (including adjunct faculty members, gender, ethnicity, terminal degrees). additional highlights of these results showed a lack of diversity (e.g., gender and ethnicity) among faculty, as well as employing faculty without a terminal degree. floyd-jones et al. (2008) did collect one specific faculty mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 41 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe career characteristic in research interests, but the results were unclear as to specific research interest topics, simply noting that 68.2% of respondents “had a strong research interest” (p. 87). the floyd-jones et al. study did offer a glimpse of conference results similar to the results found in this study in addition to faculty profile data, however, the authors offered limited direction toward other faculty characteristics. they found their respondents attended top sport management conferences of nassm and the american alliance for health, physical education, recreation and dance. floyd-jones and colleagues concluded their outline of sport management programs by offering recommendations for sport management programs in the area of hiring more females in addition to seeking out accreditation status. the present research assesses the sport management field faculty constituency and their career characteristics of journal publications and conference presentations. this research is timely as it adds to the existing literature of assessment from a distinct perspective and expands the discussion to enhance the growth and credibility of the field. “we must be vigilant in critically examining all that we have accomplished, make changes as needed, and push ourselves to grow” (pitts, 2001, p. 7). 3.1 method the current research was descriptive in nature. according to andrew, pedersen, and mcevoy (2011), descriptive research is appropriate when a study concentrates on “what is happening rather than on why it happens” (p. 8). slack (1991, 1996) and pitts (2001) call for sport management academics to broaden their career characteristics outlook focused the current research, but less is known about sport management faculty career characteristics such as journal publications and conference presentations. the data collected concentrated on faculty listed journal publications and conference presentations. the sport management faculty population was obtained via the nassm website by clicking on all represented sport management program links. all sport management programs in the united states and canada that offered a bachelor, masters, and ph.d., or a combination of these three types of degrees listed on the nassm website were reviewed for available faculty career characteristics. 3.2 data collection at the completion of data collection, nassm provided direct website links to 479 sport management programs (462 in the united states and 17 in canada). a list of college and university names was accompanied by a hyperlink that was associated with each institution on the nassm website. all functional links were utilized and reviewed. in the event a link did not work, a simple internet search was conducted for that sport management program’s main web page. from the nassm website a three-phase search process for sport management faculty profiles ensued. the three-phase search process for faculty journal publications and conference presentations. the nassm website served as a one-stop shop for many of the sport management programs around north america. one click here presented all fee paying sport management programs associated with nassm. this list of programs provided sport management main web pages offering direct links to aid in searching for faculty profiles, this was considered phase one of the data collection process. if a faculty list link was not found on the main sport management program website during the phase one process, phase two followed and the use of the main institution’s search engine was enacted with the key terms such as sport management, sport administration, mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 42 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe sport leadership and sport studies were inserted in the search bar. if a search did not produce a list of members of the sport management full-time faculty, the program was coded as ‘sport management full-time faculty not applicable’ in the main microsoft excel database. if the phase-two search produced only a sport management faculty name or list of names, the institution’s search function was used once again by searching each individual’s name for faculty profiles. this process was considered the third search phase. if this list did not produce career profiles, the individual(s) were calculated as part of the total faculty data set and no journal or conference data were calculated. if a curriculum vita was available it was considered a part of the faculty profile, collected as data, reviewed, and analyzed for this study. for the purpose of this study, conference presentation and journal publication data were collected through faculty member profiles or curriculum vita. faculty members with at least one conference presentation or one journal publication were counted (c.f. buchheit, collins, & reitenga, 2002; hasselback, reinstein, & schwan, 2000). all titles of each conference presentation and journal publication that were available on its program’s website (i.e., faculty profile or curriculum vitae) were collected and inputted into the master database for analysis. individuals with job title designation of adjunct faculty, instructor, or not labelled (<10) were not included in the data collection. during the data collection process it was determined that there was no way of knowing if a sport management faculty member did or did not have academic obligations at the time data were collected. to be consistent with the data collection process, if the faculty member was listed and data was available, all journal publication and conference presentation data were collected for that faculty member. for organizational purposes, microsoft excel was utilized for database management intentions to collect all sport management program website listed faculty member, conference presentations, and journal publication, if any. all entries of conference presentation and journal publication locations by a single faculty member were collected and entered into this database. one conference presentation listing was considered one frequency. one journal publication was also considered one frequency. once all data were collected for journals and conferences, a 0/1 coding process determined sport related and non-sport related conferences and journals to better understand the fields overall domain and interdisciplinary outlook. 3.3 data analysis content analysis was used to determine if a journal or conference had a sport or nonsport related aim and scope (denzin & lincoln, 2011). the published aim and scope of the conference website and journal website was analyzed in determining sport or non-sport related designation using sport and sport-related key word searches (e.g., athletics, physical activity, recreation, sport). a 0/1 coding process followed the content analysis phase to finalize sport and non-sport journals and conferences. determining non-sport related journals and conferences was considered new angles of sport management assessment called for by previous scholars (c.f., costa, 2005; floyd jones et al., 2008; mahony et al., 2004; pitts, 2001; slack, 1991, 1996) to assist in broad based growth of the academy. once all data were collected, the excel sorting function was used to itemize an alphabetical list of journal publication and conference presentation locations to easily view, count, and determine the total number of conferences and journals and the frequencies. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 43 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe similarly, hasselback et al. (2000) used a counting methodology to calculate and analyze publication records from a population of 3878 accounting faculty for promotion and tenure standards within the top-40 highest rated accounting journals in the industry. the authors noted that while counting articles did provide “objectivity and simplicity” (p. 81), however, the process was not as simple as it appeared. 4.1 results the intent of the current research was to review all nassm (united states and canada) recognized sport management programs websites and the faculty available within each of these programs during the 2013-2014 academic year. a comprehensive collection of data represented sport management faculty career characteristics in the areas of conference presentation locations and journal publication locations. the purpose of the current research was to explore the career characteristics of journal publications and conference presentations of sport management faculty the intention of becoming a baseline study for sport management faculty career characteristic research. at the time of data collection, there were 462 sport management programs represented on the nassm website from the united states and 17 sport management programs in canada bringing the total population for this study to 479. during the initial assessment of sport management programs in the united states, it was determined that 26 programs be omitted from data analysis phase of this project. of these 26 programs, 14 institutions were non-degree granting programs. the remaining 12 institutions were removed from analysis because they were strictly online sport management programs. online programs were removed due to the possibility that faculty for online sport management programs may also be faculty at other institutions. the removal of these programs was done to increase reliability and improve the accuracy of the results, bringing the sample size for the current study to 453. additionally, 67 or 13.9% of the sport management program population, did not have functioning links (e.g., “error 404 – page could not be found”) from the nassm website to their sport management website. in this event, additional search measures took place as described in the methods section. a total of 801 sport management faculty members were identified through the links via the nassm website. of these faculty members, 612 faculty members had a ph.d., 100 had a masters degree, six had only a bachelors degree and 83-faculty member’s level of degree earned was not found. further analysis noted that 442-sport management faculty did not have at least one conference presentation or one journal publication represented on their profile. it should also be noted here that 141 united states sport management programs and 6 sport management programs from canada had links to sport management program websites, but through the threestage search process, no sport management faculty representation was evident. a list of conference and journal frequencies is represented in table 1. a total of 4571 conference presentation frequencies were represented from the sample of sport management faculty. from this total, 4028 were designated as sport management related conferences and 543 were non-sport management related conferences. therefore, 88% of the conferences being presented by the faculty population had a sport focus and 12% had a non-sport conference focus. this was a 7.4 to 1 faculty sport to non-sport conference presentation ratio. this suggests that for approximately every seven sport related conference presentations by the north american nassm cohort; one non-sport related conference presentation was conducted. there were 665 different conferences represented. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 44 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe a total of 4903 journal publications were collected. from this total, 3706 were designated as sport management related journal publications and 1197 were non-sport management related journal publications. therefore, 74% of journal publications by the faculty population had a sport focus and 24% had a non-sport journal focus. this was 3.09 to 1 sport to non-sport journal publication ratio. this suggests that for every three sport related journal publications represented by the north american nassm cohort only one non-sport related journal article was published. there were 1008 different journal publications represented. tables 2 and 3 represent the 10 most frequently represented journal publications and conference presentations by the population for this research. table 1: sport management faculty conference presentation and journal publication frequency representation (n-801) frequency sport non sport representation sport to non-sport ratio percentage sport/nonsport conferences 4571 4028 543 665 7.4 to 1 88/12% journals 4903 3706 1197 1008 3.09 to 1 76/24% table 2: sport journal locations frequency non-sport journal locations frequency journal of sport management 335 sex roles 33 sport marketing quarterly 247 marketing management journal 20 international journal of sport management 224 cultural studies critical methodologies 19 research quarterly for exercise and sport 160 journal of african studies 15 sport management review 152 tourism management 15 international journal of sport management and marketing 99 advances in consumer research 12 journal of contemporary athletics 95 journal of applied marketing theory 12 journal of legal aspects of sport 75 journal of economics and business 12 journal of issues in intercollegiate sport 70 journal of business ethics 11 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 45 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe applied research in coaching and athletics annual 70 journal of urban affairs 11 table 3: sport conference locations frequency non-sport conference locations frequency north american society for sport management 1115 western economic association 28 sport marketing association 392 association of marketing theory & practice 22 america alliance for health, physical education, recreation, and dance 392 academy of management 13 college sport research institute 292 hawaii international on education 13 north american society for the sociology of sport 195 travel and tourism research association 13 sport and recreation law association 125 american marketing association 12 european association for sport management 96 international congress of qualitative inquiry 10 sport entertainment & venues tomorrow conference 59 forum on design management research and education 9 national recreation and park association 51 academy of marketing science 8 international conference on sport business and entertainment 49 national communication association 7 5.1 discussion and conclusion several decades have passed since the initial call to expand the focus of what the field of sport management can contribute to the greater sport management industry and society. several studies have successfully assessed areas of the sport management field, but less is known about direct faculty characteristics. the current research is evidence of several consistencies and future opportunities previous researchers such as slack (1991, 1996), pitts (2001) and others called for decades ago. however, without previous research related to sport management faculty profile characteristics, the current study offers baseline data that contributes to further interpretations of sport management assessment and adds to the existing discussion of future growth and credibility within the field. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 46 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe while the current research is a starting point for future assessment of sport management faculty characteristics there is no way to gather if the current results show that faculty journal publications and conference presentations show added legitimacy of the sport management field as a whole. the results appeared to have that those in sport management academia show a high comfort level with the context of sport with arguably slight limitations toward an interdisciplinary approach (c.f., doherty, 2012). this is noted with the larger sport to non-sport percentage and ratio toward conference presentations and journal publications. the results are not intended to present satisfactory progress toward growth or credibility, or present the good or the bad of the sport management academy at this time. simply put, this study lays the groundwork for future sport management career characteristic profile research. as previous management scholars suggested, assessing the career profile characteristics may indicate a form of enhancing credibility and with this the academy can continue to develop future trends toward credibility, status (washington & zajac, 2005), reputation (deephouse & suchman, 2008), and legitimacy (suchman, 1995). a tremendous amount of diversity was indicated through the data of journal publication and conference presentation locations accumulated. this gives indication of great effort toward an overall interdisciplinary research agenda (doherty, 2012) and a broadening of the sport management domain (slack, 1996). by these expanding perspectives of sport and non-sport conference presentations and journal publications, other fields such as political science or the technology industry (slack, 1996) may view the sport management academy differently. given the frequencies, percentages, and ratios noted in table 1, 2, and 3, the argument can be made that the current sport management faculty has established a fine threshold of credibility and other fields should take notice. moreover, to address the possibility of actual credibility measurement of the sport management field, qualitative and quantitative studies could be undertaken by requesting other disciplines (e.g., business or political science) to respond to their perceptions or credibility of the field. future research could embark on a delphi study (c.f. costa, 2005) to begin to respond to these types of queries. there were unexpected findings worth noting. first, 147 sport management programs were recognized by the nassm website, but during the three-phase search process there was no full-time sport management faculty found representing the program. while parkhouse (1987) noted that to be a verified sport management program it must offer sufficient curriculum to merit a minor or concentration, mondello et al. (2002) and mohoney et al. (2004) suggested that qualified faculty with a terminal degree within this field be among the qualifications for sport management programs. here, we do not know if there are qualified sports management faculty within these programs as data was not available. additionally, while the author understands that faculty have different journal publication and conference presentation requirements, it was surprising that 801 sport management faculty were found, 442 members of this population did not have record of at least one conference presentation or one journal publication. this is not to say that this portion of the population did not present at conferences or publish their research, the data were simply not available through the program websites. the percentages and ratio results were interesting in several ways. while previous research does not show quantitative data on sport management career characteristics, the author expected a higher percentages and ratios of journal publications and conference presentations. this anticipation was based on the literature review and mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 47 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe continued calls over the years for improvements in areas such broadening the sport management domain (slack, 1996), theoretical framework (c.f., doherty, 2013; frisby, 2005), providing continued assessment in the field (costa, 2005; floyd-jones, 2008; mahoney et al., 2004; parkhouse & pitts, 2001; weese, 2002), and interdisciplinary research (c.f., doherty, 2012; slack, 1996). one question that became evident to the researcher during the analysis of results phase was why were sport conference presentations more than double to that of sport journal publications? this could be that conference requirements are less stringent to that of journal publications (i.e., review process). also, the funding support for attending conferences could be discipline focused suggesting funds are only available to sport management faculty attending sport conferences. furthermore, once a faculty member presents at a sport conference a salami slice effect takes place (pfleegor, 2014), and through collaboration with colleagues a faculty member could develop several publications from a conference presentation idea (or vice versa) and send those manuscripts to non-sport journals or conferences. there was a significant amount of data collected for this study; however, limitations became apparent during and after data collection and analysis. profiles and curriculum vita appeared to not be regularly updated. furthermore, numerous faculty members had an abbreviated curriculum vitae listed with only selected conference presentations and selected publications. while all career characteristic data were collected, it was probable that abbreviated faculty journal and conference data did in fact affect the results. the author determined that the only way to alleviate the concern about reliability of abbreviated data was to not be selective and collect all data available on all sport management program faculty web pages. additional limitations came from collecting data from the nassm website. this site is for sport management programs that pay a fee to nassm to be a part of their website sport management program directory. there may be many more sport management programs in the united states and canada that chose not to pay this fee. other limitations arose throughout the data collection process that longitudinal data of when faculty presented and published their research would have been ideal. it was considered impossible to collect this longitudinal information, as dates did not always accompany listed conference and publication references. along these lines, it would also have proven beneficial to generate a standard deviation of conference presentations and journal publications between represented faculty members. this aspect would have shown where (i.e., yearly journal publication and conference presentation progress) these accomplishments were greatest and weakest among faculty through a regression analysis. additional limitations remain with the recent literature on sport management field assessment. while much of the literature review with the current research was relevant, it was quite dated and further analysis of similar topics should be an on-going process. additional limitations lie with the possibility of faculty using their institution’s websites to manage their career profiles. resources such as linked-in, research gate, or academia were not used as a part of the data collection process for this study and may be utilized by sport management academics and updated more often. finally, researchers such as slack (1996) and doherty (2012) suggested sport management academics should take more of an interdisciplinary approach towards their research presentations mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 48 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe and aim for publications. it was unknown if previous faculty submissions were rejected to non-sport conferences and journals, but then submitted to sport journals and vice versa. future research toward sport management faculty career characteristics could follow that of smith and washington (2013) where they collected athletic director detailed curriculum vita career path analysis. they found that athletic directors, while expected to have business experience to manage million dollar budgets, had minimal business experience. the current research could follow a similar line by showing sport management faculty career progression through academic and non-academic endeavors that may benefit the future assessment of faculty. other future research implications may be important to the credibility discussion in areas of combining sport management career characteristics and journal prestige assessment. in their evaluation of sport management journals, shilbury and rentschler (2007) evaluated and rated 13 sport management journals using four criteria: (i) journal prestige and contributions to the following areas (ii) theory, (iii) practice, and (iv) teaching. calling upon 45 senior sport management academics to use these criteria to evaluate these journals with the journal of sport management, sport management review and the sociology of sport journal receiving an ‘a’ letter grade. future research could use the current study’s existing data from table 2 and 3 and cross-reference it with shilbury and rentschler’s (2007) work to not only add to the credibility conversation, but also discuss the field’s legitimacy and status with other fields. further expansions of this study could focus on the research interests of sport management faculty to further understand the possibilities of expansion into multiple disciplines. additionally, a north american comparison over the rest of the world (i.e., asia, europe, and australia) may also prove beneficial toward further assessment. as the field of sport management moves forward with the understanding that growth and credibility is in the mind of the receiver, several questions must continually be asked. for instance, is building credibility, legitimacy, and status important for the growth of the field? is improvement in these areas necessary for the sport management field itself, or is it more selfserving (c.f., boucher, 1998)? either way, a shared and conscious effort should continue to take place through personal accountability (e.g., updating faculty profiles) and organizational accountability (e.g., continuing to promote interdisciplinary research and continued assessment). the field of sport management has seen tremendous growth over the years, primarily through the growth of its programs offered around the world. additional areas of growth may come in the form of faculty as well as the increasing amount of sport management journals available (nassm, 2014) with more growth on the way. accomplishments among nassm members are plentiful. continuing to assess and build upon the field’s infrastructure will certainly aid in enhancing the sport management field perspectives amongst peers both inside and outside of the academy. 6.1 references andrew, d. p., pedersen, p. m., & mcevoy, c. d. (2011). research methods and design in sport management. champaign, il: human kinetics. amis, j., & silk, m. (2005). rupture: promoting critical and innovative approaches to the study of sport management. journal of sport management, 19, 355-366. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 49 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe bocking, s. (2004). nature's experts: science, politics, and the environment. new brunswick, nj: rutgers university press. boucher, r. l. (1998). toward achieving a focal point for sport management: a binocular perspective. journal of sport management, 12, 76-85. buchheit, s., collins, d., & reitenga, a. (2002). a cross-discipline comparison of top-tier academic journal publication rates: 1997–1999. journal of accounting education, 20, 123130. chalip, l. (2006). toward a distinctive sport management discipline. journal of sport management, 20, 1-21. costa, c. a. (2005). the status and future of sport management: a delphi study. journal of sport management, 19. 117-142. cuneen, j. (2004). managing program excellence during our transition from potential to merit. journal of sport management, 18, 1-12. cuneen, j., & parks, j. b. (1997). should we serve sport management practice or sport management education? a response to weese's perspective. journal of sport management, 11, 125-132. deephouse, d. l., & suchman, m. (2008). legitimacy in organizational institutionalism. in r. greenwood, c. oliver, r. suddaby & k. sahalin-andersson (eds.), the sage handbook of organizational institutionalism (pp. 49-77). london, england: sage publications. de haan, d. (2011). comparisons between undergraduate sport management programmes in the united kingdom and the united states. worcester journal of learning and teaching, 5. denzin, n. k., & lincoln, y. s. (2011). the sage handbook of qualitative research. thousand oaks, ca: sage publications. desensi, j. t., kelley, d. r., blanton, m. d., & beitel, p. a. (1990). sport management curricular evaluation and needs assessment: a multifaceted approach. journal of sport management, 4, 31-58. doherty, a. (2012). "it takes a village:" interdisciplinary research for sport management. journal of sport management, 27, 1-10. doherty, a. (2013). investing in sport management: the value of good theory. sport management review, 16, 511. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 50 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe eagleman, a. n., & mcnary, e. l. (2010). what are we teaching our students? a descriptive examination of the current status of undergraduate sport management curricula in the united states. sport management education journal, 4, 1-17. fielding, l. w., pitts, b. g., & miller, l. k. (1991). defining quality: should educators in sport management programs be concerned about accreditation? journal of sport management, 5, 1-17. floyd-jones, d. f., brooks, d. d., & mak, j. y. (2008). examining sport management programs in the united states. sport management review, 11, 77-91. frisby, w. (2005). the good, the bad, and the ugly: critical sport management research. journal of sport management, 19, 1-12. hardy, s. (1987). graduate curriculums in sport management: the need for a business orientation. quest, 39, 207-216. hasselback, j. r., reinstein, a., & schwan, e. s. (2000). benchmarks for evaluating the research productivity of accounting faculty. journal of accounting education, 18, 79-97. hovland, c. i., janis, i. l., & kelley, j. j. (1953). communication and persuasion. new haven, ct: yale university press. kelley, d. r., beitel, p. a., desensi, j. t., & blanton, m. d. (1994). undergraduate and graduate sport management curricular models: a perspective. journal of sport management, 8, 93-101. lewis, g. (1982). degree programs in athletic and sport administration. unpublished report. university of massachusetts. mahony, d. f., & pitts, b. g. (1998). research outlets in sport marketing: the need for increased specialization. journal of sport management, 12, 259-272. mahony, d. f., mondello, m., hums, m. a., & judd, m. r. (2004). are sport management doctoral programs meeting the needs of the faculty job market? observations for today and the future. journal of sport management, 18, 91-110. metzger, m. j. (2007). making sense of credibility on the web: models for evaluating online information and recommendations for future research. journal of the american society for information science and technology, 58, 2078-2091. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 51 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe mondello, m., mahony, d. f., hums, m. a., & moorman, a. m. (2002). a survey of search committee chairpersons: candidate qualifications preferred for entry-level sport management faculty positions. international journal of sport management, 3, 262-281. nassm newsletter (2015). cosma news and updates. north american society for sport management newsletter, 19, 1-6. nite, c., & singer, j. n. (2013). an examination of sport management doctoral programme research requirements. educate~, 13, 24-35. north american society for sport management (2014, may 20). journals serving the community of sport management scholarship. retrieved from http://www.nassm.com/sites/default/files/sport%20management%20journals%20li st%20may%202014.pdf north american society for sport management (2015a, january 15). sport management programs. retrieved from http://www.nassm.com/infoabout/sportmgmtprograms. north american society for sport management (2015b, april 1). earle f. zeigler lecture award. retrieved from http://www.nassm.org/infoabout/awards/zeigler olafson, g. a. (1990). research design in sport management: what's missing, what's needed? journal of sport management, 4, 103-120. parkhouse, b. l. (1987). sport management curricula: current status and design implications for future development. journal of sport management, 1, 93-115. parkhouse, b. l., & pitts, b. g. (2001). definition, evolution, and curriculum. in b. l. parkhouse (ed.), the management of sport: its foundation and application (3rd ed.). new york: mcgraw-hill. peterson j., & pierce, d. (2009). professional sport league assessment of sport management curriculum. sport management education journal, 3, 110-124. pfleegor, a. (2014). publish, perish or salami slice? responsible and ethical authorship for sport management scholars. paper presented at the meeting of the north american society for sport management, pittsburgh, pa. abstract retrieved from http://www.nassm.org/files/conf_abstracts/2014-271.pdf. pitts, b. g. (2001). sport management at the millennium: a defining moment. journal of sport management, 15, 1-9. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 52 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe shilbury, d., & rentschler, r. (2007). assessing sport management journals: a multidimensional examination. sport management review, 10, 31-44. slack, t. (1991). sport management: some thoughts on future directions. journal of sport management, 5, 9599. slack, t. (1996). from the locker room to the boardroom: changing the domain of sport management. journal of sport management, 10, 97-105. smith, j., & washington, m. (2013). advancing isomorphism in higher education: a critical analysis of the careers of intercollegiate athletic directors. journal of contemporary athletics, 8(1). stier, w. f. (1993). alternative career paths in physical education: sport management. eric digest, 1-6. suchman, m. c. (1995). managing legitimacy: strategic and institutional approaches. academy of management review, 20, 571-610. united states department of education. (2014, december 20). accreditation in the united states. retrieved from http://www2.ed.gov/admins/finaid/accred/index.html?exp=2. washington, m., & zajac, e. j. (2005). status evolution and competition: theory and evidence. academy of management journal, 48, 282-296. weese, w. j. (1995). if we're not serving practitioners, then we're not serving sport management. journal of sport management, 9, 237-243. weese, w. j. (2002). opportunities and headaches: dichotomous perspectives on the current and future hiring realities in the sport management academy. journal of sport management, 16, 1-17. zakrajsek, d. (1993). sport management: random thoughts of one administrator. journal of sport management, 7, 1-6. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 2; march-april 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 21 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe assessing corporate social responsibility practices in ncaa division-i athletic departments 1john a. smith, m.s. and 2elizabeth r. anderson, 1m.s., sport administration program, health, exercise, and sport sciences, department, university of new mexico, albuquerque, nm 87131. 2ed.d, sport administration program, health, exercise and sports sciences department, college of education, university of new mexico, albuquerque, new mexico, united states. abstract: the rising prominence of intercollegiate athletics in the united states has resulted in a substantial surge in revenue for ncaa division i athletic departments. a significant contributor to this financial growth has been the introduction of individual media deals negotiated by member conferences. this abstract highlights the substantial impact of these media deals on the financial landscape of ncaa division i athletic programs, shedding light on the key drivers behind the revenue expansion. keywords: intercollegiate athletics, ncaa division i, media deals, revenue growth member conferences 1. introduction the increasing popularity of intercollegiate athletics in the united states has led to increase revenue for national collegiate athletic association (ncaa) division i athletic departments. the introduction of individual media deals for the member conferences is one of the main avenues where revenues have increased for the athletic departments. according to ncaa financial reporting from the athletic departments, the pacific athletic conference (pac-12) reported total revenues for the 12 member schools of $334 million for the 2013 fiscal year. the main enablers of the rising revenues are the individual media deals negotiated by the conferences for coverage of its member schools athletic events. the southeastern conference (sec) launched its own television network in a partnership with espn with an estimated payout of $20.9 million annually to each member school;this amount can increase depending on the popularity of the network (soloman, 2014). the top revenue generating athletic department in the country according the 2014 usa today college sports revenue database is the university of texas with $165,691,486 dollars, a $2 million dollar increase from the previous year. college athletic departments are generating as much revenue as companies listed on the forbes“100 small business list” for 2014, companies on the list include boston beer company, maker of samuel adams, nathan’s hot dogs, and churchill downs (badenhausen, 2014). college athletic departments have long operated under the guise of a department within the university that pertains to varsity athletics. with the large amounts of revenue, in direct comparison to forbes 100“best small companies,” are the athletic departments operating with behaviors of good citizenship to society. csr is the believe that corporations should act in a manner that is positive towards society and work to enhance society (t. m. jones, indexes, register, & socially, 1980). athletic departments mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 2; march-april 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 22 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe provide educational opportunities for a college education, through the giving of scholarships or other grants in aid, in exchange for their participation and representation of the school in athletic competition. the athletic department is also responsible for providing its student athletes with life skills that will make them good citizens in society when they graduate from school. the purpose of the study is to research the types and extend of corporate social responsibility behaviors evident on division i athletic department websites. the paper will provide ananalysis of the csr behaviors of ncaa division iathletic departments csr actions through the three constructscommonly researched in the literature for analysis in college athletics: environmental sustainability, cause-related marketing, and community service (babiak & wolfe, 2009; bradish, cronin, & others, 2009). it is the first time that a csr content analysis of the athletic department’s website has been used utilized. a review of the literature showed little research directly pertaining to college athletic departments. previous literature has attempted to analyze one specific construct, while the purpose of this paper is to provide a global view of csr behaviors of athletic departments (babiak & trendafilova, 2011; babiak & wolfe, 2006; breitbarth & harris, 2008; walker & kent, 2009; yong jae ko, yong chae rhee, yu kyoum kim, & taeho kim, 2014). 2. literature review 2.1 corporate social responsibility corporate social responsibility is linked to the notion that a company should be a good citizen to society because society is the one who grants the company its ability to operate (maier, 1993). csr was first fully introduced by bowen in 1953 in his book social responsibility and the businessman, and has been reproduced three times with the most recent publication in 2013 providing insight in how to carry out a csr program in business (bowen, 2013). the basis of csr is that society is granting the companies the ability to operate and they should use their abilities to make a difference in society through its unique corporate abilities. csr also provides a company with the ability to maintain a positive public relations image in society by their good deeds. it grants the company a virtual insurance policy in public relations against any of its negative attention that may arise from the companies actions (godfrey, 2005; peloza, 2006; werther jr & chandler, 2005) corporate social responsibility actions of a company affect the employees of the company as much as the actions are affecting overall society. studies have shown that when a company is participating in csr behaviors, overall employee satisfaction is positively correlated with the csr behavior as well as increasing overall value of the company (edmans, 2012). a majority of the research on csr is focused on proving a relationship between organizational practice and performance towards social demands (van buren iii & greenwood, 2008). the most effective method for conducting csr behavior in society is one where mutual benefits occur for both the company and society, resulting in a possible competitive advantage for the company conducting the csr actions (porter & kramer, 2002). when the company finds a way to conduct the csr actions in a manner that provides a competitive advantage, it is rewarding to the employees but also increases the financial performance of the company simultaneously with csr actions (orlitzky, schmidt, & rynes, 2003). the social performance model introduced by carroll in 1979, provides a method for organizations to integrate csr into its operation (carroll, 1979). mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 2; march-april 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 23 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe corporate social responsibility has been supported by the literature as a necessary action of companies because it is good for business and good for society. the company should look to make its csr actions exist as one of the corporate pillars of the company. 2.2 environmental sustainability in sport environmental sustainability is one of the three areas most commonly researched in respect to sport organizations csr behaviors (babiak & trendafilova, 2011; casper, pfahl, mcsherry, & others, 2012; mallen, stevens, & adams, 2011). the main focus of environmental sustainability literature is on recycling and operating facilities in an energy efficient manner. one study examined the intentions to recycle plastic bottles by youth sports spectators, concluding that if the receptacles were made available to recycle the spectators would participate in recycling (mccullough & cunningham, 2011). recycling is only one small component of the environmental sustainability landscape in sport. much of the attention has shifted towards operation of facilities in an energy efficient manner for the reduction in overall operating cost. the environmental sustainability movement in sport has shifted towards answering the question, how can we operate our facilities at an energy efficient standard to reduce operating cost. an increase in overall education of sport management students in environmental sustainability of facility management is one of the directions taken to increase overall awareness to the issue (mallen, adams, stevens, & thompson, 2010). overall operation of the facilities is seen as a costly venture and transforming them into environmentally sustainable areas is strongly recommended as these facilities are degrading with time (mallen & chard, 2012). the green sports alliance is one of the leading non-profit organizations that provide assistance through training and consulting to sports organizations looking to enhance its environmental sustainability. the alliance has 262 total members, with 135 venues and seven leagues across north america (green sports alliance, 2014). organizations, like the green sports alliance, work to aid and encourage sport organizations to adopt environmentally sustainable efforts and facility operation. environmental sustainability has been shown in the literature to be a positive for the sport organization due to the financial benefit it can receive by operating its facilities in a sustainable manner. operating the facilities in an environmentally sustainable manner also allows for a connection with its stakeholders showing it has a commitment to decreasing its environmental footprint while still offering cutting edge facilities for fans to enjoy the sporting events. 2.3 cause related marketing in sport cause related marketing in sport has been featured in the literature in discussion with csr. sports provide a unique environment for the promotion and awareness of special causes that provide benefit to society. one of the prominent cause related marketing areas in sport is breast cancer awareness and the national football league, stemmed by the susan g. komen foundation (selleck, 2010). due to cause related marketing through sport during october, breast cancer awareness month, overall internet search activity increased (glynn, kelly, coffey, sweeney, & kerin, 2011). sports are a vehicle for awareness messaging due to the amount of emotion that is experienced by sports fans and compassion for a particular athlete in the case of lance armstrong and nike (irwin, lachowetz, cornwell, clark, & others, 2003; lachowetz & gladden, 2003; mcglone, martin, & others, 2006). mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 2; march-april 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 24 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe cause related marketing presents an opportunity to raise awareness through the partnerships that are formed with sport. sport organizations look to capitalize on this relationship by getting fans to the stadiums to see the event where the cause is being marketed and also to purchase special edition apparel, giving proceeds to the cause (lee & ferreira, 2011). in offering the cause related apparel it is sending the message to teams stakeholders that it is participating in csr and is doing its part to try to benefit society (bronn & vrioni, 2001; smith & westerbeek, 2007). the literature has shown that sports fans care about the social actions of their teams and take this into account when they speak about their team in a favorable manner (walker & kent, 2009). cause related marketing strategy when utilized in sport provides an arena for the fan to recognize the csr actions of the organization as well as support the cause being marketed. 2.4 community service in sport community service is one of the most frequently researched areas in sport and csr (kihl, babiak, & tainsky, 2014; misener & mason, 2009). a majority of the research has centered on creating a method and delivering life skills to the student athletes through student services departments within the college athletic departments. the student services department creates the programs to involve the student athletes in their local communities, serving as outreach for the university and athletic department (jordan & denson, 1990). the student services department of the athletic department play an integral part in community relations and the csr actions of the athletic department with the community. the college experience strives to instill service learning in students and incoming freshman students seek to participate in service, but barriers inherent to the university can inhibit the service participation (cruce & moore, 2007). the desire from students to do service is apparent and the schools and student services in the athletic departments can work to reduce the barriers and encourage the participation in service projects. the active participation in community service projects allows the local community stakeholders to acknowledgethe outreach efforts of the athletic department (kihl et al., 2014). the primary participants in community service for the athletic department are student-athletes, as it provides them with added benefits in the classroom. a positive correlation was reported between service and academic success in the literature (carodine, almond, & gratto, 2001). contrary to carodine, et. al. 2001, the athletic department must not over utilize the student athletes in its csr actions,because it is shown that it can also have a negative impact on the student athlete (hill, burch-ragan, & yates, 2001). the utilization of community service provides mutual benefits to the athletic department and the student athletes. community service allows for a direct relationship with the community and the ability to build relationships with stakeholders in the community (misener & mason, 2009). 3. methods the study conducted in this paper was designed to investigate the csr actions of ncaa division i athletic departments through an analysis of environmental sustainability, cause related marketing, and community service. utilizing the usa today financial database of division i athletic departments financial reporting, the top twentyfive schools were selected based on revenue generation. the breakdown by conference affiliation was sec: 11 schools, atlantic coast conference (acc): 2 schools, big 10: 6 schools, big 12: 4 schools, and pac 12: 2 schools. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 2; march-april 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 25 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe each school’s athletic department was analyzed using its website to search for each of the three constructs. student fee and internal funding data was also collected from the usa today database. the csr content analysis of the athletic departments website is a first in sport management literature. the content analysis is an appropriate method of study, because the website serves as a main form of communication between organization and stakeholders (b. jones, temperley, & lima, 2009; lawrence, 2002; opoku, abratt, & pitt, 2006). a search was performed using the search feature provided on the website. the results that were displayed were analyzed for content describing the actions taken for the particular construct. the content was recorded in an excel spreadsheet and validated by manually searching through the website content to make sure the search feature displayed all relevant content in regards to the constructs. 4. results the overall results displayed that all the athletic departments in the study are participating in csr actions in all of the studied constructs. community service was displayed as the dominant attribute of the csr actions of the athletic departments. environmental sustainability was the weakest area displayed from the content analysis. cause related marketing was a part of every athletic department csr actions, following the model introduced by the nfl in its effort to raise awareness for breast cancer. 4.1 environmental sustainability environmental sustainability appeared in the content of every athletic department website that was included in this study. the most commonly reported effort to increase environmental sustainability was to promote a “go green” game centered around a football game, typically in the beginning of the season not played against a conference opponent. a majority of the athletic departments reported a partnership with the sustainability office in the school. one school displayed an innovative approach to environmental sustainability, including having its own advisory board composed of coaches, student athletes, and staff. 4.2 cause related marketing cause related marketing was displayed as a construct that was utilized frequently to raise awareness for cancer. breast cancer was the predominant cause that marketed in association with events in the athletic department. other causes that were reported were: prostrate cancer, leukemia, childhood obesity, and seizures. all of the sports in the athletic department took part in cause related marketing, each participating in breast cancer awareness during their respected athletic seasons. basketball coaches reported participation in coaches v. cancer awareness games, wearing white shoes to raise awareness for the american cancer society. the school that reported a unique take on cause related marketing was the university of minnesota who raised awareness for epilepsy, because the head coach of the football team suffered from epilepsy.the university of minnesota was the first athletic department to host a game focused on epilepsy (patterson, 2014). 4.3 community service the predominant method of csr action in athletic departments is to utilize student athletes to participate in community service projects in the local communities. the sec has a community service conference team for each sport it sponsors that provides recognition of high achieving student athletes in their local communities. every athletic department in the study reported the total amount of community service hours accumulated by its student athletes in an academic year. the average for student athlete community service hours among the athletic departments in the study was 2,500 hours for the academic year. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 2; march-april 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 26 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe the student services department is the area that conducts the student service learning programs. the common name for these programs are the champs life skills program, and provides incentives for the student athletes participation by creating a point system that accounts for the participation in various service projects. an hour of community service would donate one point in the system, points are totaled at the end of each semester or academic year and their athletic departments recognize the high achieving student athletes. one school produced an annual report highlighting the achievements of its student athlete’s participation in the local community, totaling over 8,000 hours of community service. the report was easily located on the website and provided individual features of the highest achieving student athlete’s community service actions. 5. discussion the results of the content analysis displayed csr activity amongst all of the athletic departments in the study. it is apparent that the athletic departments are taking csr seriously especially in community service from its student athletes. community service is the primary focus of the athletic departments and it correlates with the literature stating that community service is a valuable tool for building a positive reputation in the community (misener & mason, 2009). the building of a positive reputation in the community through community service projects, leads to the creation of social insurance with the community stakeholders of the athletic department and building a more committed fan base for the sports teams(godfrey, 2005, 2009). the teaching of life skills through service learning is also supported by the literature and appears to be a focus of the athletic departments overall goal for the development of its student athletes. the literature base supports the notion that financial performance acts simultaneously with csr.the notion of financial performance of a company acting simultaneously with csr in business, can be applied to overall academic performance and service learning projects instilled by an athletic department. the current study also provides support of the notion that service learning through community service also aids in overall academic performance of student athletes(carodine et al., 2001; jordan & denson, 1990; orlitzky et al., 2003). the financial performance of the athletic departments is positive and the actions towards csr are supported by the literature and the results of this study. the revenue generation of the athletic departments would place them on the forbes100 “best small companies” list and they are also displaying positive efforts in csr towards their local communities. the unique social structure that surrounds sports makes the athletic departments the ideal industry to produce a lasting impact through csr actions. 6. conclusions the csr actions of the athletic departments appear to show a positive trend towards making an impact on society and its local stakeholders. community service is the primary avenue in which csr actions are expressed from the athletic departments, which could be associated to the model produced by the nfl. the nfl relies on players to have individual foundations that execute community outreach projects in their local communities. the main difference between the nfl model and the one utilized by athletic departments, is the student athletes are not compensated by the athletic department and must tend to other areas as well such as schoolwork. the athletic departments should be applauded for their efforts to reach the community through community service projects, but must not rely solely on the student athletes for this mission, as the literature stated, the athletes can experience a negative relationship with academics (hill et al., 2001). mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 2; march-april 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 27 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe the cause related marketing for the athletic departments is utilized to get fans in the seats that purchase tickets to watch an event, while raising awareness for a cause. the athletic departments sometimes will make a philanthropic donation to the cause as a result of the marketing effort, donating a portion of ticket revenue,or sales of cause related merchandise to the selected cause. the partnership formed through the cause related marketing effort produces a relationship that leverages the stakeholder relationship of the fan with the athletic department for the mutual benefit of the cause. the relationship can prove to be mutually beneficial as shown by the increase in website searches for breast cancer awareness in october, due to the nfl’s efforts to wear pink on the field (glynn et al., 2011). the question exist is who is really benefiting from the cause related marketing efforts in college athletics? environmental sustainability is still in its infancy with college athletics but athletic departments are catching on to the savings in operating cost by updating facilities to operate in an energy efficient manner. the rate that athletic departments are building new facilities to keep up in the arms race, environmental sustainability will become easier for the athletic departments to accomplish, because the design of new facilities can be created to maximize efficiency. if an athletic department seeks to build a competitive advantage in environmental sustainability, it must be an effort that links the athletic department with the schools goals and programming but also with the stakeholders in the community. the university in the study located in the pacific northwest was the most active in environmental sustainability in this study due to the nature of community stakeholders and the attitudes of the student population at the school. overall, csr is taking place in college athletics is evident by the sample of division i athletic departments in this study. community service is the driving force for athletic departments csr actions; they are also utilizing cause related marketing and environmental sustainability to execute their csr actions. the actions of the athletic departments resemble those of their forbes 100 “best small companies” list counterparts based off of revenue generation annually. while csr actions are occurring, more could be done to build better relationships with the stakeholders in the community. 7. future directions the scope of this study was to examine a comprehensive perspective of the current state of csr actions of ncaa division i athletic departments. more research needs to be conducted to measure the effectiveness of leadership within the athletic departments to build an integrated csr program. does stakeholder management theory provide a new way of conducting business in college athletics that increases the effectiveness of the csr actions? due to the comparison established between ncaa division i athletic departments annual revenues and that of forbes100 “best small companies”, further research should investigate the similarities in csr actions being executed by both. the areas discussed for future directions following this study will provide greater insight into college athletics that previously has been neglected in research. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 2; march-april 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 28 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe references babiak, k., &trendafilova, s. (2011). csr and environmental responsibility: motives and pressures to adopt green management practices. corporate social responsibility and environmental management, 18(1), 11–24. babiak, k., & wolfe, r. (2006). more than just a game?corporate social responsibility and super bowl xl. sport marketing quarterly, 15(4), 214. babiak, k., & wolfe, r. (2009). determinants of corporate social responsibility in professional sport: internal and external factors. journal of sport management, 23(6), 717. badenhausen, k. (2014).america's best small companies 2014. retrieved on november 2, 2014 from http://www.forbes.com/sites/kurtbadenhausen/2014/10/15/americas-best-smallcompanies-2014/. bowen, h. r. (2013). social responsibilities of the businessman.university of iowa press. bradish, c. l., cronin, j. j., & others. (2009). special issue: corporate social responsibility in sport. journal of sport management, 23(6), 691–794. breitbarth, t., & harris, p. (2008). the role of corporate social responsibility in the football business: towards the development of a conceptual model. european sport management quarterly, 8(2), 179–206. bronn, p. s., &vrioni, a. b. (2001). corporate social responsibility and cause-related marketing: an overview. international journal of advertising, 20(2), 207–222. carodine, k., almond, k. f., &gratto, k. k. (2001). college student athlete success both in and out of the classroom. new directions for student services, 2001(93), 19–33. carroll, a. b. (1979). a three-dimensional conceptual model of corporate performance. academy of management review, 4(4), 497–505. casper, j., pfahl, m., mcsherry, m., & others. (2012). athletics department awareness and action regarding the environment: a study of ncaa athletics department sustainability practices. journal of sport management, 26(1), 11–29. cruce, t. m., & moore, j. v. (2007). first-year students’ plans to volunteer: an examination of the predictors of community service participation. journal of college student development, 48(6), 655–673. edmans, a. (2012). the link between employee satisfaction and firm value, with implications for corporate social responsibility. the academy of management perspectives, amp– 2012. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 2; march-april 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 29 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe glynn, r. w., kelly, j. c., coffey, n., sweeney, k. j., &kerin, m. j. (2011). the effect of breast cancer awareness month on internet search activity-a comparison with awareness campaigns for lung and prostate cancer. bmc cancer, 11(1), 442. godfrey, p. c. (2005). the relationship between corporate philanthropy and shareholder wealth: a risk management perspective. academy of management review, 30(4), 777–798. godfrey, p. c. (2009). corporate social responsibility in sport: an overview and key issues. journal of sport management, 23(6), 698–716. green sports alliance. (2014). retrieved from http://greensportsalliance.org/about/ hill, k., burch-ragan, k. m., & yates, d. y. (2001). current and future issues and trends facing student athletes and athletic programs. new directions for student services, 2001(93), 65–80. irwin, r. l., lachowetz, t., cornwell, t. b., clark, j. s., & others. (2003). cause-related sport sponsorship: an assessment of spectator beliefs, attitudes, and behavioral intentions. sport marketing quarterly, 12(3), 131–139. jones, b., temperley, j., & lima, a. (2009). corporate reputation in the era of web 2.0: the case of primark. journal of marketing management, 25(9-10), 927–939. jones, t. m., indexes, s., register, e. i., & socially, m. (1980). corporate social responsibility.california management review, 22(2). retrieved from http://www.nsk.co.kr/investors/pdf/documents/ar201003e_13.pdf jordan, j. m., & denson, e. l. (1990). student services for athletes: a model for enhancing the student-athlete experience. journal of counseling & development, 69(1), 95–97. kihl, l., babiak, k., &tainsky, s. (2014). evaluating the implementation of a professional sport team’s corporate community involvement initiative. journal of sport management, 28(3), 324–337. doi:10.1123/jsm.2012-0258 lachowetz, a. j., & gladden, j. (2003). a framework for understanding cause-related sport marketing programs.international journal of sports marketing and sponsorship, 4(4), 205–225. lawrence, a. t. (2002). the drivers of stakeholder engagement. journal of corporate citizenship, 2002(6), 71– 85. lee, j., & ferreira, m. (2011). cause-related marketing: the role of team identification in consumer choice of team licensed products. sport marketing quarterly, 20(3), 157– 169. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 2; march-april 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 30 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe maier, p. (1993). the revolutionary origins of the american corporation. the william and mary quarterly, 51– 84. mallen, c., adams, l., stevens, j., & thompson, l. (2010). environmental sustainability in sport facility management: a delphi study. european sport management quarterly, 10(3), 367–389. mallen, c., & chard, c. (2012). “what could be” in canadian sport facility environmental sustainability. sport management review, 15(2), 230–243. mallen, c., stevens, j., & adams, l. j. (2011). a content analysis of environmental sustainability research in a sport-related journal sample. journal of sport management, 25(3), 240–256. mccullough, b. p., & cunningham, g. b. (2011). recycling intentions among youth baseball spectators. international journal of sport management and marketing, 10(1), 104– 120. mcglone, c., martin, n., & others. (2006). nike’s corporate interest lives strong: a case of cause-related marketing and leveraging. sport marketing quarterly, 15(3), 184–188. patterson, c. (2014). minnesota coach jerry kill donates $100k to start epilepsy fund. retrieved october 30, 2014, from http://www.cbssports.com/collegefootball/eyeon-college-football/24564422/minnesotacoach-jerry-kill-donates-100k-to-startepilepsy-fund misener, l., & mason, d. s. (2009). fostering community development through sporting events strategies: an examination of urban regime perceptions. journal of sport management, 23(6), 770. opoku, r., abratt, r., & pitt, l. (2006). communicating brand personality: are the websites doing the talking for the top south african business schools? journal of brand management, 14(1), 20–39. orlitzky, m., schmidt, f. l., &rynes, s. l. (2003). corporate social and financial performance: a meta-analysis. organization studies, 24(3), 403–441. peloza, j. (2006). using corporate social responsibility as insurance for financial performance. california management review, 48(2), 52. porter, m. e., & kramer, m. r. (2002). the competitive advantage of corporate philanthropy. harvard business review, 80(12), 56–68. soloman, j. (2014). sec announces $20.9 million average payout per school. retrieved on october 29, 2014 from http://www.cbssports.com/collegefootball/writer/jon-solomon/24577128/secannounces-209-million-averagepayout-per-school mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 2; march-april 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 31 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe selleck, l. g. (2010). pretty in pink: the susan g. komen network and the branding of the breast cancer cause. nordic journal of english studies, 9(3), 119–138. smith, a. c., &westerbeek, h. m. (2007).sport as a vehicle for deploying corporate social responsibility. journal of corporate citizenship, 2007(25), 43–54. van buren iii, h. j., & greenwood, m. (2008). enhancing employee voice: are voluntary employer–employee partnerships enough? journal of business ethics, 81(1), 209– 221. walker, m., & kent, a. (2009). do fans care? assessing the influence of corporate social responsibility on consumer attitudes in the sport industry. journal of sport management, 23(6), 743. wertherjr, w. b., & chandler, d. (2005). strategic corporate social responsibility as global brand insurance. business horizons, 48(4), 317–324. yong jae ko, yong chae rhee, yu kyoum kim, &taeho kim. (2014). perceived corporate social responsibility and donor behavior in college athletics: the mediating effects of trust and commitment. sport marketing quarterly, 23(2), 73–82. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 41 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe sport theme feature films: a valuable resource for sport management educators 1david michael pearson, 2tiantian lam 1internal medicine specialist in york, usa 2phd student at university of michigan’s earth and environmental sciences, ann arbor, michigan, united states abstract this paper examines the use of feature films as an instructional tool for cognitive reinforcement in physical education (pe) and sport management (sm) courses. the paper begins by discussing the use of feature films as an instructional medium in the social sciences and humanities. it then reviews the limited research that has been conducted on the use of feature films in pe and sm courses. the paper concludes by arguing that the use of feature films can be an effective way to promote cognitive learning in these courses. keywords: feature films, instructional tool, cognitive reinforcement, physical education, sport management 1. introduction for over a century feature films have depicted and reflected a myriad of sociocultural issues and historical circumstances in american society. like other aspects of society, the motion picture industry has been impacted as well as influenced by social, political, and economic factors; and as such films have reflected these issues. movies, metaphorically, are mirrors of the cultures that produce them (campbell, 2005; dickerson, 1991; pearson, 2010). as a result; they often reflect the mood, sentiment, and cultural disposition of american society.pragmatically, they have served as purveyors and inculcators of values, mores, and customs. unbeknownst to many, the sport film has been one such vehicle. an example of this socialization aspect was the use of the 1940 film “knute rockne: all american” during freshman orientations at notre dame. the use of the feature film as an instructional medium is not new (bailey & ledford, 1994; marcus & monaghan, 2009; voller&widdows, 1993).it has been used quite extensively in the social sciences as well as the humanities (downey, jackson, puig, & furman, 2003; metzger, 2007; valdez & halley, 1999).yet few very studies have addressed the feature film as an instructional tool for cognitive reinforcement in physical education (or kinesiology) and sport management. the latter of which is a physical education by-product and viewed as a hybrid discipline. ironically, many contemporary sport management programs include a course addressing sport related socio-cultural issues because of their interrelatedness. frequently referred to as filmography or videography, those employing this medium cite some of the salient benefits as: (a) the ability to stimulate interest; (b) concept reinforcement; (c) instructional diversity; and (d) the group dynamics effect that may come from a feature film discussion (godwin, 2003).the ease in which films can be incorporated into the classroom is also a noteworthy attribute. several students or an entire class can view films to highlight simple symbolism or complex contextual cues. they can also provide a common ground for drawing comparative interpretations from the same teaching stimuli. conversely, books are more individual in nature and subject to individual interpretations, meanings, and depictions. although the meanings of films may mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 42 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe differ, the presentation can be a shared or collective experience. sport films, in the context of this discussion, offer much more. perceived for many years as a mere cinematic display of nonsensical comedic relief, unwavering heroic altruism, and hypnotic value inculcation, a closer look at the sport film genre reveals a portal through which american society can be analyzed and assessed. presently, a body of research exists that highlights some of the trends and nuances within american society, sport, and film (baker, 2003; cartier, 2014; daniels, 2005; pearson, curtis, haney, & zhang, 2003; tudor, 1997).this research has examined some of the socio-cultural and historical issues, media depictions and characterizations, and contemporary themes addressed in sport films. pedagogically sport films serve as a viable instructional medium (bryant & mcelroy, 1997; marcus & monaghan, 2009); one that can enable the instructor to reproduce a situation whereby the student can vicariously enter the world of the depicted character. thus, the student can be engaged in the era, lifestyle, political-economic system, and prevailing socio-cultural milieu. as a result, a clearer understanding and more focused analysis can be achieved. statement of the problem although the sport film has been a fixture in american popular culture since the nascent years of the motion picture industry, a paucity of published research and/or information related to the pedagogical impact of this medium has been addressed in sociology of sport and physical education texts. this shortcoming does not imply a gross omission, but quite possibly the need for a broader discussion regarding the term “media and sport.”this paper will discuss (a) the pedagogical value of films, specifically sport theme feature films, as an instructional tool via a sport film analysis project;(b) the efficacy and value of a sport film project via a two-part questionnaire; and (c) the development of a reliable scale for measuring students’ perceptions of the film analysis project. lastly, it will call attention to the dearth of space devoted to sport films as a pedagogical instructional tool, and provide an example of how sport films have been used for over a decade in a required graduate level sport managementcore course. literature review pedagogical significance early studies by babcock (1967) and cawthon (1968) identified heightened enthusiasm and increased understanding of human situations through films.more contemporary studies (azzarito, 2010;hovet, 2006; metzger, 2007;valdez, & halley, 1999) have documented similar findings, thereby corroborating some of the perceived benefits of film as an instructional tool.bailey and ledford (1994) cited the employment of contemporary films in the classroom as having a significant impact on retention through the mental stamping of vivid images in the mind.helping students interpret and conceptualize social phenomena, as well as develop a social perspective are salient pedagogical assets of films.they can reinforce existing socio-cultural concepts and lead to the discovery of new ones (cartier, 2014; tipton &tiemann, 1993; wollensky, 1982).burton (1988), a major proponent of feature films for instructional purposes, noted that film in all of its formats can be an invaluable teaching tool; while maynard (1977) suggested that they can be as legitimate as books in the curricula.they are essentially texts and can be used in virtually the same context in the classroom (voller&widdows, 1993).the employment of the feature film to address sociocultural issues and themes has significant pedagogical relevance, according to dickerson (1991): a sociocultural film analysis assumes that a film or any cultural artifact is not created in a vacuum. rather it reflects, in a variety of ways, the culture that produced the artifact. therefore, an intense examination of a cultural artifact will produce meaningful conclusions about the values of the culture producing the artifact.(p. 4) scholars from a variety of disciplines have contended that films in general, and sport films in particular, have assisted in the acculturation of immigrants, as well as people around the world (jowett, 1976; pearson, haney, mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 43 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe curtis, & zhang, 2001; sklar, 1994).in fact, they have served as instructional tools by which individuals have learned and acquired american values and mores. contextual cues due to the pervasiveness of film in contemporary society it would appear that its use in academe would be far more prevalent. films enable the instructor and student to reproduce a situation for mutual understanding and optimal analysis. within the context of this re-creation the learner can vicariously enter the world of the depicted character. the ability of feature films to capture such rich situational social dynamics is an invaluable asset (gregg, hosley, weng, &montemayor, 1995). films have an even greater function than illustration since “a good film can provide emotional immediacy and probing insight” (demerath, 1981, p. 71). the engaging affect that film has on its viewers, as noted by max weber as “verstehen” (abel, 1948) or “motivational understanding” (abel, 1970), affords individuals the opportunity to view the world through the eyes of another empathetically and vicariously. burton (1988) elaborated on this unique aspect: if the film is a strong one, the viewer may not just watch the unfolding screenplay, but he or she participates in it. he or she will often identify with one of the characters, and the result of the experience may be that the viewer may learn something of what it feels like to stand in the shoes of a person of a different time, nationality, ethnic group, or of some other situation vastly dissimilar to his or her own . . .(p. 264) the expansive nature of sport within society has led many social scientists to view it as a microcosm of society. and like society, sport is a social construction (coakley, 2015) constantly evolving through the interactions between and among people within their varied environments. the employment of the sport theme feature film has provided a unique window for students to explore a myriad of issues in sport and society; particularly those who aspire to work in the physical activity industry (i.e., sport, fitness, recreation, and health).this situational circumstance is important to note because it provides individuals with a means for explaining social phenomena, which is consistent with an interactionist perspective, and symbolic interaction theory in particular. according to symbolic interaction theory (blumer, 1969), individuals construct their own social worlds based on various elements within society (i.e., individuals, groups, institutions, etc.).researchers agree that films are influential in shaping our views of reality as well (bailey & ledford, 1994; giroux, 2008; sochen, 1993). this is achieved through the continual construction of our social worlds with film images, depictions, and metaphors. sport film research contemporary sport film studies have been instrumental in highlighting some of the salient socio-cultural and historical issues in american society (king &leonard, 2006).for example, pearson et al. (2001) found distinct trends in the kinds of american sport films made over a 69-year period.they opined that the kinds of sport films made and subsequently released were inextricably tied to social, cultural, political, and economic influences, as well as historical circumstances (e.g., great depression, world war ii, civil rights movement, title ix, etc.).in essence, the disposition of american society had a substantial impact on the images, depictions, and story lines of sport films. similar studies have examined the depiction and characterization of women and ethnic minorities in sport films (baker, 2003; campbell, 2005; daniels, 2005;pearson, 2010; tudor, 1997), while others chronicled thematic trends (crawford, 1988; kibby, 1998; mosher, 1982).arguably the most comprehensive study of sport films from their inception through the mid-1980s was compiled by zucker and babich (1987).although inclusive of foreign films, “shorts,” and silent films, this compilation of sport films is noteworthy. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 44 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe textbook incorporation based upon a cursory review of 15 prominently used and nationally distributed sociology of sport texts, the term "media and sport" rarely referred to or included sport film research.interestingly, most text space was reserved for discussions pertaining to print (i.e., newspapers and magazines), broadcast (i.e., television and radio), and electronic (i.e., internet and twitter) medias (e.g., coakley, 2015; sage & eitzen, 2013; woods, 2011). yet, sport films are also a viable media source that warrants discussion.presently aconsiderable amount of time, expense, and national attention have been devoted to sport films.some of which have been critically acclaimed and/or have won the most coveted awards in the motion picture industry (e.g., raging bull, 1980; jerry maguire, 1996; million dollar baby, 2004;blind side, 2009; etc.).they have been found to influence, impact, and reflect various societal trends and patterns.toplin (1993) echoed this sentiment in his film anthology, and mentioned that historians have frequently used literature, art, and music to analyze change in american society.film was no exception: in the past two decades historians have given increasing attention to another valuable source – hollywood movies. they have examined the ways in which themes developed in the movies sometimes reveal or verify shifts in the public’s interests, hopes, fears, and prejudices. (p. vii) for example, filmmakers were discouraged from making auto-racing films during wwii by the federal government because of the rationing of various products used in the war effort (e.g., gasoline, rubber, steel, etc.).consequently, a dearth of these films wasreleased during the war years.other film studies, which have employed content analysis, have yielded data on the lack of female sport role models, limited depictions, and stereotypic characterizations (crawford, 1984; pearson, 2010; tudor, 1997). procedures sport film analysis assignment for the past 15 years my colleagues and i have studied sport films and have employed them in the classroom as an instructional tool.we have been a major proponent of their use, and have standardized a project that has been a salient feature of a required graduate course serving both physical education and sport management students at our university (see appendix a).the sport film analysis project has been a fixture in the graduate course, which meets once a week (three hours) for 15 weeks, during the spring semester.initial class meetings traditionally address salient socio-cultural concepts and themes manifested in sport (i.e., deviance, violence, women, role modeling, nationalism, etc.).the project commences with the formation of randomly assigned groups.the random assignment of students to groups is designed to discourage cliques and assure unbiased selection.this can be accomplished through various means. the film analysis necessitates the identification of various socio-cultural concepts and/or issues addressed in class, thereby reinforcing lecture and textbook content.each film analysis group is required to: (a) highlight and discuss the socio-cultural issues identified, (b) show their selected film, (c) respond to questions posed by classmates, and (d) construct two objective questions which may be used on the final examination.the latter requirement is a pedagogical strategy employed to encourage student participation and class attendance.prior to the analyses an example of a film analysis is discussed to acquaint students with the requisite format and structure.several lists of sport theme feature films, as well as information pertaining to public library holdings and commercial video/dvd store rentals, are disseminated to students. method scale development a film analysis attitude scale (faas) was developed to examine students’ perceptions toward the use of a film analysis as an integral part of the course requirements and to examine whether a change of attitude was evident after the introduction of the film analysis assignment. development of the faas was based on a thorough review mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 45 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe of related literature. two university professors who teach in the area of sport management and have expertise in research deign, as well as scale development, examined the content validity of the scale. exploratory factor analysis was used to examine the factor structure of the scale, whereas the alpha reliability coefficients were used to determine its internal consistency. the initial faas had 12 items, and the responses were based on a 5-point likert scale (“strongly agree”, “agree”, “uncertain”, “disagree” and “strongly disagree”). only the first 11 items of the faas were used to measure the students’ attitudes toward the film analysis, whereas the last item assessed students’ preference of an examination over the film analysis project. in addition, an open-ended question was included at the end to seek students’ opinions and recommendations of the film analysis assignment. demographic data a total of 160 students were enrolled in the course during the years that the study was conducted. the course was “housed” in the department of health and human performance (hhp), which was in the college of education. it was a required graduate course for students enrolled in the hhp’s sport management program of study. the gender of those enrolled was 51% female and 49% male. the ethnic breakdown of the students was as follows: white 68%, black 20%, hispanic 9%, and asian 3%. the average age of students enrolled in the university’s master’s degree programs was 29. the questionnaire respondents (n = 141) were students who enrolled in the face-to-face graduate sport management course over a seven-year period from 1998 through 2010.the study does not include several years when the course was taught on-line due to a slightly different course structure, and the inability to obtain a reasonable response from distance learning students. the faas was distributed to students during class at the very beginning of the semester. theywere told the purpose of the study and informed that their participation would be strictly confidential and voluntary. students who participated in the study were asked to create a personal code to identify them instead of using their real names. this procedure was necessary since they would use the same personal code when completing the questionnaire the second time (i.e., toward the end of the semester after their film analysis assignment was completed). on the second questionnaire a qualitative research component, in the form of an open-ended prompt, was included to elicit students’ general reactions and recommendations regarding the film analysis assignment. ideally, the inclusion of this prompt would allow students to express their unbiased perspectives pertaining to this pedagogical technique.in turn, this information would be employed to improve specific aspects of the course. results spss 16.0 for windows (spss, 2008) was used for data analysis. the factor reduction procedure was used to conduct the exploratory factor analysis. the criteria for retaining the factors was based on the eigenvalues equal to or greater than one (guttman, 1954) while comparing to the scree test (cattell, 1966). paired-sample ttests were used to compare the mean differences between pretest and posttest scores. using the alpha extraction and promax rotation technique, three factors emerged. one item, which had double loading (> .37) across two factors, was discarded. the same factor reduction procedure was employed again to the data set without the deleted item. as a result, three factors were identified: enhancement (3 items), interaction (2 items), and preference (5 items).these three factors accounted for 65.74% of the total explained variance. item description and results of the pattern matrix are presented in table 1. all items had a factor loading of .40 or higher without double loading. cronbach’salpha for the three factors were .76, .77, and .76, respectively. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 46 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe table 1: factor loadings of the three-factor film analysis attitude scale (faas) i ii iii i felt very comfortable when the film analysis project was assigned. 0.53 -0.14 0.05 the film analysis project will help me better understand sociological issues/themes. 0.76 -0.03 0.23 films appear to provide excellent examples of sociological issues conveyed through sport settings. 0.80 0.15 -0.24 the film analysis project will enable me to establish and build rapport with other members in my group. -0.01 0.97 -0.13 the use of groups to perform the film analysis will enable me to learn from group members. -0.01 0.58 0.27 i would prefer to do an individual film analysis as opposed to a group analysis. 0.19 -0.26 -0.60 the film analysis project will make me and my classmates more responsible for learning various sociological issues/themes. 0.19 0.20 0.48 the allotment of points (or percentage of the grade) for the film analysis is appropriate. 0.16 -0.09 0.66 too much class time will be spent on the film analysis project. 0.11 0.03 -0.77 i would prefer to have an examination over the sociological issues/themes covered in the text than the film analysis project. -0.01 0.09 -0.57 among theparticipants (n= 141), 86 completed both questionnaires and were used for data analysis. paired sample t-tests were used to compare the mean differences between the pretest and posttest scores. results showed that there were significant (p< .01) mean differences in four of those 10 items. the results of the t-tests are depicted in table 2. table 2: paired samples t-tests comparing pretest and posttest attitude scores diff. t p enhancement: 1. i felt very comfortable when the film analysis project was assigned. .512 3.53 .001* 2. the film analysis project will help me better understand sociological issues/themes. .453 4.73 .000* 3. films appear to provide excellent examples of sociological issues conveyed through sport settings. interaction: .279 3.00 .004* 1. the film analysis project will enable me to establish and build rapport with other members in my group. .035 0.34 .738 2. the use of groups to perform the film analysis will enable me to learn from group members. preference: -.105 -1.04 .301 1. i would prefer to do an individual film analysis as oppose to a group analysis. -.116 -0.71 .483 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 47 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 2. the film analysis project will make me and my classmates more responsible for learning various sociological issues/themes. .198 1.71 .091 3. the allotment of points (or percentage of the grade) for the film analysis is appropriate. .518 5.04 .000* 4. too much class time will be spent on the film analysis project. -.163 -1.23 .222 5. i would prefer to have an examination over the sociological issues/themes covered in the text than the film analysis project. -.047 -0.32 .752 diff. = mean difference * p< .01 in addition to the quantitative data results, qualitative techniques such as analysis in terms of frequency counts and nonfrequency analysis (fraenkel & wallen, 2000)were employed. this necessitated the categorization of themes or responses (i.e., positive, negative, and neutral) based on the open-ended prompt that solicited students’ reactions and recommendations pertaining to the film analysis assignment. a partial listing of positive, negative, and neutral student reactions are documented in appendix b. results of the content analysis revealed that a total of 56 students responded to the open-ended prompt. of that number, 42 (75%) of the respondents believed that the film analysis was of benefit, and contributed to their overall understanding of the course concepts. for example: “i really enjoyed it. it was a break from the normal classroom lecture, while it allowed us to learn at the same time. it drew my attention toward areas i had not investigated before” (respondent delta, 2000). in addition, many of the students were of the opinion that the collaborative aspect of the project enabled them to learn from other students in and outside their respective group. one respondent summarized this sentiment: “since my classmates brought up better ideas, the analysis went deeper. i needed the members in my group. it would be stressful if it was an individual assignment” (respondent!!, 2010). most of the students who responded favorably toward the film analysis project indicated that they tend to conceptualize sociological issues better because they saw them and analyze films a bit more critically due to the assignment. contrarily, five of the 56 respondents (9%) viewed the film analysis project negatively. one student stated: “it was difficult to equally assign workload among group members, & w/graduate work, i would like to be totally responsible for my grade” (respondent 2223, 2010). another student felt that more instructor guidance was necessary: “more input from you [instructor] on the films. more clips of the movies & class discussion rather than watching the entire movie” (respondent 9424, 2002). although there were few unfavorable responses documented, those that were revolved around collaborative projects, viewing entire films, and group selection. lastly, nine of the 56 respondents’ comments (16%) were deemed to be neutral. this thematic categorization was delineated because of the respondents’ “middle of the road” responses. the responses that were categorized as neutral were characteristic of basic suggestions and recommendations that respondents would like to see incorporated in future classes. one student, for example, wrote: “2 pages was too short – would like to have seen all movies – possibly larger groups with more involvement” (respondent bb, 2010). another student’s response aptly conveys an ambivalent positive – negative statement: “i would have liked to work on a film of greater social significance. however, my group could not agree on a film. regardless, i enjoyed taking a deeper look at our film and examining its social impact” (respondent t1, 2002). interestingly, none of the neutral responses suggested or alluded to a desire to discontinue the film analysis project as a learning activity. discussion based on the results of this study, it could be concluded that the faas was a valid instrument that could be used to measure students’ attitudes toward the film analysis assignment. the data suggest that the film analysis project mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 48 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe changed the perception of many students in diverse ways. first, when it was uncertain in the beginning, the students later found they were comfortable in completing the film analysis assignment and collaborating with other students. they also found that the project helped them better understand sociocultural issues, which were conveyed through sport settings. in addition, students also felt it was fair to use the project to determine part of their final grade in the course. as a matter of fact, most students strongly preferred to participate in the film analysis project rather than sit for a written examination covering selected course content. in conclusion, this study supported previous research studies that a film analysis could be used to enhance students’ learning experience. it also supports the notion that a collaborative project can stimulate group discussion and shared peer learning. lastly, similar to both demerath (1981) and burton (1988), students expressed a vicarious affect and heightened empathy when viewing films with certain socio-cultural themes and concepts in mind, as well as “verstehen” (abel, 1948) or “motivational understanding” (abel, 1970). however, caution should be taken when using it as a teaching aid. as pointed out by downey, jackson, puig, and furman (2003), though films might simplify or minimize real-life social or psychological complexities and could engage students on multiple levels in their learning process, the characters could not actively engage in dialogue or form relationships with the students. therefore, students should exercise their critical thinking skills to identify and manage these limitations. as a result of this study, we contend that several other factors must be considered to maximize student benefits when assigning a film analysis project in a graduate level sport management course.among them are the following: (a) the sport films available to students and the selected film; (b) the ambivalence of some students toward collaborative projects; (c) the decision to have groups show all or part of analyzed films; and (d) the laissez-faire leadership style and shared governance within groups. the latter point alludes to the freedom within groups to address the project collaboratively; however, when there is no identified leader issues pertaining to equity of work can become an inhibiting factor. this may be one of the more salient obstacles encountered when students engage in a collaborative project like the film analysis assignment. conclusion we believe, as do other scholars involved in this type of research, that sport films have much more to offer than their box office appeal and entertainment value. pedagogically, they can provide a stimulating, interactive, learning environment that facilitates the acquisition and retention of course content. students’ in-class attentiveness, unbridled reactions, dynamic discussions, and course evaluations attest to the instructional impact of sport films. our study, with its complimentary research methodology, corroborated many of these aspects. the implementation of the faas demonstrates the efficacy of quantifying students’ perspectives toward an instructional strategy utilizing sport films, thereby validating their salient benefits. on a personal level sport films can impact the development of self-identity, selfworth, and self-esteem via various depictions and characterizations (or the lack thereof). and like print and broadcast medias, they do offer a viable means for examining american culture regardless of the “poetic license” that filmmakers take; a point argued by baker (1998) in his analysis of the jackie robinson story (1950). interestingly, the film was perceived to be very liberal for its time, even though it made no mention of robinson’s near dishonorable discharge from the military for his anti-jim crow stand. briley (2005) also noted the poetic license or “artistic freedom” extended to filmmakers in his discussion of sport films during the reagan administration and how films are inextricably tied to the society and era in which they were released. this suggests that learning can be achieved in diverse ways through the implementation of sport films in the classroom. this is not to suggest that all sport films have redeeming value and are worthy of discussion, but there is quite often a message conveyed whether it is subtle or overt. we have always been of the opinion that the overrepresentation, under-representation, and omission of certain segments of american society (e.g., women, mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 49 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe ethnic minorities, physically challenged, etc.), as well as the depictions and characterizations in sport films warrant discussion. it is our hope that discussions regarding the media and sport in contemporary sociology of sport texts be broader and more inclusive of sport films due to their sociocultural and historical significance. in addition, since many sport management and physical education programs include a sport sociology oriented course, it is imperative that the pedagogical strategy employed be dynamic, innovative, and contemporary. lastly, although we found the faas to be a reliable scale for measuring students’ perceptions toward the use of a sport film analysis, as an instructional strategy, further research with a larger sample is necessary to determine the instrument’s validity. references abel, t. (1948).the operation called verstehen.the american journal of sociology, 54, 211-218. abel, t. (1970). the foundation of sociological theory. new york, ny: random house. azzarito, l. (2010).future girls, transcendent femininities and new pedagogies: toward girls’hybrid bodies? sport, education and society, 15(3), 261-275. babcock, d. (1967). the use of motion pictures in teaching slow learners.report resumes.verona, ny: vernonverona-sherrill central school. (eric documentreproduction service no. ed 019 271) bailey, d. h., & ledford, b. r. (1994). the feature film as an instructional medium.international journal of instructional media, 21(2), 147-154. baker, a. (1998). sport films, history, and identity.journal of sport history, 25(2), 217-233. baker, a. (2003). contesting identities: sports in american film. urbana, il: university of illinois press. bergan, r. (1982). sports in the movies. new york, ny: proteus. blumer, h. (1969). symbolic interaction: perspective and method. englewood cliffs, nj: prentice hall. briley, r. (2005). basketball’s great white hope and ronald reagan’s america: hoosiers (1986). film & history: an interdisciplinary journal of film and television studies, 35(1), 1219. bryant, j. e., &mcelroy, m. (1997). sociological dynamics of sport and exercise. englewood, co: morton. burton, c. e. (1988). sociology and the feature film.teaching sociology, 16, 263-271. campbell, a. (2005). women, sport, and film class.women’s studies quarterly, 33(1/2), 210-223. cartier, n. (2014). black women on-screen as future texts: a new look at black pop culture representations. cinema journal, 53(4), 150-157. cawthon, d. l. (1968).introduction to film. oklahoma consortium on research development mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 50 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe pilot grant: final report. (eric document reproduction service no. ed 021546) coakley, j. j. (2015).sports in society: issues & controversies (11th ed.). new york, ny: mcgraw-hill. crawford, s. a. g. m. (1984). the celluloid athlete.journal of physical education, recreation and dance, 55(8), 24-27. crawford, s. a. g. m. (1988). the sport film: its cultural significance. journal of physical education, recreation and dance, 59(6), 45-49. daniels, d. b. (2005). you throw like a girl: sport and misogyny on the silver screen. film &history, 35, 29-38. demerath, n. j., iii. (1981). through a double-crossed eye: sociology and the movies. teaching sociology, 9(1), 69-82. dickerson, g. e. (1991). the cinema of baseball: images of america, 1929-1989. westport, ct: meckler. downey, e. p., jackson, r. l., puig, m. e., & furman, r. (2003). perceptions of efficacy in the use of contemporary film in social work education: an exploratory study. social work education, 22(4), 401410. fraenkel, j. r., & wallen, n. e. (2000). how to design and evaluate research in education (4th ed.). boston, ma: mcgraw-hill. giroux, h. a. (2008). hollywood film as public pedagogy: education in the crossfire. afterimage, 35(5), 7-13. godwin, j. (2003). film in the classroom: toward a more effective pedagogy(master’s thesis). retrieved from http://scholarcommons.usf.edu/etd/1373 gregg, v. r., hosley, c. a., weng, a., &montemayor, r. (1995). using feature films to promote active learning in the college classroom. in teaching of psychology: ideas and innovations. proceedings of the 9th annual conference on undergraduate teaching of psychology, ellenville, 32-43. hovet, t. (2006) the teacher as exhibitor: the pedagogical lessons from early film exhibition. pedagogy, 6(2), 327-335. jowett, g. (1976). film: the democratic art. boston, ma: little-brown. kibby, m. d. (1998). nostalgia for the masculine: onward to the past in the sport films of theeighties.canadian journal of film studies, 7(1), 16-28. king, c. r., & leonard, d. j. (2006). visual economies of/in motion: sport and film. new york, ny: peter lang. maynard, r. a. (1971). the celluloid curriculum: how to use movies in the classroom. newyork, ny: hayden. marcus, s. a., & monaghan, m. (2009). tasting the fluoride: the potential of feature film to enhance the instruction of the women’s movement. social studies research and practice, 4(1), 13-30. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 51 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe metzger, s. a. (2007). pedagogy and historical feature film: toward historical literacy. film &history: an interdisciplinary journal of film and television, 37(2), 67-75. mosher, s. d. (1982). sport movies grow up. journal of physical education, recreation and dance, 53(2), 3536. mosher, s. d. (1983). the white dreams of god: the mythology of sport films. arena review, 7(2), 15-19. pearson, d. w. (2001). the depiction and characterization of women in sport film.women in sport & physical activity journal, 10(1), 103-124. pearson, d. w., haney, c. a., curtis, r. l., & zhang, j. j. (2001). social change and sport films: shifts in content across cultural eras 1930-1998. international sports journal, 5(2), 136-152. pearson, d. w., curtis, r. l., haney, c. a., & zhang, j. j. (2003). sport films: social dimensions over time 19301995. journal of sport & social issues, 27(2), 145-161. pearson, d. w. (2010).absence of power: sheroes in sport films post-title ix. in l. k. fuller (ed.), sports, rhetoric, and gender: global and universal contexts (pp. 233-247). new york, ny: peter lang. sage, g. h., & eitzen, d. s. (2013).sociology of north american sport (9th ed.). new york, ny: oxford university press. sklar, r. (1994). movie-made america: a cultural history of american movies (rev. ed.). new york, ny: vintage. sochen, j. (1993). the prices of power: women’s depictions in film. in j. combs (ed.), movies and politics: the dynamic relationship (pp. 97-113). new york, ny: garland. tipton. d. b., &tiemann, k. a. (1993). using the feature film to facilitate sociological thinking. teaching sociology, 21, 187-191. toplin, r. b. (ed.). (1993). hollywood as mirror: changing views of “outsiders” and “enemies” in american movies. westport, ct: greenwood. tudor, d. v. (1997). hollywood’s vision of team sports: heroes, race, and gender. new york, ny:garland. valdez, a., & halley, j. (1999). teaching mexican american experiences through film: private issues and public problems. teaching sociology, 27(3), 286-295. voller, p., &widdows, s. (1993). feature film as text: a framework for classroom use. elt journal, 47, 342353. wollensky, r. p. (1982). an introduction to the use of educational film in teaching sociology: using films in sociology courses. washington, dc: american sociological association. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 52 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe woods, r. b. (2011). socialissues in sport (2nd ed.). champaign, il: human kinetics. zucker, h. m., & babich, l. j. (1987). sport films: a complete reference. jefferson, nc: mcfarland. appendix a sport film analysis project goal: to acquaint students with, and increase their understanding of, various socio-cultural issues in sport conveyed through film (videocassette or dvd). task: within randomly formed groups, students will select a movie that has a sport-related theme. with assistance from group members students will analyze the movie in an attempt to identify salient socio-cultural issues in sport. a minimum of five socio-cultural issues must be identified and corroborated through the literature. each group will work collaboratively to select, analyze, and synthesize their findings. a sport film analysis paper no longer than three and one-half pages in length will be required of each group. randomly selected groups will present their film and give a brief overview (10-12 minutes) of their analysis in class. grading: a total of 20 percent of the total grade (20 pts.) will be awarded for the project. grading will be based on several factors: 1) organization and documentation, 2) relevance of material, 3) depth of analysis, 4) clarity, and 5) basic writing skills. each group member will receive the same grade. remember, this is a collaborative effort. procedure: 1) select a movie to analyze from the list provided. 2) with group member assistance analyze the movie. 3) prepare a succinct written summary (3 – 3 ½ pages) of your analysis. 4) identify at least five salient socio-cultural issues in sport (e.g., deviance, race, violence, discrimination, sexism, etc.) and elaborate on them in your summary. 5) write a brief introductory paragraph addressing the following: setting, time period, ses of major character(s), etcetera, to help put the film in perspective. 6) select the film to be analyzed and notify the instructor as soon as possible. 7) write two multiple-choice questions (in confidence) based on your film that may be used on the final examination. the questions must have five options (a-e). include the answer for each question project due date: tba points to remember: • start early by contacting your partners and selecting a sport film to review. • only instructor approved films may be analyzed. • the maximum movie length to be shown in class is two hours. • film designation will depend on instructor notification (“first come – first serve” on film). • the summary must be typed, double-spaced, and with a 12-pt. font. • projects must be paginated. • group members should contribute equally to the project. • select films from the instructor approved list. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 53 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe • consult the instructor if there are questions. appendix b partial listing of students’ reactions positive responses: • “the film analysis was a great idea; it was the type of project that i believe graduate school should have more of. i would strongly recommend using more analysis in the future” (respondent 3567, 2004). • “great teaching tool. never realized the extent that sport films use many other real world themes. there are many messages other than the sport itself. thanks for the education!” (respondent 3914, 2003). • “interesting idea. i was not sure about the project at first, but i enjoyed the assignment & the presentations of other groups” (respondent boz, 2002). neutral responses: • “i just have a bias against group work” (respondent dem, 2010). • “we should have done more films and more presentations. sometimes people learn more from what they see than what they hear!!!” (respondent slim, 1998). • “i really enjoyed doing the film analysis. next time i think that all groups should show their films and discuss their issues. this is a very good idea that needs to be kept in the course” (respondent 1421, 2000). negative responses: • “i would not show movies in class time” (respondent snake, 1998). • “it was a hassle to try to organize our group. we ended up doing most of the work over the internet and one of our groups didn’t have access. it would’ve been easier as a solo project” (respondent sjsvbc, 2000). mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 16 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe exploring the differences in the perceptions and undertaking of core responsibilities of national coaching standards by beginner, intermediate and elite sport coaches michael j. smith and jennifer a. jones university of illinois at chicago abstract: sport coaches play a vital role in the development of athletes, both on and off the field. however, the coaching profession is complex and evolving, and there is a lack of consistency in coaching requirements across sports. this can create confusion for coaches and athletes, and may lead to suboptimal coaching performance. governing bodies should do everything possible to ensure that sport coaches receive high-quality education and training, so that they can be effective in their roles. keywords: sport coaches, coaching education, coaching effectiveness, consistency, standards introduction sport coaches are important figures impactingathletes‟onand off-field success, health, well-being and personal development (eichner, 2018; lauer & dieffenbach, 2013; roxas&ridinger, 2016). additionally, coaches often play critical roles such as mentor, parental figure, tactician and academic tutor (davis, 2005).more recently, the coaching profession has evolved and developed into a more complex profession, in which their roles include more than the traditional responsibilities of directing practices, overseeing training and managing game personnel (e.g., bush & silk, 2010; duffy et al., 2011; gilbert &trudel, 2004). given the diverse nature of coaches‟ roles, their knowledge, skills and experiences have garnered considerable attention from sport organizations such as the society of health and physical educators (shape america), the united states olympic committee (usoc), and the international council for coaching excellence (icce). these organizations, among others, have been instrumental in the development of appropriate sport coaching standards. despite the continued growth of the coaching profession and the on-going development and revisions to the national standards for sport coaches (nssc) in the united states, there are still important issues that remain unresolved in the areas of formal education, training opportunities and core responsibilities for sport coaches (cushion et al., 2010; duffy et al., 2011). one of the more prominent issues in this regard is the consistency of coaching requirements (e.g., education and qualification) across sports (hedland, fletcher, & dahlin, 2018).while there are a multitude of coaching-related education and training resources (e.g., coaching certification, clinics, seminars, books, videos), the lack of consistent and formal coach education and training requirements may create confusion on what coaches need to know to become an effective coach. this is especially concerning, because previous research suggests that formal education and training programs have a more positive impact on both coaches and athletes compared to informal training (fraser-thomas &côté, 2009). while coaches need to fulfill dynamic and evolving roles, it is also important to provide consistency in coaching performance as it pertains to goal setting, ethics, safety and inclusion. furthermore, sport organizations may also havean additional burden ofdeveloping their own set of specialized standards and requirements in the absence of formal coach education or in the case there are, unique aspects of a sport not covered by traditional sport coaching education (dawson & phillips, 2013).governing bodies should do everything possible to ensure sport coaches receive high quality education, and as a result, they mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 17 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe are effectivein the various roles and challenges they face. in sport coaching and education research, this is often described as coaching effectiveness. côté and gilbert (2009) define coaching effectiveness as “the consistent application of integrated professional, interpersonal, and intrapersonal knowledge to improve athletes‟ competence, confidence, connection, and character in specific coaching context” (p. 316). coaching standards of practice can be utilized as aresource that can provide consistency to sport coaching education offerings and subsequently increase the knowledge and skills associated with coaching effectiveness. many governing bodies in sports have created standards in which the knowledge and skills needed to be an effective coach are listed. due to recent updates to the national standards for sport coaches (nssc) in the united states (shape america, 2019), the purpose of this research is two-fold. first, in order to understand whether or not the updated nssc reflect core responsibilities sport coaches undertake, an examination of how frequently sport coaches use the 42 national standards is reported. second, sport coaches‟ perceptions of the 42 national standards and their relationship to being an effective coach is also displayed. finally, prior research (gilbert &côté, 2013; gilbert &trudel, 2005) has consistently shown there are often differences between diverse levels of coaches (e.g., beginner, intermediate, elite). because the nssc are developed to guide the education and training of coaches at all levels, the results are all segmented and analyzed based on coaches self-perceived coaching level. national standards for sport coaches from a brief, historical perspective as it relates to coaching standards in the united states, there have been substantial changes since the mid-1980s. the implementation of these changes was due in part to accommodate the ever-changing context in which coaches operate as it relates to education, practice and science (bodey, brylinsky, & kuhlman, 2008). in 1984, a set of youth sport coaching standards were presented in a position paper published by the national association of sport and physical educators (naspe). that version subsequently underwent a series of revisions, which were supported by over 150 sport governing bodies,and the result was the 1995 national standards for athletic coaches(nsac). this versión consisted of eight domains and 37 coaching standardsspread across those domains. with the various sport stakeholders in mind (i.e., administrators, athletes, the public), another revision was undertaken and released in 2006 which led to the renaming of the standards to the national standards for sport coaches (nssc). the2006 version also contained eight domains but an additional three standards were added, bringing the total to 40 (naspe, 2006). the nssc are used to inform various stakeholders (i.e., coach educators, sport administrators, athletes) about the core responsibilities that coaches should possess in providing a quality experience for their athletes. utilizing the notion of core responsibilities, the most recent revision, completed in 2019 and outlined ingano-overway, van mullem, long, thompson, benham, bolger, driska, moreno, and schuster (2020), consistsof a robust set of seven areas of core responsibilities for sport coachesand42 coaching standards (see appendix). whilethe nssc were originally created to provide guidanceto coaches and related stakeholders, the latest revision creates a greater specification of those stakeholders (e.g., sport administrators, athletes and their families) and updated information about the knowledge and skills sport coaches should possess. additionally, in the most recent nssc,coaches can evaluate their own learning process in an effort to benchmark or improve their overall coaching effectiveness (ganooverway et al., 2020). the updated nssc are partly a response to the emergence of new issues inthe sport coaching profession (e.g., players‟health and wellness, concussion protocol, wearable technology, training methodologies, education, virtual coaching) and the development ofcompeting international coaching frameworks (e.g., european coaching framework, seelara-bercial et al., 2017). the seven core responsibilitiesof coaching and the respective number of standardsunder each of the those are: set vision, goals and standards for sport programs(standards 1-5); engage in and support ethical practices (standards mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 18 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 6-8); build relationships (standards 9-11); develop a safe sport environment(standards 12-20); create a positive and inclusive sport environment (standards 21-23); conduct practices and prepare for competition (standards 2437); and strive for continuous improvements (standards 38-42). each of the 42 standards fit within a particular core responsibility, and each area of core responsibilities contains between three to 14 standards. the subsequent sections providesfurther details concerning the seven core responsibilities. set vision, goals and standards for sport programs the managerial aspects of the coaching profession are on full display within the core responsibilities included in this area. standards within this core responsibility include everything from developing a coaching philosophy to managing resources. these standards and responsibilities are in-line with vallée and bloom‟s (2005) notion of the program-building coach. most importantly, program-building coaches possess strong organizational skills and have a vision for the program that unites the various groups of stakeholders, especially program administrators. westfall (2020) found that even the most undesirable conditions within the coaching profession can beovercome by setting a clear vision. engage in and support ethical practices there has been a tremendous amount of scholarly work (e.g., agnew, henderson, & woods, 2017; hardman, jones, & jones, 2010) regarding the establishment of a code of conduct; modeling, teaching and reinforcing ethical behavior; and helping others to develop ethical decision-making. for example, the ethical practices of coaches have garnered considerable attention with in the popular press and media. constandt, de waegeneer, and willem (2018) found that coaches have considerable influence on ethical player behavior and this is further supported by a wealth of literature in this area (e.g., burton, welty peachey, & wells, 2017; desensi, & rosenberg, 2010; sagas & wigley, 2014). in other words, it is incumbent upon sport coaches to both model and teach athletes how to be ethical in one‟s decision-making and choices. build relationships coaches are required to manage a number of relationships in their day-to-day work responsibilities. beyond the relationship that must be developed with players, there are critical relationships that cannot be overlooked. for example, relationships with sport administrators, other coaches and staff, referees, parents and supporters, and the media all may be important to build. moreover, norris, didymus, andkaiseler (2020) found that coaches should look to build connections which provide emotional and social support as these will come in handy during difficult times and serve to help alleviate burnout and increase psychological well-being. develop a safe sport environment the safety and welfare of athletes of all ages is instrumental to the success of any sport organization. this set of responsibilities entails some of the most critical aspects within the coaching profession and includes standards related to injury prevention, nutrition, monitoring for signs of abuse or violent behavior, and adverse playing conditions. diamond, callahan, chain, and solomon (2016) found high rates of hazing from middle school to collegiate athletics with an overwhelming majority (80%) reporting it as an organized team function. coaches have a responsibility of preventing such abuses and for being active participants in the development of policies and procedures. in the case of sexual abuse, johnson, hanna, and novak (2020) emphasized the need to developmultiple policies, as only one policy is insufficient, and to put in place additional safety measures (e.g., education, awareness, monitoring) to help protect athletes. whatman, walters, and schluter (2018) cited coaches „attitude to injury‟ as having a dramatic impact on the implementation of injury prevention strategies and the subsequent involvement of key stakeholders.from a mental health perspective, coaches are viewed as a facilitator of early symptom detection and a resource for directing athletes to seek out the proper care (kroshus, chrisman, coppel, & herring, 2019). mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 19 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe create a positive and inclusive sport environment coaches, administrators and all stakeholders within a sporting context maintain a duty to uphold an inclusive environment void of prejudice and other biases. cunningham (2015) described sport as possessing a “changeaverse nature” (p. 44) and that certain areas within sport (e.g., intercollegiate athletics) suffer from a high degree of institutionalization. cunningham also found, however, that individual agents and outside stakeholder groups are the most likely to undertake change. the coach, in this regard, has the ability to wield a tremendous amount of power to become a change agent to advocate for inclusivity in all aspects of a sport program. magnanini (2017) noted that inclusive coaches are in a position to design programs that recognize and build upon the strengths of all athletes, regardless of ability and other demographic and socioeconomic characteristics. conduct practices and prepare for competition the technical aspect of coaching entails a tremendous amount of preparation, education and training. coaching education and development have long been some of the more highly assessed and scrutinized areas within the profession (e.g., newman, santos, cardoso, & pereira, 2020; paquette, &trudel, 2018). stodter and cushion (2019) found that there are various gaps in the theory and practice of coach educators which has led to confusion and inconsistencies in the profession. the facets of planning, teaching, assessing and adapting can involve tremendous challenges that coaches need to overcome. involving all stakeholders in this process through the“it takes a village” mentality, is somewhat of a necessity to achieve success. the combination of the various technical aspects of coaching are evident in the standards outlined within this core responsibility and coaches must demonstrate the ability to plan, teach, assess and adapt (shape america, 2019). westfall (2020) suggested that success in these technical aspects must be achieved even under the harshest conditions. as such, coaches must be wary of becoming overly tactical (e.g., kinnerk, harvey, macdonncha, & lyons, 2018) with regards to their responsibilities and incorporate positive coaching attributes such transformational leadership and fostering relationships with athletes. strive for continuous improvement as coaches gain knowledge and experience, it isconceivable they desire to improve their skills and abilities, not just for the benefit of the various stakeholders assessing their performance but for themselves.through this constant self-reflection, coaches must counter the notion of sport as being “changeaverse” (cunningham, 2015).under stressful circumstances, like change or with other issues, reflection is an effective tool in the coach decision making process (wharton &roussi, 2015). some of the various processes used to achieve the highest degree of self-reflection include journaling (gilbert &trudel, 2013), reflective conversation (gilbert, 2017), and the development of a personal coaching narrative (gearity, 2014). when examining the pursuit of mastery in coaching, van mullem and dahlin (2017) found that progress in the area of reflection occurs away from the game. consistent with vallée and bloom (2005), the process of self-reflection has a cyclical effect and also benefits the other six core responsibilities. coaching expertise and context one of the primary questions regarding the nssc,its seven core responsibilities and 42 standards, is the applicability to the various coaching expertise levels and contexts (gano-overway et al., 2020). although the nssc were designed to provide the fundamental guidelines for all coaching-related professionals, the knowledge and skills contained in the standards may be applied differently based expertise and context.beginner coaches who are new to coaching or to coaching a particular sport, can benefit fromfoundational knowledge such as proper practice plans, effective team organization, administrative strategies, positive motivation techniques and ethical coaching behaviors (murray, schoenstedt, &zwald, 2013). intermediate coaches are characterized as the ones who gained some coaching experience but need additional knowledge and skills for a specific age group or sport. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 20 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe for example, appropriate training materials for intermediate coaches may be those concerned with social development, complex organization skills, techniques for evaluating athletes, and creating developmentally appropriate training plans. finally, elite coaches are those with significant coaching experience (e.g., 10 or more years). these coaches may have a wealth of practical and conceptual knowledge learned over time through reflection, engagement and experience (culver &trudel, 2008; schempp, mccullick, & mason, 2006). while elite coaches are more likely to be “innovators” by relying on applied knowledge, they can also benefit from newer information derived by evidence-based research and best practices. specifically, sport organizations and governing bodies are recommended to utilize the nssc by tailoring specific needs of coaches depending on their level of expertise.for instance, coaches at different stages of their career may have different approaches and philosophies as it relates to their coaching practices. because most coaches do not spend their time developing philosophical beliefs earlier in their careers (wilcox &trudel, 1998), it is likely that beginner coaches‟ priorities are not centered around, for example, setting a vision, goals, and standards (see nssc standard 1). elite or expert coaches, on the other hand, are more likely to have developed their coaching knowledge and philosophies over time through experience (gilbert &trudel, 2005), and subsequently, may have an increased understanding and use of the nssc standards. purpose of the study the nssc offers a robust list of core responsibilities and standards all sport coaches should learn about and be able to execute. to date, research regarding sport stakeholders‟ perceptions of the core responsibilities and standards within the nssc is limited. while previous research on coaches‟ perceptions of coaching standardsis sparse (see hedlund et al., 2018 as an exception), because the nssc was updated in 2019, new research is warranted (gano-overway et al., 2020). in addition, to our knowledge, no prior research has segmented results based on the self-perceived level of coaches. anecdotal evidence aside, at some levels of sport coaching, coaches and their organization may have sufficient resources to hire experts to manage and oversee specific aspects of their team and athletes (e.g., the hiring of dedicated athletic trainers, physical trainers, nutritionists, etc.). while this does not remove the responsibility or oversight, coaches still should understand basic principles and practices of specialized experts on their staff, while also recognizing it may be beyond the scope of responsibilities for sport coaches to undertake certain tasks. for example, depending on legal jurisdiction, in many states within the united states, it would be illegal, or at the very least ethically questionable for a sport coach or parent to have a minor continue playing in a competition after suffering head trauma (e.g., a concussion) through contact/collision (kim & connaughton, 2020). as a result, due to legal liabilities, coaches may not have certain responsibilities, however in many cases, they must understand the important issues and responsibilities of the people working around them. based on the newly updated nssc, it is first necessary to examine the frequency of respondents‟ use of the listed 42 core responsibilities. if behaviors under examination do not accurately reflect frequent behaviors of sport coaches, then alternative research questions might be warranted. second, because coaching effectiveness is an abstract, complex and often multidimensional construct to measure (e.g., effective at winning championships, effective at developing talented players, effective at helping athletes to succeed in life), numerous researchers have instead measured the concept of being a successful coach (see côté&gilbert, 2009; gilbert, lichtenwaldt, gilbert, zelezny, &côté, 2009; horn, 2008; jowett, 2017). as a result, the question: “in your opinion, in order to be a successful sport coach, how important is it to be able to use the knowledge and skills described in the standard?” was used to measure the perceived relationship between the standard and coaching effectiveness. finally, because it remains largely unknown whether coaches‟ perceptions of the nssc are associated with their self-perceived level of being a beginner, intermediate or elite coach (trudel& gilbert, 2013), when the analysis was undertaken, the results were segmented based on the three groups. methodology mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 21 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe participants and procedures after receiving irb approval to undertake this research, using amazon‟s mechanical turk (mturk) and offering approximately 40 cents per completed response, us-based coaches aged 18 and older from across the us were solicited for participation. in total, 1,982 respondents agreed to participate in this research. after filtering out ineligible (e.g., non-coaches, international coaches, under 18-year old coaches) participants at the outset of the electronic surveyand incomplete responses after all data were collected, 1,235 responses were subjected to analysis. in summary, coaches were 35.95% female, had an average age of 33.87 years old, and had an average of 6.06 years of coaching experience. in terms of their self-perceived coaching level, 29.2% were beginners, 53.2% were intermediate, 17.6% were elite coaches. when asked at what level they primarily coach, the top five responses were youth/community sports (20.67%), college/university sports (16.75%), middle/junior high school sports (12.83%), elementary school sports (10.97%), and senior high school sports (10.09%). in terms of their role, 14.30% were full-time, paid head coaches, while 16.26% were full-time, paid assistant coaches, and 13.42% were volunteer coaches. when asked about their race, 53.28% indicated white/caucasian, 13.32% black/africanamerican, 11.36% asian/pacific islander, and 6.95% hispanic/latinx. finally, in terms of where respondents currently lived, 49 of 50 states, plus the district of columbia, guam and american samoa all were represented in the sample, and the top five states represented were california (11.56%), indiana (10.09%), texas (9.50%), florida (7.15%) and new york (6.37%). instrumentation due the online and monetary compensation provided to support the survey data collection, first, four filter questions were asked to receive respondent‟s agreement to participate, ensure minimal response bias, and check basic facts about each respondent. in order to move forward, respondents initially needed to agree to participate in the research. next, because the nssc is a us-specific document used by numerous governing bodies, respondents were asked to confirm they currently lived in the us or its territories. subsequently, respondents were asked to confirm that they had had at any point in their life been a sport coach of any type or at any level. finally, respondents were asked to confirm their age was currently 18 years old or older. if respondents responded in the affirmative to all four questions, then they were able to complete the online questionnaire. all others were thanked for their time and interest and disallowed to continue with the survey and blocked from further attempts at completing it. after entering the main portion of the online survey research, randomly selected blocks of questions about each of the 42 standards were posed to respondents. after first being shown the exact text of each randomly selected standard, respondents were then asked two questions about each standard. first,they were asked “in your role as a sport coach, how frequently do use the knowledge and skills described in standard #?” a 7-point (1-7) scale with the ordered answer choices never, rarely, occasionally, sometimes, frequently, usually and all the time used. after answering the first question, the second question appeared and asked “in your opinion, in order to be a successful sport coach, how important is it to be able to use the knowledge and skills described in standard #?” again, a 7-point (1-7) scale was used with the ordered answer choices not at all, of little importance, slightly important, moderately important, very important, extremely importance and absolutely essential. the 42 standards and each pair of questions and answer choices were randomly shown to all respondents. finally, questions about respondents coaching experiences and demographics were posed to respondents before the survey concluded. on average, respondents took between 10-15 minutes to complete the survey. data analysis for this research, due to the large number of results (i.e., 84 results, each of which shows mean scores forthe three types of coaches [i.e., 252 group results in total are calculated]), analysis of variance (anova) was used to examine the differences between the three groups of coaches (beginner, intermediate and elite) for the results of mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 22 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe all 84 questions. to simplify the reporting of the results, figures for different set of results from the core responsibilities are shown below. in addition, accompanying each figure are the anova results for each standard among the three groups. results the five most frequently used core responsibilities overall were “standard 12: create a respectful and safe environment which is free from harassment and abuse” (mean = 5.30, standard deviation = 1.65), “standard 06: abide by the code of conduct within their coaching context” (mean = 5.23, standard deviation = 1.65), “standard 15: monitor environmental conditions and modify participation as needed to ensure the health and safety of participants” (mean = 5.18, standard deviation = 1.58), “standard 30: know the skills, elements of skill combinations and techniques, competition strategies and tactics, and the rules associated with the sport being coached” (mean = 5.16, standard deviation = 1.52), and “standard 16: reduce potential injuries by instituting safe and proper training principles and procedures” (mean = 5.12, standard deviation = 1.64).when examining the data trends and conducting anova testing, 39 of 42 groups had statistically different results between the coaches. the three core responsibilities where statistically significant results were not found were “standard 12: create a respectful and safe environment which is free from harassment and abuse”(f[2, 1016] = 1.88, p is not significant), “standard 15: monitor environmental conditions and modify participation as needed to ensure the health and safety of participants”(f[2, 1016] = 0.23, p is not significant), and “standard 16: reduce potential injuries by instituting safe and proper training principles and procedures”(f[2, 1016] = 1.57, p is not significant). the five core responsibilities respondents felt were most importantare “standard 12: create a respectful and safe environment which is free from harassment and abuse” (mean = 5.40, standard deviation = 1.64), “standard 17: develop awareness of common injuries in sport and provide immediate and appropriate care within scope of practice” (mean = 5.30, standard deviation = 1.60), “standard 16: reduce potential injuries by instituting safe and proper training principles and procedures” (mean = 5.30, standard deviation = 1.59), “standard 7: model, teach and reinforce ethical behavior with program participants” (mean = 5.25, standard deviation = 1.57), and “standard 6: abide by the code of conduct within their coaching context” (mean = 5.23, standard deviation = 1.59). after examining the trends of the data and conducting anova testing, 36 of 42 groups had statistically different results between the three groups of coaches. the six core responsibilities where statistically significant results were not found included “standard 6: abide by the code of conduct within their coaching context” (f[2, 1016] = 1.25, p is not significant),“standard 12: create a respectful and safe environment which is free from harassment and abuse”(f[2, 1016] = 1.94, p is not significant), “standard 14: identify and mitigate physical, psychological and sociocultural conditions that predispose athletes to injuries” (f[2, 1016] = 1.08, p is not significant), “standard 15: monitor environmental conditions and modify participation as needed to ensure the health and safety of participants” (f[2, 1016] = 1.79, p is not significant), “standard 16: reduce potential injuries by instituting safe and proper training principles and procedures” (f[2, 1016] = 1.92, p is not significant), and “standard 21: implement a positive and enjoyable sport climate based on best practices for psychosocial and motivational principles to maximize athlete and team well-being and performance” (f[2, 1016] = 2.86, p is not significant). table 1 results for the frequency of use of core responsibilities set vision, goals and standards for sport program 5.50 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 23 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe note: anova results: standard 01: (f[2, 1016] = 14.54, p<.001), standard 02: (f[2, 1016] =18.16, p<.001), standard 03: (f[2, 1016] = 9.75, p<.001), standard 04: (f[2, 1016] = 13.61, p<.001), standard 05: (f[2, 1016] = 7.34, p<.01) table 2 results for frequency of use engage in and support ethical practices 5.50 note: anova results: standard 06: (f[2, 1016] = 3.42, p<.05), standard 07: (f[2, 1016] = 4.17, p<.05), standard 08:(f[2, 1016] = 3.17, p<.05) table 3 results for frequency of use build relationships 5.50 note: anova results: standard 09: (f[2, 1016] = 8.81, p<.001), standard 10: (f[2, 1016] = 8.02, p<.001), standard 11: (f[2, 1016] = 6.23, p<.01) table 4 results for frequency of use develop a safe sport environment 5.50 4.30 4.50 4.70 4.90 5.10 5.30 beginner intermediate elite standard 01 standard 02 standard 03 standard 04 standard 05 4.30 4.50 4.70 4.90 5.10 5.30 beginner intermediate elite standard 06 standard 07 standard 08 4.30 4.50 4.70 4.90 5.10 5.30 beginner intermediate elite standard 09 standard 10 standard 11 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 24 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe note: anova results: standard 12: (f[2, 1016] = 1.88, p is not significant), standard 13: (f[2, 1016] = 6.70, p<.01), standard 14: (f[2, 1016] = 3.07, p<.05), standard 15: (f[2, 1016] = 0.23, p is not significant), standard 16: (f[2, 1016] = 1.57, p is not significant), standard 17: (f[2, 1016] = 4.70, p<.01), standard 18: (f[2, 1016] = 4.60, p<.05), standard 19: (f[2, 1016] = 12.56, p<.001), standard 20:(f[2, 1016] = 14.25, p<.001) table 5 results for frequency of use create a positive and inclusive sport environment 5.50 note: anova results: standard 21: (f[2, 1016] = 3.68, p<.05), standard 22: (f[2, 1016] = 6.58, p<.01), standard 23: (f[2, 1016] = 16.82, p<.001) table 6 results for frequency of use conduct practices and prepare for competition planning standard 24 standard 25 standard 26 4.30 4.50 4.70 4.90 5.10 5.30 beginner intermediate elite standard 21 standard 22 standard 23 4.30 4.50 4.70 4.90 5.10 5.30 5.50 beginner intermediate elite standard 28 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 25 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe standard 27 note: anova results: standard 24: (f[2, 1016] = 18.56, p<.001), standard 25: (f[2, 1016] = 11.86, p<.001), standard 26: (f[2, 1016] = 12.75, p<.001), standard 27: (f[2, 1016] = 13.84, p<.001), standard 28: (f[2, 1016] = 8.19, p<.001), standard 29: (f[2, 1016] = 8.28, p<.001) table 7 results for frequency of use conduct practices and prepare for competition teaching 5.50 note: anova results: standard 30: (f[2, 1016] = 3.61, p<.05), standard 31: (f[2, 1016] = 10.03, p<.001), standard 32: (f[2, 1016] = 7.21, p<.01), standard 33: (f[2, 1016] = 9.42, p<.001) table 8 results for frequency of use conduct practices and prepare for competition assessing and adapting 5.50 note: anova results: standard 34: (f[2, 1016] = 7.07, p<.01), standard 35: (f[2, 1016] = 12.99, p<.001), standard 36: (f[2, 1016] = 14.77, p<.001), standard 37: (f[2, 1016] = 10.07, p<.001) table 9 results for frequency of use 4.30 4.50 4.70 4.90 5.10 5.30 beginner intermediate elite standard 30 standard 31 standard 32 standard 33 4.30 4.50 4.70 4.90 5.10 5.30 beginner intermediate elite standard 34 standard 35 standard 36 standard 37 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 26 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe strive for continuous improvement 5.50 note: anova results: standard 38: (f[2, 1016] = 14.41, p<.001), standard 39: (f[2, 1016] = 14.45, p<.001), standard 40: (f[2, 1016] = 10.63, p<.001), standard 41: (f[2, 1016] = 8.47, p<.001), standard 42: (f[2, 1016] = 5.73, p<.01) table 10 results for the importance to successful coaching of the following standards set vision, goals and standards for sport program 5.70 note: anova results: standard 01: (f[2, 1016] = 12.72, p<.001), standard 02: (f[2, 1016] = 12.65, p<.001), standard 03: (f[2, 1016] = 12.77, p<.001), standard 04: (f[2, 1016] = 5.95, p<.01), standard 05: (f[2, 1016] = 9.03, p<.001) table 11 results for the importance to successful coaching of the following standards engage in and support ethical practices 5.70 4.30 4.50 4.70 4.90 5.10 5.30 beginner intermediate elite standard 38 standard 39 standard 40 standard 41 standard 42 4.50 4.70 4.90 5.10 5.30 5.50 beginner intermediate elite standard 01 standard 02 standard 03 standard 04 standard 05 4.50 4.70 4.90 5.10 5.30 5.50 beginner intermediate elite standard 06 standard 07 standard 08 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 27 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe note: anova results: standard 06: (f[2, 1016] = 1.25, p is not significant), standard 07: (f[2, 1016] = 3.20, p<.05), standard 08: (f[2, 1016] = 5.37, p<.01) table 12 results for the importance to successful coaching of the following standards build relationships 5.70 standard 11: (f[2, 1016] = 6.50, p<.01) table 13 results for the importance to successful coaching of the following standards develop a safe sport environment 5.70 note: anova results: standard 12: (f[2, 1016] = 1.94, p is not significant), standard 13: (f[2, 1016] = 3.97, p<.05), standard 14: (f[2, 1016] = 1.08, p is not significant), standard 15: (f[2, 1016] = 1.79, p is not significant), standard 16: (f[2, 1016] = 1.92, p is not significant), standard 17: (f[2, 1016] = 4.02, p<.05), standard 18: (f[2, 1016] = 3.21, p<.05), standard 19: (f[2, 1016] = 7.38, p<.01), standard 20: (f[2, 1016] = 6.48, p<.01) table 14 results for the importance to successful coaching of the following standards create a positive and inclusive sport environment 5.70 note: anova results: standard 09: (f[2, 1016] = 7.75, p<.001), standard 10: (f[2, 1016] = 6.19, p<.0 1) , 4.50 4.70 4.90 5.10 5.30 5.50 beginner intermediate elite standard 09 standard 10 standard 11 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 28 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe note: anova results: standard 21: (f[2, 1016] = 2.86, p is not significant), standard 22: (f[2, 1016] = 3.27, p<.05), standard 23: (f[2, 1016] = 9.37, p<.001) table 15 results for the importance to successful coaching of the following standards conduct practices and prepare for competition planning standard 24 standard 25 standard 26 standard 27 note: anova results: standard 24: (f[2, 1016] = 14.58, p<.001), standard 25: (f[2, 1016] = 11.93, p<.001), standard 26: (f[2, 1016] = 9.31, p<.001), standard 27: (f[2, 1016] = 3.47, p<.05), standard 28: (f[2, 1016] = , p<.001), standard 29: (f[2, 1016] = 11.09, p<.001) table 16 results for the importance to successful coaching of the following standards conduct practices and prepare for competition teaching 5.70 note: anova results: standard 30: (f[2, 1016] = 7.68, p<.001), standard 31: (f[2, 1016] = 11.70, p<.001), standard 32: (f[2, 1016] = 10.83, p<.001), standard 33: (f[2, 1016] = 9.28, p<.001) table 17 results for the importance to successful coaching of the following standards conduct practices and prepare for competition assessing and adapting 5.70 4.50 4.70 4.90 5.10 5.30 5.50 beginner intermediate elite standard 21 standard 22 standard 23 4.50 4.70 4.90 5.10 5.30 5.50 beginner intermediate elite standard 30 standard 31 standard 32 standard 33 4.50 4.70 4.90 5.10 5.30 5.50 5.70 beginner intermediate elite standard 28 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 29 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe note: anova results: standard 34: (f[2, 1016] = 9.01, p<.001), standard 35: (f[2, 1016] = 6.63, p<.01), standard 36: (f[2, 1016] = 4.52, p<.05), standard 37: (f[2, 1016] = 4.47, p<.05) table 18 results for the importance to successful coaching of the following standards strive for continuous improvement 5.70 note: anova results: standard 38: (f[2, 1016] = 8.69, p<.001), standard 39: (f[2, 1016] = 12.05, p<.001), standard 40: (f[2, 1016] = 11.00, p<.001), standard 41: (f[2, 1016] = 7.26, p<.01), standard 42:(f[2, 1016] = 7.50, p<.01) discussion in 2019, the national standards for sport coaches were revised for a third time since their initial creation in 1984. in the newly revised standards, “the core responsibilities, underlying knowledge, and professional, interpersonal, and intrapersonal skills coaches need to create quality sport experiences for athletes” (ganooverway, 2019, para. 3) were created and updated to demonstrate what sport coaches need to know and understand in various areas often under their charge. at the same time, there has been a recognition that different types of coaches at different levels and within different types of organizations all may have diverse perspectives, roles and responsibilities. as a result, the current research attempts to identify some of these areas of similarity and differences, while at the same time, providing and opportunity to evaluate and understand the relevance and importance of knowledge and information such as a list of national standards and core responsibilities of sport coaches. in this research, for 39 of 42 standards, there were differences found between in the frequency of use of each standard among beginner, intermediate and elite coaches. in all of these cases, higher level coaches more frequently used most standards when compared to those with less expertise and experience. however, the three cases in which there were no statistically significant differences among all three groups of coaches share an interesting connection, in that all are part of the section of the standards labelled as “developing a safe sporting environment.” in other words, regardless of any differences, sport coaches‟ frequency of behaviors in terms of 4.50 4.70 4.90 5.10 5.30 5.50 beginner intermediate elite standard 34 standard 35 standard 36 standard 37 4.50 4.70 4.90 5.10 5.30 5.50 beginner intermediate elite standard 38 standard 39 standard 40 standard 41 standard 42 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 30 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe “standard 12: create a respectful and safe environment which is free from harassment and abuse,”“standard 15: monitor environmental conditions and modify participation as needed to ensure the health and safety of participants, and “standard 16: reduce potential injuries by instituting safe and proper training principles and procedures” indicate there is a similarity ofunderstanding among all types of coaches aboutthe ideas engendered in these standards. while the media often portrays sport coaches, especially elite professional ones as focused and caring more about winning than and their players‟ health and safety, these results suggest that coaches across the board are indeed aware of and engage in behaviors focused on ensuring respect and safety within the sporting environment in similar ways. in terms of success, effective coaching and their relationship to the national standards, while again, there are differences found between beginner, intermediate and elite sport coaches, in six areas, those perceptions are found to be similar. in these results, one area where perceptions are similar is in “engaging in and supporting ethical practices,” four stem from “developing a safe sport environment,” and one is based in “creating a positive and inclusive sport environment.” each of these three areas focus not about the skills one is coaching, but instead how coaches create a positive and ethical environment in which their players can practice, compete and develop the skills necessary to be a better player and person. specifically, the six areas where differences between the three groups of coaches were not found included “standard 6: abide by the code of conduct within their coaching context,” “standard 12: create a respectful and safe environment which is free from harassment and abuse,” “standard 14: identify and mitigate physical, psychological and sociocultural conditions that predispose athletes to injuries,” “standard 15: monitor environmental conditions and modify participation as needed to ensure the health and safety of participants,” “standard 16: reduce potential injuries by instituting safe and proper training principles and procedures,” and “standard 21: implement a positive and enjoyable sport climate based on best practices for psychosocial and motivational principles to maximize athlete and team wellbeing and performance.” while a similar phenomenon can be seen in these results compared to the earlier ones, in that the health and safety of athletes are important, in these cases, a second group of standards related to creating an ethical, respectful, positive and enjoyable environment is perceived as something that all types of coaches similarly note are important when it comes to being successful and effective. conclusion, implications and future research in this research, the frequency of the use and the importance, relative to being a successful coach, of 42 core sport coaching core responsibilities were examined. both sets of results were segmented based on respondents‟ selfperceived beginner, intermediate or elite level of coaching. the results indicated that while there are statistically significant differences in many areas and levels of coaching, there are several areas where similarities are about, notably in areas focused the safety, health and wellness of athletes as well as fostering environments in which ethics, respect, and having positive and enjoyable experiences are important. one of the largest resulting takeaways, therefore, is that one of the main ways in which all types of coaches both behave and think similarly is through focusing energies on how they coach, the environment they create and an athlete‟s wellness first focus. standards established for coaches have long served the profession and have guided the path of many beginner, intermediate and elite coaches alike. based on the results of this particular study, it is important to continually reassess and amend the standards underpinning how coaches perform their job responsibilities. the dynamic nature of the coaching profession and the significant role of a coach has served as a reminder of the necessity to adapt to the needs of athletes and the myriad stakeholders involved in the administration of sport. while the main purpose of this study was to discern the frequency of use and importance of the 42 core responsibilities listed in the nssc for various levels of coaches, the implications are far reaching. while there are numerous implications of this research, in brief, the findings from this study can be used to assist sport coaches, sport coaching educators, future task forces overseeing future revisions, and other stakeholders. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 31 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe more importantly, sport coaches themselves may now have an enhanced level of confidence that if they maintain a good understanding of the principles and practices underlying the 42 core responsibilities, then the results support and reinforce the continued use of the nssc standards in their present form and to maintain one‟s sport coaching readiness and facilitate life-long learning activities. sport coaching educators can use these results to identify areas where sport coaching education may be lacking and additional activities are required to prepare coaches for these roles and responsibilities. in addition, the coaching standards taskforce (gano-overway et al., 2020) and other practitioner-based sport organizations can also use these results to examine how coaches self-report their use of the standards and apply them to their coaching responsibilities. in the future, sport coaches, sport coaching educators and the coaching standards task force will again undertake and attempt to improve the nssc. the results of this research suggest some ways in which this process could be undertaken to examine the behaviors and perceptions sport coaches have of many of the core responsibilities they have. at the same time, future iterations of the nssc might be wise to note that there are some areas of core responsibilities which are always important and should be ever-present in a coaches‟ mind, including the health, safety and wellness of athletes. at the same time, different types of coaches at different levels of coaching and those with different sets of coaching experiences may perceive different areas as important. as a result, some areas of coaching education may have be more important than others, and coaches would then be well-advised to always take those areas into consideration and to attempt to improve and enhance their knowledge, skills and ability to be effective in those areas. references bodey, k. j., brylinsky, j., & kuhlman, j. (2008). advocacy with ncr: tips and techniques: advocating for coaching education with the new national coaching report. strategies, 22(1), 34-36. doi:10.1080/08924562.2008.10590807 côté, j., & gilbert, w. (2009). an integrative definition of coaching effectiveness and expertise. international journal of sports science & coaching, 4(3), 307-323. doi:10.1260/174795409789623892 covey, s. r. (2004). the 7 habits of highly effective people. new york: rosettabooks. culver, d., &trudel, p. (2008). clarifying the concept of communities of practice in sport. international journal of sports science & coaching, 3(1), 1-10. doi:10.1260/174795408784089441 cushion, c., nelson, l., armour, k., lyle, j., jones, r., sandford, r., & o‟callaghan, c. (2010). coach learning and development: a review of literature. london, uk: sports coach uk. davis, p.g. (2005). performance appraisal for coaches. paper presented at the icce coaching conference. hong kong, china. dawson, a., & phillips, p. (2013). coach career development: who is responsible? sport management review, 16, 477-487. doi:10.1016/j.smr.2013.03.003 duffy, p., hartley, h., bales, j., crespo, m., dick, f., vardhan, d., ... &curado, j. (2011). sport coaching as a „profession‟: challenges and future directions. international journal of coaching science, 5(2), 93-123. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 32 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe eichner, e.r. (2018). football team rhabdomyolysis: the pain beats the gain and the coach is to blame. current sports medicine reports, 17, 142-143. doi:10.1249/jsr.0000000000000484 fraser-thomas, j., &côté, j. (2009). understanding adolescents‟ positive and negative developmental experiences in sport. the sport psychologist, 23(1), 3-23. doi:10.1123/tsp.23.1.3 gano-overway, l. a., & dieffenbach, k. (2019). current practices in united states higher education coach education programs. international sport coaching journal, 6(2), 226-233. doi:10.1123/iscj.2019-0013 gano-overway, l., van mullem, p., long, m., thompson, m., benham, b., bolger, c., driska, a., moreno, a., & schuster, d. (2020). revising the national standards for sport coaches within the usa. international sport coaching journal, 7(1), 89-94. doi:10.1123/iscj.2019-0058 gilbert, w., &côté, j. (2013). defining coaching effectiveness: focus on coaches‟ knowledge. in p. potrac, w. gilbert, & j. denison (eds.), routledge handbook of coaching (pp. 147-171). new york, ny: routledge gilbert, w., lichtenwaldt, l., gilbert, j., zelezny, l., &côté, j. (2009). developmental profiles of successful high school coaches. international journal of sports science & coaching, 4(3), 415-431. gilbert, w., &trudel, p. (2005). learning to coach through experience: conditions that influence reflection. the physical educator, 62, 32-44. griffo, j.m., jensen, m., anthony, c.c., baghurst, t., &kulinna, p.h. (2019). a decade of research literature in sport coaching (2005-2015). international journal of sports science & coaching, 14, 205-215. doi:10.1177/1747954118825058 hedlund, d. p., fletcher, c. a., & dahlin, s. (2018). comparing sport coaches‟ and administrators‟ perceptions of the national standards for sport coaches. the physical educator, 75(1), 1-24. doi:10.18666/tpe2018v75-i1-7537 hedlund, d.p., fletcher, c.a., pack, s.m., & dahlin, s. (2018). the education of sport coaches: what should they learn and when should they learn it? international sport coaching journal, 5, 192-199. doi:10.1123/iscj.2017-0110 horn, t. s. (2008). coaching effectiveness in the sport domain. in t. s. horn (ed.), advances in sport psychology (pp. 239-267,455-459). champaign, il: human kinetics. international council for coaching excellence, the association of summer olympic federations, & leeds metropolitan university. (2013). international sport coaching framework. champaign, il: human kinetics. jowett, s. (2017). coaching effectiveness: the coach–athlete relationship at its heart. current opinion in psychology, 16(august), 154-158.doi: 10.1016/j.copsyc.2017.05.006 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 33 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe kim, s., &connaughton, d. p. (2020). youth soccer parents‟ attitudes and perceptions about concussions, journal of adolescent health. doi: 10.1016/j.jadohealth.2020.04.029 kinnerk, p., harvey, s., macdonncha, c., & lyons, m. (2018) a review of the game-based approaches to coaching literature in competitive team sport settings, quest, 70(4), 401-418. doi:10.1080/00336297.2018.1439390 lara-bercial, s., north, j., hämäläinen, k., oltmanns, k., minkhorst, j., & petrovic, l. (2017). european sport coaching framework. champaign, il: human kinetics. lauer, l., & dieffenbach, k. (2013). psychosocial training interventions to prepare youth sport coaches. in p. potrac, w. gilbert, & j. denison (eds.), routledge handbook of sports coaching (pp. 451-462). abingdon, uk: routledge. lyle, j. (2002). sports coaching concepts: a framework for coaches‟ behaviour. london: routledge. murray, m., schoenstedt, l., &zwald, d. (2013). recommended requisites for sport coaches. journal of physical education, recreation & dance, 84(8), 7-12. doi:10.1080/07303084.2013.832968 national association for sport and physical education [naspe]. (2006). quality coaches, quality sports: national standards for sport coaches (2nd ed.). reston, va: aahperd. nelson, l.j., & cushion, c.j. (2006). reflection in coach education: the case of the national governing body coaching certificate. the sport psychologist, 20(2), 174-183. doi:10.1123/tsp.20.2.174 roxas, a.s., &ridinger, l.l. (2016). relationships of coaching behaviors to student-athlete well-being. higher education politics & economics, 2, 95-109. doi:10.32674/hepe.v2i1.21 schempp, p., mccullick, b., & mason, i. (2006). the development of expert coaching. in r. l. jones (ed.), sports coach as educator: reconceptualising sports coaching (pp. 145-161). london, uk: routledge. shape america. (2019). national standards for sport coaches (3rd ed.). retrieved from https://www.shapeamerica.org/standards/coaching/ default.aspx trudel, p., & gilbert, w. (2013). the role of deliberate practice in becoming an expert coach: part 3 creating optimal settings. olympic coach magazine, 24(2), 15-28. united states olympic committee. (2017). quality coaching framework. champaign, il: human kinetics. werthner, p., &trudel, p. (2006). a new theoretical perspective for understanding how coaches learn to coach. the sport psychologist, 20(2), 198-212. doi:10.1123/tsp.20.2.198 whatman, c., walters, s., schluter, p. (2018). coach and player attitudes to injury in youth sport. physical therapy in sport, 32, 1-6. doi:10.1016/j.ptsp.2018.01.011 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 34 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe wilcox, s., &trudel, p. (1998). constructing the coaching principles and beliefs of a youth ice hockey coach. avante, 4, 39-66. appendix national standards for sport coaches (shape america, 2019) set vision, goals and standards for sport program 1. develop and enact an athlete-centered coaching philosophy. 2. use long-term athlete development with the intent to develop athletic potential, enhance physical literacy, and encourage lifelong physical activity. 3. create a unified vision using strategic planning and goal-setting principles. 4. align program with all rules and regulations and needs of the community and individual athletes. 5. manage program resources in a responsible manner. engage in and support ethical practices 6. abide by the code of conduct within their coaching context. 7. model, teach and reinforce ethical behavior with program participants. 8. develop an ethical decision-making process based on ethical standards. build relationships 9. acquire and utilize interpersonal and communication skills. 10. develop competencies to work with a diverse group of individuals. 11. demonstrate professionalism and leadership with all stakeholders. develop a safe sport environment 12. create a respectful and safe environment which is free from harassment and abuse. 13. collaborate with program directors to fulfill all legal responsibilities and risk management procedures associated with coaching. 14. identify and mitigate physical, psychological and sociocultural conditions that predispose athletes to injuries. 15. monitor environmental conditions and modify participation as needed to ensure the health and safety of participants. 16. reduce potential injuries by instituting safe and proper training principles and procedures. 17. develop awareness of common injuries in sport and provide immediate and appropriate care within scope of practice. 18. support the decisions of sports medicine professionals to help athletes have a healthy return to participation following an injury. 19. model and encourage nutritional practices that ensure the health and safety of athletes. 20. provide accurate information about drugs and supplements to athletes and advocate for drug-free sport participation. create a positive and inclusive sport environment 21. implement a positive and enjoyable sport climate based on best practices for psychosocial and motivational principles to maximize athlete and team well-being and performance. 22. build inclusive practices into the program for all groups (e.g., race/ethnicity, gender/gender identity/gender expression, religion, socioeconomic status, sexual orientation, nationality, etc.) which are aligned with current legal and ethical guidelines. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 35 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 23. understand the importance of including athletes with disabilities in meaningful participation in established sport programs and consider options for athletes who cannot participate in traditional sport opportunities. conduct practices and prepare for competition plan 24. create seasonal and/or annual plans that incorporate developmentally appropriate progressions for instructing sport-specific skills based on best practices in motor development, biomechanics, and motor learning. 25. design appropriate progressions for improving sport-specific physiological systems throughout all phases of the sport season using essential principles of exercise physiology and nutritional knowledge. 26. plan practices to incorporate appropriate competition strategies, tactics and scouting information. 27. incorporate mental skills into practice and competition to enhance performance and athlete well-being. 28. create intentional strategies to develop life skills and promote their transfer to other life domains. 29. understand components of effective contest management. teach 30. know the skills, elements of skill combinations and techniques, competition strategies and tactics, and the rules associated with the sport being coached. 31. develop and utilize pedagogical strategies in daily practices. 32. craft daily practice plans based on sound teaching and learning principles to promote athlete development and optimize competitive performance. 33. use appropriate motivational techniques to enhance performance and athlete engagement during practices and competitions. assess 34. implement appropriate strategies for evaluating athlete training, development and performance. 35. engage athletes in a process of continuous self-assessment and reflection to foster responsibility for their own learning and development. adapt 36. adjust training and competition plans based on athlete needs and assessment practices. 37. use strategic decision-making skills to make adjustments or improvements or change course throughout a competition. strive for continuous improvement 38. regularly engage in self-reflection or peer-reflection to deeply examine situations, generate potential solutions, and think through those solutions. 39. develop an evaluation strategy to monitor and improve staff and team performance. 40. improve coaching effectiveness by seeking to learn the latest information on coaching through various avenues of coach development. 41. engage in mentoring and communities of practice to promote a learning culture and continual improvement. 42. maintain work-life harmony and practice self-care to manage stress and burnout. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 68 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe factors influencing the use of fitness and recreation centers by college students john l. castle, susan m. smith and david a. jones abstract: the rising rates of obesity and other chronic diseases among college students have led to a growing demand for fitness and recreation centers on college campuses. these centers offer a variety of services, such as exercise classes, intramural sports, and health and wellness programming, to help students improve their overall health and well-being. keywords: fitness and recreation centers, college students, obesity, chronic diseases, health and wellness introduction over the past several years, factors relating to the overall health and wellness of college students have caused colleges and universities to adapt their recreational services to the student population. these services include student recreation centers and/or fitness centers, exercise classes, intramural programs, and health and wellness programming to enhance opportunities for physical fitness and an overall improvement in health status of college students. in response to the rise in obesity rates, society is looking toward fitness and recreation centers as a contributing factor in trying to combat this nationwide problem, which is affecting millions of young adults (watson, ayers, zizzi, & naoi, 2006). the construction of student fitness and recreation centers on college campuses has become a massive business over the last several years (miller, noland, rayens, & staten, 2008). although society has recognized the need for recreational facilities in improving overall quality of life in the student body, it is reported that college age students are not getting an adequate amount of physical activity. kilpatrick, hebert, & bartholomew (2005) state that the level of physical activity declines from high school to college, and activity patterns in college populations are generally insufficient to improve health and fitness. specifically, only 38% of college students participate in regular vigorous activity. only 20% participate in regular moderate activity. estimates suggest that up to 50% of college students do not use their student recreation centers (src) (nirsa, 2002). more seriously, it is also reported that almost half of college students report a decrease in physical activity after graduation. many students are already sedentary upon entering college and physical activity levels further decline during the college years (caspersen, pereira, & curran, 2000). sedentary behavior is related to increased risk of death as a result of the development of chronic disease as well as depression and anxietyrelated problems (camacho, roberts, lazarus, kaplan & cohen, 1991). “for college students in particular, physical activity protects against unhealthy weight gain, a means to manage the effects of the stresses of college life, and early prevention against future chronic disease” (miller et al., 2008, mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 69 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe p.87). bryant, banta & bradley (1995) suggest that the primary reasons for students leaving schools (lack of fit, inadequate social opportunities, and poor grades) may all be reduced through the use of a src. to improve the effectiveness of these on-campus fitness and recreation centers, administrators, directors, and managers need to be aware of factors related to fitness and recreation center usage within the college setting. for this reason, it is important for fitness and recreation center managers and directors at colleges and universities to implement a campus facility with adequate health and wellness programs to ensure effective recruitment and retention of their students as well as overall health and wellness. this will serve as an outlet for students to create healthy behaviors during college, so they may continue them into their personal and professional lives after graduating. problem statement the purpose of this research is to investigate the factors related to usage of fitness and recreation centers on college campuses. this study will analyze specific demographics and the reasoning behind their pattern of usage. research questions 1. what are the factors that influence fitness and recreation center participation? 2. do specific demographic factors such as gender, ethnicity, alcohol and tobacco consumption have an effect on fitness and recreation center participation? 3. what are the primary factors that contribute to male and female non-usage in college fitness and recreation centers? 4. what are the primary factors behind male and female motivation to use college fitness and recreation centers? 5. does motivation in relation to on-campus, off-campus, and commuter living situations have an effect on usage of fitness and recreation centers? limitations 1. this study assessed only one institution in western pennsylvania, so data cannot be used to generalize college students as a whole. 2. this research does not take into great detail the adequacy or inadequacy of the campus recreational facilities or their programs. 3. knowledge of existing facilities may affect participants’ responses to the survey. review of literature the purpose of this study is to assess factors related to usage of campus fitness and recreation centers by college students. the review of literature will examine a.) the prevalence of obesity in society coupled with a lack of physical activity in college students, b.) how colleges and universities are using recreational facilities as a recruitment and retention mechanism, and c.) the primary reasons behind students’ use of fitness and recreation centers. obesity and lack of physical activity the prevalence of obesity in america over the past several decades has been and continues to be a nationwide issue. in response to this issue, colleges and universities have been prompted to take considerable interest in their mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 70 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe fitness and recreational facilities and programs (miller, et al., 2008). the u.s. department of labor and the bureau of labor statistics (2009) reported that numerous college students engage in frequent sedentary behavior including spending hours in classrooms, time on school work and studying, using computers, and using video gaming systems. the importance of physical health within the student body is a concern for university administrators in attempting to tackle the obesity issue. providing adequate health and wellness facilities and programs is pivotal in enhancing student wellness. ogden and carroll (2010) indicated that an estimated 34.2% of u.s. adults age 20 and older are overweight, 33.8% are obese, and 5.7% are extremely obese. body mass index (bmi) is frequently used when categorizing extreme weight conditions such as: overweight, with a bmi of 25.0– 29.9, obesity, with a bmi greater than or equal to 30.0, and extreme obesity, with a bmi greater than or equal to 40.0 (ogden and carroll, 2010). sax (1997) determined that a student’s health and wellness in college years are paramount in determining healthy behavioral lifestyles throughout adulthood. this period of time in a student’s life is when he or she develops behaviors that will either improve or discourage their overall quality of life in the future. the years a student spends in college are a period of time when primary causes of death and disease are significantly linked to the risky behavior choices of the individual (sax, 1997). enhancing student wellness has been a point of emphasis for colleges and universities over the past several decades (keating, guan, pinero, & bridges, 2005). in 2006, the national college health assessment was distributed and results from 94,806 students were obtained. five health problems were identified, including (1) alcohol, tobacco, and other drug use, (2) sexual health, (3) weight, nutrition, and exercise, (4) mental health, and (5) personal safety and violence (acha, 2006). addressing these issues is a very important step in promoting health and wellness to college students. benefits of physical activity have been rigorously documented in the literature. specifically for college students, involvement in physical activity helps protect against weight gain, prevents possible chronic disease, and provides a mechanism for managing stress in college life (miller et al., 2008). particularly, “only 38% of college students participate in regular vigorous activity, and only 20% participate in regular moderate activity” (kilpatrick et al., 2005, p.87). a cross-sectional study by jones, ainsworth, croft, macera, lloyd, and yusuf (1998, p. 285) reported that “65% of college-age women and 61% of college-age men do not meet the centers for disease control and prevention-american college of sports medicine (acsm) guidelines for moderate physical activity.” this excessive display of sedentary behavior is closely associated with risk of death from the development of chronic diseases (blair, kampert, kohl, barlow, macera, paffenbarger, & gibbons, 1996) as well as depression and anxiety issues (camacho et al., 1991). these illnesses are currently present in 20-30% of the adult population within the united states (kessler, mcgonagle, zhao, nelson, hughes, eshleman, wittchen, & kendler, 1994). these numbers represent a dramatic drop in physical activity within the transition period from high school to college life. in a recent study on the impact of new campus recreation centers by zizzi, ayers, watson, & keeler (2004), it was reported that rates of physical activity in the united states have not improved over the last 20 years regardless of significant funds spent on educational and informational programming (buckworth, 2000; dishman, 1994; usdhhs, 2000). mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 71 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe usage patterns students’ initial decision to begin attending fitness and recreation centers as well as their decision on sustained usage involves many different factors. willis and campbell (1992) discuss five motivationsfitness, appearance, pleasure, social factors, and mental recreationfor engaging in physical activity. it has also been reported that age is the most significant factor in influencing involvement and adherence in sport and physical activity (rudman, 1989). in a study by bryant et al. (1991), it was determined that 30% of initial enrollment decisions were a result of the quality of the campus recreational facilities. adequacy or inadequacy of facilities, therefore, is suggested to play a factor in usage or non-usage.in a study on characteristics of users and non-users, participants completed an internet survey which yielded results that high-users had higher gpas, lower fat intake, lower bmis, and smoked less when compared with the moderate and non-user groups. the non-user group had significantly more time invested in electronic media as compared to the high-user group. this data suggests that the association between student academics and health measures is positively correlated with campus recreational facilities (todd et al., 2009). in an extensive study completed in 2004, zizzi et al. assessed the impact of new student recreation centers. the researchers obtained results from two surveys. one was developed as a “user” survey meant for students who reported using their recreational facility or recreational programs on campus. the other was a “non-user” survey for students who reported not using these facilities or programs. their results revealed similar results in that more users lived on campus, were non-smokers, had been high school athletes, and currently categorized themselves as regular exercisers as compared with non-users. three main characteristics were determined to be motivating factors in users of student recreation centers. these motivations included staying in shape, aiding in fat loss, and increasing self-esteem. in regards to exercise barriers, lack of time, feeling too tired, other time commitments, and inconvenience prevented non-users from using the recreational facilities. the study also provided data to suggest that the construction of recreation centers on college campuses may promote regular physical activity from previously sedentary students. in this particular study, 40% of users reported that they were not exercising on a regular basis prior to the construction of the recreation center on their campus. drummond and lenes (1997) take a broader look at the fitness industry and factors for initial involvement and sustained participation. they identify eight reasons for joining including socialization, intrinsic motivation, extrinsic motivation, aquatic-related facilities, recreational facilities, resistance equipment, aerobic equipment, and amenities. several of these characteristics overlap with usage patterns found in that of students on college campuses.in a study by miller et al. (2008), researchers aimed to determine demographic, psychosocial, and environmental characteristics associated with physical activity. sallis, bauman, and pratt (1998) stated that the convenience of exercise facilities is significantly associated with physical activity. this supports the idea that students who live on campus are more likely to take advantage of the student recreation centers and fitness centers as opposed to students living off campus. huston, evenson, bors & gizlice (2003) have stated that individuals who have convenient access to facilities for physical activity are nearly twice as likely to take advantage of these facilities when compared with individuals without this access. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 72 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe a study done by haines (2001) also supported this idea of convenience in relation to living arrangement and fitness facility location. results from nirsa’s quality and importance of recreational sports instrument taken by students at a large mid-western university indicated that 75% of males and 62% of females reported that the accessibility of recreational facilities and programs on campus was a significant predictor of initial enrollment at a specific college or university as well as their decision to stay at that university. results of a study by miller et al. (2008), assessing characteristics of users and nonusers revealed that males were more likely to use the recreational facilities as opposed to females. students participating were more likely to be lower-standing students (freshman and sophomores), and more likely to live on campus. fraternity and sorority members used the facilities more than non-greek students. users had overall lower bmis than non-users, and students reporting consuming alcohol within the past month were more likely to use the recreational facilities than students who did not consume this amount. a logistic regression model was also used to determine certain predictors of usage, including, “sex, class standing, living situation, belonging to a fraternity or sorority, and the desire to change one’s weight” (miller et al., 2008, p.93). perceived benefits to participation also play a significant role in fitness and recreation center initial involvement and continued use. banta, bradley & bryant (1991) evaluated the significance of campus recreation programs at six different universities. results from their data collection using nirsa’s qirs instrument revealed the most frequent responses to benefits of recreational sports. these responses included “stress reduction, feeling of physical well-being, sense of accomplishment, weight control, sport skills, physical strength, fitness, and friendship. methodology the purpose of this study was to investigate factors that influenced fitness and recreation center usage or nonusage within undergraduate students at a university located in western pennsylvania. specifically, this study aimed to evaluate the rationale behind students’ use or lack of use of the recreational facilities and programs provided to them on campus through their activity fee. the primary objectives in this study were to (a) determine and comprehend the factors that influenced fitness and recreation center usage and non-usage (b) investigate whether specific demographic factors had an effect on fitness and recreation center participation and to (c) determine usage in relation to location of living situation at college. participants participants included a random sample of 1,100 students from the entire undergraduate population at the university totaling 12,827 students. the study aimed to analyze factors related to patterns of use in fitness and recreation centers within a higher education institution. students were both male and female enrolled at the university for the spring semester and were between the ages of 18-25. the students’ participation was completely voluntary. instrumentation this study used a quantitative research design, and collected data through a descriptive 26-item adapted online questionnaire. the survey was distributed through qualtrics©to students through their university email account. questions included multiple choice, short-answer, text-box entry, and likert-type scale questions. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 73 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe several of the questions included in the survey were adapted and revised from a survey by zizzi et al. (2004), “assessing the impact of new student recreation centers.” this study combined user and non-user surveys developed by zizzi et al. (2004), into one 26item online questionnaire. for this research, a pilot study was conducted to ensure validity and reliability of the self-developed questionnaire used for data collection within the study. a cronbach’s alpha coefficient calculated for the 48 variables was .879, respectively. a cronbach’s alpha coefficient is used to measure internal consistency or reliability, and the minimally acceptable objectivity is .70 (baumgartner & hensley, 2006, p. 330). the closer the value is to 1.00 the greater the reliability. the results of the data analysis indicated that the variables had strong internal validity. question 11 of the survey was not included in the cronbach’s alpha analysis because of the insufficient number of variables reported. in addition, the questions were analyzed by a panel of experts within the health and physical education department at the institution, who had significant backgrounds in health and promotion, sport management, and exercise science. surveys are frequently used in the sport industry because of their efficiency and effectiveness. the advantages of electronic surveys include economic feasibility, timely distribution, and a quicker response rate. electronic surveys can be just as effective as mailed surveys (andrews, nonnecke, & preece, 2003; taylor, 2000; yun & trumbo, 2000). according to andrews, et al. (2000), it is not uncommon when receiving electronic responses to get a response rate of 20% or lower. this response rate is actually considered to be significant for online responses. the survey was designed to assess the rationale behind student participation in university fitness and recreation centers. demographic factors such as age, gender, ethnicity, status at institution, athlete or non-athlete, and grade point average were included. this survey was submitted to both departmental health and physical education and university wide institutional review board for human subject approval. procedure and design analysis patterns of usage and non-usage of campus recreational facilities were assessed using the 26-item adapted online questionnaire. it was explained to the subjects that their participation in the survey and research was voluntary and that all information would be kept completely anonymous by the researcher. the survey was distributed through the qualtrics program on march 15, 2011, and the timetable for data collection lasted for 5 weeks. the software distributed the survey to a random sample of 1,100 students within the entire undergraduate population. the panel was randomly constructed by the applied research laboratory. once the panel was created, the researcher began to send initial emails to the students, which included a brief introductory statement of purpose and a link to the survey included within the email. the students had 5 weeks to complete the survey. during week two, a follow-up email was sent reminding students who had not yet participated that the opportunity was still available. a third follow-up email was sent on week three and week four. within the follow-up emails, a brief introduction described the study and informed the students who had not participated that the questionnaire was still available. consent was implied if students opted to take the survey. after the five-week period, the survey deactivated and was no longer accessible to the students. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 74 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe the statistical association between motivation and participation was tested using chisquare, correlation, and frequencies method of data analyses. motivation in relation to living arrangements and usage of the campus recreational facilities was tested using a one-way analysis of variance (anova). all variables were tested using the statistical package for the social sciences (spss) version 19 software. data and analysis the purpose of this study was to investigate usage patterns of campus fitness and recreation centers by students on college campuses. the following questions were addressed: 1.) what are the factors that influence fitness and recreation center participation? 2.) do specific demographic factors such as gender, ethnicity, alcohol and tobacco consumption have an effect on fitness and recreation center participation? 3.) what are the primary factors that contribute to male and female non-usage in college fitness and recreation centers? 4.) what are the primary factors behind male and female motivation to use college fitness and recreation centers? 5.) does motivation in relation to on-campus, off-campus, and commuter living situations have an effect on the usage of fitness and recreation centers? response rate 1,100 male and female undergraduate students at indiana university of pennsylvania were emailed the questionnaire used in this study. there were 186 responses recorded in qualtrics as completing the survey in its entirety for a response rate of 16.9%. the 95% confidence interval for a true response rate is between 14.7% and 19.1%. results the first part of the questionnaire consisted of demographic information of the respondents and also addressed living situation, alcohol use, use of tobacco, grade point average, involvement in extra-curricular activities, and if the respondent uses or does not use the recreational facilities provided to them on campus. demographics of the students that participated, 53.2% were females and 22.6% were males (99 females, 42 males). there were 45 respondents that did not specify either male or female (24.2%). there were 76% of females and 83% of males who reported being recreational facility users. overall, 77.6% of the respondents were users, and 22.4% were non-users. the most represented ethnicity of the respondents was caucasian (88%) with the next most represented ethnicity being african american (5.7%). table one displays the respondents’ year in college, which is distributed fairly evenly across the different grade levels. table 1: year in college of respondents year in college frequency percent freshman 45 24.2 sophomore 29 15.6 junior 34 18.3 senior 34 18.3 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 75 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe no response 44 23.7 total 186 100.0 note: table 1 illustrates respondents’ year in college, number of variables represented, and percentage from the entire sample of students. figure one displays the age of the respondents with a majority of both males and females being age 21 and below. in regards to living situation, 93% of students reported living either on-campus, or off-campus within one mile of the university. in regards to tobacco use and alcohol consumption, 81.7% of the respondents reported that they never use any form of tobacco. figure 3 illustrates the distribution of alcohol consumption on a weekly basis reported by the respondents. thirty-three percent (n= 47) reported that they do not consume alcohol and 26% (n= 37) reported drinking more than five drinks per week. the second portion of the questionnaire assessed factors related to users and nonusers. when respondents were asked if they used the recreational facilities provided to them on campus, 77.6% reported that they do use the facilities, and 22.4% reported not using the facilities as illustrated in figure 4. usage 0 5 10 15 20 25 30 35 40 18 19 20 21 22 23 23 and above age of respondents figure 1. distribution of ages of college students figure 1. age ranges of both male and female respondents. 0 20 40 60 does not consume 1 2 drinks 3 4 drinks 5 6 drinks 6+ drinks number of drinks figure 3. alcoholic drinks consumed per week mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 76 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe in determining the factors that influence fitness and recreation center participation, including demographic factors, a non-parametric chi-square goodness of fit test was calculated comparing the frequency of occurrence of each variable that influenced fitness and recreation center usage. it was hypothesized that gender, year in college, ethnicity, living situation, having health concerns, who the respondents attend the facilities with, and means of transportation would all be significant factors in determining fitness and recreation center several variables were found to be statistically significant in influencing fitness and recreation center participation. all of these variables were significant at the p<.01 level. the following variables were found to be statistically significant factors that influenced fitness and recreation center participation: who students attend the facilities with (sometimes by themselves and sometimes with friends); means of transportation the respondents primarily use to get to the facilities (mainly walking); gender; ethnicity; age; living arrangement in proximity to the recreational facilities; extra-curricular activities; time of day (most often in evening hours); how often respondents used the facility within the last month; length of time spent at the facility; tobacco use; and alcohol consumption. the different types of activities that the respondents said they performed while at the fitness and recreational facilities was also a statistically significant factor that influenced usage at the p<.001 level. specific time of day that students choose to attend the fitness and recreation centers is a statistically significant factor that influences usage with 60% of respondents reporting they would use the facilities between 6pm and 10pm. the primary activities students engage in at these facilities are cardiovascular and resistance training. year in college was not a significant factor in influencing usage, p<.277. table two and figures five through nine provide information on factors that affect fitness and recreation center usage.from the information illustrated within the following figures the researcher can suggest that since a large majority of participants responded that they indeed use the facility, table 2: chi-square results of factors that influence usage variable df x² p value time of day 2 10.400 .006 health concerns 3 54.750 .000 transportation 3 205.333 .000 participation. 0 20 40 60 80 100 120 usage or non usage figure 4. usage versus non usage figure 4. illustration of female and male respondents who reported using or not using the users non users mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 77 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe who respondents attend with 3 30.741 .000 gender 1 23.043 .000 ethnicity 4 407.759 .000 age 6 49.169 .000 living situation 2 46.420 .000 extra-curricular activities 5 147.183 .000 tobacco use 3 245.887 .000 alcohol consumption 4 25.077 .000 attended within the last month 4 20.056 .000 length of time at facility 6 47.868 .000 note: table 2 illustrates the specific variable that influences usage. df= degrees of freedom, x²= chi-square value, *p>.01several trends become apparent. users of the fitness and recreation centers are more likely not to have any health concerns. they spend about 45 minutes to 1 hour at the facility where they mainly perform cardio and resistance training, and their primary means of transportation to the facilities is walking. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 78 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 79 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 0 20 40 60 80 100 120 yes no figure 7. cardiovascular activity performed at the facilities figure 7. illustration of respondents who reported cardiovascular activity as the primary activity they perform while at the recreational facilities. 0 10 20 30 40 50 60 70 80 90 100 yes no figure 8. resistance training performed at facilities figure 8. results of respondents whose primary activity perfromed at the recreational facilities is resistance training. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 80 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe non-usage when conducting a pearson chi-square test for independence, the researcher observed factors related to male and female non-usage. thirty-one out of 186 respondents reported factors that attributed to their non-usage. a chisquare test of independence was calculated comparing factors related to non-usage. the only statistically significant relation found (x²(4) = 10.571, p<.032) between male and female non-usage was the location of the facilities being too far away from the respondents’ living arrangement. the researcher can suggest that proximity of the recreational facility to the student’s living arrangement can have an adverse effect on the participation of that individual. a chi-square test of independence was also calculated comparing factors related to reasons for usage. a pearson chi-square correlation was calculated showing a statistically significant relation (x² (4) = 21.046, p<.000) between male and female usage and maintaining their weight as a motivational factor to use the facilities. a statistically significant relation was also found between male and female usage and losing weight as a factor in their usage (x² (4) = 19.234, p<.001). increasing self-esteem, overall health and fitness, stress relief, and prevention of health problems were not significant factors in respondents’ motivation to use the recreational facilities. users also reported factors that influenced their occasional nonusage. a chi-square test of independence was also calculated comparing male and female occasional non-usage. a pearson chi-square correlation revealed that a statistically significant relation was found between male and female occasional non-usage and lack of time as a motivational factor (x² (4) = 13.252, p<.010). a statistically significant relation was also found between male and female occasional usage and lack of energy as a contributing factor (x² (4) = 11.147, p<.025), as well as too much schoolwork (x² (3) = 10.109, p<.018), 0 10 20 30 40 50 60 70 80 90 100 campus bus walk bicycle, skateboard, scooter vehicle types of transportation figure 9. means of transportation figure 9. distribution of different types of transportation respondents reported using to get to the recreational facilities on campus. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 81 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe inadequate facility operational hours suitable to the respondents’ schedule (x² (4) =10.071, p<.039), and respondents’ hesitancy to want to invest financially in classes offered at the facilities (x² (4) =21.494, p<.000). a pearson chi-square correlation was calculated comparing the benefits experienced by male and female users. data revealed that both males and females reported perceived strength gains as a benefit of usage (x² (2) = 6.140, p<.046). this was the only statistically significant variable found in relation to benefits experienced from using the recreational facilities. a one-way anova (analysis of variance) was calculated comparing the location of the respondents’ living arrangement (on-campus, off-campus, and commuter) and its influence on their usage of the recreational facilities on campus. for the first question within table 3, minimum and maximum values one through five represent choices on the questionnaire: 1 = never, 2 = 1-5 times, 3 = 5-10 times, 4 = 1020 times, and 5 = 20-30 times. there were 108 respondents who answered the question, 103 of them live either on-campus or off-campus within one mile of the university. the respondents reported using thefacility between five and 20 times within the last month. the mean for on-campus was m= 3.97 and the mean for off-campus within one mile was m= 3.71. for the second question, minimum and maximum values two through seven represent successively greater lengths of time table 3: living arrangement and influence on usage how often has the respondent usedthe facilities within the last month? n mean std. deviationstd. error min. max. ______ on-campus 58 3.97 1.633 .214 off-campus, 1 5 within 1 mile 45 3.71 1.590 .237 1 off-campus, 5 greater than 1 mile 5 3.60 1.673 .748 2 total 108 3.84 1.607 .155 1 5 how long does the respondent spend at the facilities? 5 n mean std. deviation std. error min. max.___ on-campus 58 4.90 1.495 .196 2 7 off-campus, within 1 mile 43 4.53 1.453 .222 2 7 off-campus, greater than 1 mile 5 5.40 1.673 .748 4 7 total 106 4.77 1.488 .145 2 7 ______ mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 82 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe note: n= number of respondents, std. deviation = standard deviation from the mean, std. error = standard error of the mean, min = minimum value respondents chose on the question, max = max value respondents chose on questionnaire. that student spends at the recreational facilities. respondents who live on-campus or off-campus within one mile reported spending between one hour to one and one half hours at the facilities. respondents who live off-campus greater than one mile reported spending between one and one quarter hours to one and three quarter hours at the facilities. no statistically significant difference was found (f (2,105) = .373, p>.05), (f (2,103) = 1.198, p>.05) between both variables (how often have respondents’ used the recreational facilities provided to them within the last month, and how long do they spend at the recreation center when they are there) and their living arrangement while attending college. respondents were also asked their opinion on how college and university directors and administrators can recruit more students to take advantage of the facilities, what they believe prevents students from using the facilities on campus, and their overall opinion on the facilities and programs located on their campus. using a pearson chisquare test for independence, the researcher found that to recruit more students to use the facilities, respondents said that fitness and recreation center managers should offer promotional deals such as a percentage off of a user’s membership if he or she gets a friend to join (x² (4) = 12.159, p<.016) as well as having personal trainers available (x²(4) = 10.857, p<.028). table 4: anova results how often has the respondent usedthe facilities within the last month? sum of squares df mean square f sig. between groups 1.949 2 .974 .373 .690 within groups 274.375 105 2.613 total 276.324 107 how long does the respondent spend at the facilities? sum of squares df mean square f sig. between groups 5.289 2 2.645 1.198 .306 within groups 227.277 103 2.207 total 232.566 105 note: analysis of variance of variables associated with how often respondents use the facilities. df = degrees of freedom, f = ratio of explained to unexplained variance, sig. = significance level. a chi-square was also calculated when analyzing what the respondents’ felt was the reason behind students’ nonusage on campus. a pearson chi-square test for independence revealed that respondents believed that being too lazy was a statistically significant factor related to student non-usage (x²(4) = 13.318, p<.010) as well as not knowing how to properly use the machines in the facilities (x²(4) = 9.630, p<.047). mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 83 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe even though a vast majority of the participants reported being users of the campus recreational facilities, a significant number of students stated that they would still attend a university even if it did not provide them with a campus fitness and/or recreation center (x² (4) = 10.395, p<.034). when asked if the student fitness and/or recreation centers on campus were a factor in their decision to attend the university, 86 out of 108 (79.6%) respondents stated that the facilities were ultimately not a factor in their decision to attend the university. summary, conclusion and future directions findings from this research suggest that there are specific factors that significantly influence fitness and recreation center participation by students on college campuses. according to the data obtained from this research, males are more likely to use their recreational facilities on campus than females, and there are an overwhelmingly larger number of users as opposed to non-users. however, as the research has shown, students still are not exercising as much as they should be. approximately 87.9% of respondents were caucasian, so this data cannot be generalized to represent all ethnicities and races of college students as a whole. however, this did represent well over three quarters of the ethnicities at the institution as a university with 11,746 being caucasian out of a total 12,827 undergraduate students. comparisons should only be made to institutions with similar recreational opportunities and facilities with students of a much similar demographic. further research in the area of fitness and recreation center usage should look at the college population as a whole and over time, perhaps a longitudinal study across the students’ entire collegiate career. most students reported living either on-campus or off-campus within one mile of the university. the data from this research is fairly consistent with results from prior studies (watson et al., [2006]; zizzi et al., [2004]; miller et al.,[2008]). we can suggest that users are more likely to be male, caucasian, non-smokers, live on-campus or off-campus within a mile of the college or university, age 21 and under, not involved in any type of extracurricular activity, and have no health concerns. users’ primary means of transportation to the recreational facilities on-campus is walking, and the main activities they perform at the facilities are resistance training and cardiovascular training. factors related to motivation to use include maintaining and losing weight. the most statistically significant factor related to benefits from usage was reported to be perceived strength gains. factors related to occasional non-usage within the user population included lack of time within the respondents’ schedule to allot to utilizing the fitness and recreational facilities, lack of energy, too much schoolwork, and inadequate operational hours that do not suit the respondent’s schedule. the most statistically significant factor found to influence non-usage was living arrangement and how far in comparison the respondent was located to the recreational facilities. the farther away the respondent lived from the facilities, the less likely they were to attend. the data showed that females were less likely to use the fitness and recreational facilities as opposed to their male counterparts. when asked what universities can do to increase student recruitment and retention efforts of the fitness and recreational facilities on campus, respondents stated that offering promotional deals such as discounts off of membership prices and having certified personal trainers available would assist in providing incentives for students to participate. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 84 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe although a large majority of the respondents were users, a significant number of students reported that they would still attend a university that did not provide them adequate recreational facilities. future directions further research is necessary to evaluate the importance of campus fitness and recreation centers. understanding factors related to usage and the patterns of use within each student demographic will be paramount in understanding how to target different populations to successfully increase physical activity through fitness and recreation center participation. the main demographic that colleges and universities should focus on targeting is the female population, students age 21 and above, as well as different minority races and ethnicities. it would be beneficial for future research to focus solely on non-user demographic groups assessing their rationale for nonusage. if colleges and universities can successfully implement an initiative such as an incentive program to increase participation, students may be more inclined to use the facilities because of the idea of positive reinforcement. understanding perceived barriers to participation such as proximity to the facility, lack of time, and inadequate operational hours can assist university administrators and fitness and recreational facility directors in reevaluating their efforts to better accommodate the college population to help ensure overall student success and well-being. references american college health association. (2007). american college health association national college health assessment spring 2006 reference group data report. journal of american college health, 55, 195-206. andrews, a., nonnecke, b., & preece, j. (2003). electronic survey methodology: a case study in reaching hard to involve internet users. international journal of human-computer interaction, 16(2), 185-210. banta, t. w., bradley, j., & bryant, j. (eds.). (1991). quality and importance of recreational services: technical manual and survey. corvallis, or: nirsa. baumgartner, t. a., & hensley l. d. (4th ed.)(2006). conducting & reading research in health & human performance. new york, ny: mcgraw-hill. blair, s. n., kampert, j. b., kohl iii, h.w., barlow, c. e., macera, c. a., paffenbarger, r.s., & gibbons, l.w. (1996). influences of cardiorespiratory fitness and other precursors on cardiovascular disease and all-cause mortality in men and women. journal of the american medical association, 276, 205-210. bryant, j. a., banta, t. w., & bradley, j. l. (1995). assessment provides insight into the impact and effectiveness of campus recreation programs. naspa journal, 32, 153160. buckworth, j. (2000). physical activity determinants and interventions. international journal of sport psychology, 31, 305-320. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 85 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe camacho, t.c., roberts, r. e., lazarus, n. b., kaplan, g. a., & cohen, r. d. (1991). physical activity and depression: evidence from the alameda county study. american journal of epidemiology, 143, 220-231. caspersen cj, pereira ma & curran km. (2000). changes in physical activity patterns in the united states, by sex and cross-sectional age. medicine and science in sportsand exercise. 32(9), 1601-1609. dishman, r. k. (ed). (1994). advances in exercise adherence. champaign, il: human kinetics. drummond, j. l., & lenes, h. s. (1997). the fitness facility membership questionnaire: a measure for reasons for joining. perceptual and motor skills, 85, 907-916. haines, d. (2001). undergraduate student benefits from university recreation. nirsa journal, 25, 25-33. huston, s. l., evenson, k. r., bors, p., & gizlice, z. (2003). neighborhood environment, access to places for activity, and leisure-time physical activity in a diverse north carolina population. american journal of health promotion, 18, 58-69. jones, d. a., ainsworth, b. e., croft, j. b., macera, c. a., lloyd, e. e., & yusuf, h. r. (1998). moderate leisuretime physical activity: who is meeting the public health recommendations? a national cross-sectional study. archives of family medicine, 7, 285289. keating, x., guan, j., pinero, j., & bridges, d. (2005). a meta-analysis of college students’ physical activity behaviors. journal of american college health, 54, 116-125. kessler, r. e., mcgonagle, k. a., zhao, s., nelson, c. b., hughes, m., eshleman, s., wittchen, h. u., & kendler, k. s. (1994). lifetime and 12-month prevalence of dsm-iii-r psychiatric disorders in the united states. archives of general psychiatry, 51, 8-19. kilpatrick, m., hebert, e., & bartholomew, j. (2005). college students’ motivation for physical activity: differentiating men’s and women’s motives for sport participation and exercise. journal of american college health, 54(2), 87-94. miller, k. h., noland, m., rayens, m. k., & staten, r. (2008). characteristics of users and non-users of a campus recreation center. recreational sports journal, 32, 87-96. national intramural-recreational sports association [nirsa]. (2002). 2002 national intramural-recreational sports association recreational sports report. unpublished paper. ogden, c. l., & carroll, m. d. (2010). prevalence of overweight, obesity, and extreme obesity among adults: united states, trends 1976-1980 through 2007-2008. centers for disease control and prevention. atlanta, mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 86 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe ga. retrieved from http://www.cdc.gov/nchs/data/hestat/obesity_adult_07_08/obesity_adult_07_08.pdf. rudman, w., j. (1989). age and involvement in sport and physical activity. sociology of sport journal, 6, 228246. sallis, j. f., bauman, a., & pratt, m. (1998). environment and policy interventions to promote physical activity. american journal of preventative medicine, 15, 379-397. sax, l. (1997). health trends among college freshmen. journal of american college health, 45, 252-262. taylor, h. (2000). does internet research work? comparing electronic survey results with telephone survey. international journal of market research, 42(1), 51-63. u.s. department of health and human services. (2000). healthy people 2010. retrieved february 2, 2011, from http://wwww.health.gov/healthypeople/document/html/uih/uih_bw/uih_4.htm. u.s. department of labor, bureau of labor statistics. (2009). american time use survey. retrieved from http://www.bls.gov/tus. watson, j. c., ayers, s. f., zizzi, s., & naoi, a. (2006). student recreation centers: a comparison of users and non-users on psychosocial variables. recreational sports journal, 30, 9-19. retrieved from sportdiscus with full text database. willis, j. d., & campbell, l. f. (1992). exercise psychology. campaign, il: human kinetics publishers. yun, g. w., & trumbo, c. w. (2000). comparative response to a survey executed by post, email, and web form. journal of computer mediated communication. zizzi, s., ayers, s. f., watson ii, j. c., & keeler, l. a. (2004). assessing the impact of new student campus recreation centers. naspa journal, 41(4), 588-630. mailto:topacademicjournals@gmail.com top health sciences research journal vol.7, issue 1; january-febuary 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/thsrj; mail: topacademicjournals@gmail.com 1 | t o p h e a l t h s c i e n c e s r e s e a r c h j o u r n a l | https://topjournals.org/index.php/thsrj risk factors for readmission of cardiac patients doe jane university of south dakota, beacom school of business, 414 e. clark street, vermillion, sd 57069, usa. abstract: hospital readmissions are a major problem in the united states, costing billions of dollars each year. this study aimed to identify the factors that can predict cardiac patient readmissions. a retrospective cohort study was conducted of patients who were discharged from a hospital with a diagnosis of heart failure. the risk of readmission was assessed using a variety of factors, including age, gender, race, ethnicity, comorbidities, and discharge medications. the results showed that the following factors were associated with an increased risk of readmission: age, female gender, black race, hispanic ethnicity comorbidities such as diabetes, chronic obstructive pulmonary disease, and chronic kidney disease discharge medications such as diuretics and beta-blockers a risk score was developed based on these factors and was found to be a significant predictor of readmission. this study provides valuable insights into the factors that can predict cardiac patient readmissions. the risk score developed in this study can be used to identify patients who are at high risk of readmission and to target interventions to prevent these readmissions. keywords: hospital readmission, cardiac patient, risk factors, risk score, heart failure, diuretics, betablockers introduction and motivation american health care consumers struggle to find balance between access to health care services, the cost of health care, and the quality of the health care. due to rising costs, new legislation, changing population health care needs, and discrepancies in defining quality, maximizing the value proposition within american health care is complicated. one approach has been the hospital readmissions reduction program (hrrp), part of the 2010 patient protection and affordable care act (ppaca), that penalizes hospitals with higher-than-expected readmission rates, up to 3% of their total medicare payments (http://go.cms.gov/1l93lh4). hospital readmissions, according to centers for medicare and medicaid, are common, costly, and most importantly correctable. more than 2,000 hospitals are penalized for readmission and therefore forfeit about $280 million in medicare funds annually. it is not just cost of unnecessary hospitalizations but a social impact (externalities) in lost wages and production as well as improvement in care. this study aims to identify the factors that can predict characteristics of cardiac patient readmissions. specifically, weaimed to achieve two goals: 1) identify significant risk factors that can predict cardiac patient readmissions and 2) develop a risk score for readmission and validate it. mailto:topacademicjournals@gmail.com http://go.cms.gov/1l93lh4 http://go.cms.gov/1l93lh4 top health sciences research journal vol.7, issue 1; january-febuary 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/thsrj; mail: topacademicjournals@gmail.com 2 | t o p h e a l t h s c i e n c e s r e s e a r c h j o u r n a l | https://topjournals.org/index.php/thsrj identification of risk factors that can predict, with varying levels of certainty, whether a cardiac patient will be readmitted following discharge from the hospital can advance the practice of medicine. more importantly, quality of care can be improved with providers mindful of characteristics in their patient population which can increase the risk of readmissions this type of risk scoring tool is customized to patient specific data, resulting in a more targeted approach. consequently, generalization of this score is possible across various regions. 1.2 literature review the u.s. healthcare system historically spends far more per capita on health care than the rest of the world. data from the world bank shows the u.s. spends approximately $9,146 for health per capita. only norway and switzerland spend more (the world bank, 2015). the patient protection and affordable care act (ppaca) is the first attempt to reduce cost while improving access, through insurance, and thus improving quality. success in these areas remains to be proven. in an attempt to juggle these varied attributes, numerous population health management (pm) initiatives are being developed in an attempt to provide systemic solutions (snowdon, 2014) hospital readmissions are found in 20% of medicare beneficiaries costing $19 billion annually. according to ban off, milner, rimar, greer and canavan (2016), heart failure (hf) is the most common of cardiac-related readmissions; alone it accounts for $1 billion. readmission risk assessment can be used to help target the delivery of these resource-intensive interventions to the patients at greatest risk. past studies have identified the benefit of interventions to reduce admissions. unfortunately, an effective readmission remains elusive.; transitional care interventions may reduce readmissions among chronically ill. (falvey, burke, malone, ridgeway, mcmanus, & stevens lapsley, 2016). readmission scores are not unique but often lack specificity to the disease at hand. van walraven and associates (2010) developed the lace index which relies on four variables; los (“l”), acuity of the admission (e.g., emergency admission) (“a”), charlson comorbidity index score (“c”), and the number of previous emergency department visits in the past 6 months (“e”). the lace index has been validated using a mix of medical and surgical patients. wang and colleagues (2014) test the lace index with patients with hf and find that the index does not predict unplanned readmission within 30 days reliably. similarly, in a study of general medical patients in the united kingdom, the lace index shows fair predictive value for 30-day readmission with a c-statistic of 0.55 (cotter, bhalla, wallis, & biram, 2012), and in medical patients in canada, the index identifies50% the patients readmitted within 30 days of discharge but does not identify the other half (gruneir et al., 2011). choudhry and coauthors (2013) have been developing allcause hospital readmission risk-prediction models to identify adult patients at high risk for 30-day readmission upon admission and discharge. unfortunately, the evidence to date points to a score that may generally identify readmission risk but fail in identifying specific to the cardiovascular population. within cardiovascular medicine, several attempts have been made to categorize readmission risk. a systematic review of statistical models to predict a hf patient’s risk of readmission by ross and colleagues (2008) reveal substantial inconsistencies in patient characteristics that are predictive of readmission in this population. most models rely on retrospective administrative data; however, a few relied on real-time administrative data. some of the models incorporate primary data collection, an effort that often creates limits practical application. banoff et. mailto:topacademicjournals@gmail.com top health sciences research journal vol.7, issue 1; january-febuary 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/thsrj; mail: topacademicjournals@gmail.com 3 | t o p h e a l t h s c i e n c e s r e s e a r c h j o u r n a l | https://topjournals.org/index.php/thsrj al. (2016) advance an automated algorithm within the emr which transitioned the model to a usable tool in the clinical setting called the hospital score. the hospital score includes seven variables: hemoglobin at discharge, discharge from oncology, sodium level at discharge, having a procedure, type of admission, number of admissions in past year, and los. the hospital score has fair discriminatory power for prediction of 30day readmission in medical patients (donze, aujesky, williams, & schnipper, 2013). however, the hospital score does not include information from nursing assessments in their estimation of risk for 30-day readmission. both also lack data on the patient’s condition throughout the hospitalization. valid risk adjustment methods are required for calculation of risk-standardized readmission rates, which are used for hospital comparison, public reporting, and reimbursement determinations. models that are designed for these purposes will have good predictive ability; be deployable in large populations; use reliable data that can be easily obtained; and use variables that are clinically related to and validated in the populations in which use is intended. this can be very easily automated and is very convenient for physicians charged with making discharge decisions. this risk score formula provides an opportunity to identify high risk patients at the time of discharge. it may help them enroll in preventive programs, if the doctor recommends such action and increase reimbursement potential from third party payers. this risk score can be used as a proactive measure to screen out high risk patients. this formula groups cardiac patients in to three groups: low risk; medium risk and high risk based on ranges of the risk score. the risk score is based t-test results and on chi-square values from logistic regression results. the statistical results are based large sample and hence reliable. 2. methodology statistical results have been obtained from statistical models (logistic regression, t-tests, and discriminant analysis). several interventions that involve multiple components (e.g., patient needs assessment, medication reconciliation, patient education, arranging timely outpatient appointments, and providing telephone follow-up) have successfully reduced readmission rates for patients discharged to home. to help sanford health system direct resources and services to patients with greater likelihood of readmission, a number of risk stratification methods are available. outcomes can better define the role of home-based services, information technology, mental health care, caregiver support, community partnerships, and new transitional care personnel (kripalani, theobald, anctil, and vasilevskis, 2014). logistic regression and t-test results identify (statistically) significant variables that can predict cardiac readmissions. de-identification of protected health information is in accordance with the health insurance portability and accountability act (hipaa) privacy rule. the data set is de-identified and approved by the sanford privacy board and in addition is also irb approved by university of south dakota. sanford has multiple hospitals that admit for cardiovascular events. there are four regional hospitals and almost 40 critical access hospitals. the researchers identified records of 19,263 cardiac patients out of which 2,687 have been readmitted once or more. each patient, to be part of the sample, has had at least one cardiac event. a random sample of 33,642 non-cardiac patient records has been selected for further analysis in the future. a univariate test (t-test for mean differences) and cohen’s d are used for feature selection and logistic regression and discriminant analysis models are developed. these two are multivariate models. mailto:topacademicjournals@gmail.com top health sciences research journal vol.7, issue 1; january-febuary 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/thsrj; mail: topacademicjournals@gmail.com 4 | t o p h e a l t h s c i e n c e s r e s e a r c h j o u r n a l | https://topjournals.org/index.php/thsrj 3. data description the sample from a large integrated health system in the midwest is used in this study which includes data from 19,263 cardiac patients. of these 2,687 cardiac patients are readmitted (read) and 16,576 (not read) are not readmitted. the 2,687 readmitted cardiac patients are coded as 1 and the other 16,576 are coded as 0. table 1: variable description variable description problem list diagnoses listed cardev # of cardiac events cslos length of stay for each cardiac event hsdrx # of prescriptions during time period gender male or female patage patient age in years bmi most recent body mass index a1c a1c l diast most recent diastolic blood pressure l syst most systolic blood pressure no shows # of appointments that the patient missed race patient race marital status married or single alcohol use self-reported alcohol use patient location patient location (sf/fargo or not) discharge location home or snf the researchers’ have16 variables on these 19,263 patients. a t-test is performed for mean differences between these two groups – read and not read. variables with insignificant t-scores are dropped, since they do not contribute to the group separation. more specifically, the research team drop race (t = 0.395), marital status (t = 0441), systolic pressure (t = 0.64), alcohol use (t = 1.924) and patient location (t= 0.386). researchers also drop discharge location, a1c, and smokeless tobacco use due to too many missing variables or low cohen’s d. the remaining 8variables have significant t-scores and/or high cohen’s d and are used in the multivariate models (logistic regression and discriminant). they are: cardiac events, problem list, patient age, bmi, diastolic pressure, no shows, hsd rx, and gender. many of these 8 explanatory variables have missing values and if any one of these explanatory variables are missing, that record (patient) is dropped from analysis. mailto:topacademicjournals@gmail.com top health sciences research journal vol.7, issue 1; january-febuary 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/thsrj; mail: topacademicjournals@gmail.com 5 | t o p h e a l t h s c i e n c e s r e s e a r c h j o u r n a l | https://topjournals.org/index.php/thsrj the final sample to be used in various analyses consists of 6,064 patients. this is divided into two samples – 4,869 patients in the training sample and 1,195 patients in the validation sample. out of 4,869 patients in the training sample, 1,669 are read patients and 3,200 are not read patients. out of 1,195 patients in the validation sample, 417 are read cardiac patients and 778 are not read cardiac patients. 4.1 descriptive statistics a summary of descriptive statistics is in table 2. for readmitted cardiac patients (read) and not readmitted cardiac patients (not read), this table reports the mean, the standard deviation, and t-statistics for several explanatory variables of interest. mean values indicate that the read patients have higher a1c, number of prescriptions, longer problem list, longer hospital stay, more cardiac events and are older than the control group. however, read cardiac patients have lower mean values for body mass index and diastolic blood pressure. ttests for mean difference indicate that cardiac events, number of no shows, number of prescriptions, length of stay and problem list are significantly different between the two groups at the 1 percent level. t-test results also indicate that patient age, body mass index, and diastolic pressure are significantly different between the two groups. effect size as measured by cohen’s d is significant (large) for the following variables: cardiac events, no shows, number of prescriptions, length of stay, and problem list. table 2: descriptive statistics variables group code n mean std. deviation t-statistic cohen’s d patage 1 0 2687 70.54 13.25 2.52b 0.048 16575 69.82 16.41 bmi 1 2613 29.76 6.86 -2.94 a -0.059 0 15103 30.20 7.94 cardev 1 2687 2.16 1.37 35.78a 0.911 0 16575 1.20 0.59 cslos 1 2686 5.45 5.75 7.74 a 0.182 0 6775 4.48 4.86 a1c 1 1818 6.68 1.59 2.42b 0.066 0 8172 6.58 1.45 lsystolic 1 2687 124.11 20.47 0.64 0.013 0 16571 123.84 19.67 ldiastolic 1 2687 68.99 13.10 -3.67 a -0.053 0 16571 69.98 12.92 noshows 1 2187 7.90 12.55 10.74 a 0.292 0 10729 4.91 7.27 hsdrx 1 0 2631 365.17 396.43 14.99 a 0.336 15399 242.72 328.20 mailto:topacademicjournals@gmail.com top health sciences research journal vol.7, issue 1; january-febuary 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/thsrj; mail: topacademicjournals@gmail.com 6 | t o p h e a l t h s c i e n c e s r e s e a r c h j o u r n a l | https://topjournals.org/index.php/thsrj problist 1 2687 6.04 3.77 22.49 a 0.494 0 16575 4.31 3.19 group code: 1 = readmitted (read) cp 0 = not read cp a two-tailed significance at < 0.01 level b two-tailed significance at < 0.05 level patage = patient age; cardev = cardiac event; cslos = cardiac surgery length of stay hsdrx = # of prescriptions over 3 years; problist = diagnoses listed cardiac events include: asa, arrhythmia, cvd, angina, ambulatorycardiacmonitoring icd9 89.50, rhythmekg icd9, and electrographic telemetry icd9 89.54, dyspnea, & renal disease. 4.2: correlation analysis table 3: pearson correlation coefficients bmi ce los ld ns hsd gen d pl bmi 1.000 ce .002 1.000 los .007 .077 1.000 ld .017 -.020 -.012 1.000 ns .008 .071 .018 .041 1.000 hsd .008 .053 .010 -.131 .232 1.000 gend .039 -.050 -.038 -.008 .009 -.001 1.000 pl .060 .401 .119 -.004 .022 .027 -.029 1.000 ce = cardiac event; los = length of stay; ld =last diastolic; ns = no shows; gend = gender; hsd = # of prescriptions over 3 years; pl = diagnoses listed there are a number of strong correlations among the variables and the pearson correlation coefficients are reported in table 3. no shows variable is positively correlated with cardiac events, hsd_rx, and to diastolic pressure. cardiac events are strongly correlated with problem list indicating patients with multiple health problems have more cardiac events. there is a positive relationship between gender and bmi indicating higher bmi for males. there is a positive association between length of stay and cardiac events, indicating a higher risk for longer stays. diastolic blood pressure is negatively correlated with hsd_rx. even though some of these relationships among independent variables are significant at conventional levels, none of the correlations are greater than 0.401. only one correlation (out of 45) is greater than 0.4 and it is at 0.401 between cardiac events and problem list. judge, griffiths, hill and lee (1985), suggest that multicollinearity problems arise only when the correlations among independent variables are higher than 0.8. hence, the degree of collinearity present among independent variables appears to be too small to invalidate estimation results. the vif values are also computed mailto:topacademicjournals@gmail.com top health sciences research journal vol.7, issue 1; january-febuary 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/thsrj; mail: topacademicjournals@gmail.com 7 | t o p h e a l t h s c i e n c e s r e s e a r c h j o u r n a l | https://topjournals.org/index.php/thsrj and all eight of them are less than 1.209 and this also indicates that multicollinearity is not an issue. only if a vif value exceeds 10, multicollinearity is a concern. 5.1multivariate model – logistic regression using the independent variables in a multivariate context, however, allows one to examine their relative explanatory power and can lead to better predictions since the information which is contained in the crosscorrelations among variables is utilized. a primary objective of many multivariate statistical techniques is to classify entries correctly into mutually exclusive groups. discriminant analysis and logistic regression are examples of such multivariate models. in this study, the following logistic regression (logit) model is proposed: pr (y=1|x) = f ( 0 + 1x1 + 2x2+.....+ kxk) the dependent variable y is a dichotomous (0, 1) variable representing the two groups, cardiac patients readmitted (y=1) and cardiac patients not readmitted (y=0) firms. the independent variables x1 , x2 , .... xk include: gender, bmi, problem list, cardiac events, length of stay, last diastolic, no shows, and hsd rx. it is assumed that no exact linear dependencies exist among x's across k, and that the relationship between y's and x's are non-linear or logistic (i.e., p(y =1|x) = exp ( k xk) / [1 + exp( k xk)].) the null hypotheses would be: h0 : k = 0, where k = 1,….k logit results appear in table 4. of the eight explanatory variables, six are statistically significant and those six are discussed here. table4: logistic regression analysis results (y=1|x) = 0 + 1 genderi+ 2 bmii + 3 cardev i + 4 cslosi + 5 ldiasti + 6 nosowsi + 7 hsdrxi + 8 problisti model i model ii variable coefficient coefficient (chi-square) (chi-square) inter -3.450 -3.283 (135.14) a (217.14) a gender 0.13 0.413 (0.03) (41.53) a bmi -0.015 -0.011 (6.81) a (7.08) a cardev 1.991 1.155 (776.36) a (812.07) a cslos -0.058 --------- (11.50) a --------- ldiast -0.005 -0.005 (2.80) (4.04) b noshows 0.022 0.001 (26.66) a (50.00) a mailto:topacademicjournals@gmail.com top health sciences research journal vol.7, issue 1; january-febuary 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/thsrj; mail: topacademicjournals@gmail.com 8 | t o p h e a l t h s c i e n c e s r e s e a r c h j o u r n a l | https://topjournals.org/index.php/thsrj hsdrx 0.000 0.001 (28.41) a (51.89) a problist 0.063 0.019 (24.25) a (4.16) b n 4,869 9,299 a two-tailed significance at < 0.01 level b two-tailed significance at < 0.05 level dependent variable: 1 = readcp 0 = notreadcp nagelkerke r square = 0.432; 0.259 model log likelihood = 4435.71; 7159.02 % correctly classified = 81.7; 84.0 h2 (null) suggests that there is no statistically significant difference in bmi between read and not read groups. the coefficient estimate for the cash turnover ratio is -0.015 and is statistically significant at the 0.01 level. this suggests bmi values are different between the two groups. interestingly, average bmi scores are slightly higher for read group. both groups are somewhat obese. h3 (null) suggests that there is no statistically significant difference in the cardiac events measure between read and not read groups. the coefficient estimate for cardiac events variable is 1.991 and is highly statistically significant at the 0.0001 level. this suggests that cardiac events measure is significantly different between the two groups. read patients had, on average, much higher cardiac events than the control group. h4 (null) suggests that there is no statistically significant difference in length of stay between read and not read groups. the coefficient estimate for cardiac events variable is -0.058 and is highly statistically significant at the 0.001 level. this suggests that length of stay is significantly different between the two groups. read patients have had, on average, longer stay than the control group. h6 (null) suggests that there is no statistically significant difference in the no shows measure between read and not read groups. the coefficient estimate for the no shows variable is 0.022 and is highly statistically significant at the 0.0001 level. this suggests that no shows measure is significantly different between the two groups. read patients missed, on average, more appointments than the control group. this is along the expected lines. h7 (null) suggests that there is no statistically significant difference in the hsd rx measure between read and not read groups. the coefficient estimate for hsd rx variable is 0.0001 and is highly statistically significant at the 0.0001 level. this suggests that number of prescriptions measure is significantly different between the two groups. read patients had, on average, many more prescriptions than the control group. mailto:topacademicjournals@gmail.com top health sciences research journal vol.7, issue 1; january-febuary 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/thsrj; mail: topacademicjournals@gmail.com 9 | t o p h e a l t h s c i e n c e s r e s e a r c h j o u r n a l | https://topjournals.org/index.php/thsrj h8 (null) suggests that there is no statistically significant difference in the problem list measure between read and not read groups. the coefficient estimate for the problem list variable is 0.063 and is highly statistically significant at the 0.0001 level. this suggests that the problem list measure is significantly different between the two groups. read patients had, on average, many more health problems listed than the control group. this is called comorbid illnesses in the literature and has been significant in predicting readmission in prior literature. 5.2 classification by multivariate models o'leary (1987) recommends validating decision support systems (alternatively risk score algorithms) against other statistical models, if tests against human experts are very expensive. first, the multiple discriminant analysis model is employed in this study as a content validation tool to evaluate the risk score. the purpose of discriminant analysis (da) is to find the linear combination of risk factors that best discriminates between groups that are partitioned. da is often applied to problems where the dependent variable is dichotomous. da classifies entries into mutually exclusive groups by maximizing the inter-group to intra-group variance-covariance from a set of predictor variables. conventional statistical methods such as da and logistic regression (logit) attempt to arrive at group separation by simultaneously considering all attributes. the discriminant analysis results are described in table 5. the canonical correlation for the discriminant function is 0.535, and the chi-square statistic is 1639.51 suggesting significance at p=0.0001 level. the relation between hospital readmissions and the risk factors that are contained in the model appears to be strong. wilk's lambda, a measure of residual discrimination, is 0.724 and suggests that other factors outside the model may also influence readmissions. however, to an extent, it is not critical to include every variable that might be significant for the purpose of our study. this is because, adding every variable to the model will complicate the model, make it less parsimonious, and impractical to use. table 5: discriminant analysis results panel a: da: training sample results classification matrix predicted group total actual group % correct notreadcp readcp notreadcp 88.9% 2845 355 3200 readcp 64.9% 586 1083 1669 type i error: 11.1% ** type ii error: 35.1% panel b: da: holdout sample results classification matrix predicted group total actual group % correct notreadcp readcp notreadcp 90.6% 705 73 778 readcp 66.9% 138 279 417 mailto:topacademicjournals@gmail.com top health sciences research journal vol.7, issue 1; january-febuary 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/thsrj; mail: topacademicjournals@gmail.com 10 | t o p h e a l t h s c i e n c e s r e s e a r c h j o u r n a l | https://topjournals.org/index.php/thsrj type i error: 9.4% ** type ii error: 33.1% ** type i (ii) error is defined as the percentage of notreadcp (readcp) patients that were classified as readcp (notreadcp) patients. table 4 gives the classification matrix obtained from da. panel a of table 4 gives the training sample results indicating that the 8-variable discriminant analysis model classifies 64.9 percent of the readmitted patients and 88.9 percent of the not-readmitted patients correctly. panel b of table 4 shows that when the discriminant model is employed to analyze the holdout sample, 66.9 percent of the readmitted and 90.6 percent of the not-readmitted cases are grouped correctly. researchers also performed a logistic regression (logit) analysis using the same data sets for the training and the holdout samples and the logit results are reported in table 6. the training sample results indicate that the 8variable logit model classifies 65.7 percent of the readmitted patients and 90.1 percent of the not-readmitted patients correctly (see panel a of table 5). when the logit model is applied to analyze the holdout sample, 66.4 percent of the readmitted patients and 91.6 percent of the not-readmitted patients are grouped correctly (see panel b of table 5). when you analyze the type ii errors, (33.1% and 33.6% for the two models in the holdout sample), it shows that both models perform equally well, but there is certainly room for improvement. table 6: logit analysis results panel a: logit: training sample results classification matrix predicted group total actual group % correct notreadcp readcp notreadcp 90.1% 2883 317 3200 readcp 65.7% 573 1096 1669 type i error: 9.9% ** type ii error: 34.3% panel b: logit: holdout sample results classification matrix predicted group total actual group % correct notreadcp readcp notreadcp 91.6% 713 65 778 readcp 66.4% 140 277 417 type i error: 8.4% ** type ii error: 33.6% ** type i (ii) error is defined as the percentage of noreadcp (readcp) patients that were classified as readcp (noreadcp) patients. 6. preliminary risk score for cardiac patient readmission a preliminary risk score for cardiac patient readmission is given in appendix a. this risk score is based on t-statistics and chi-square statistics (from logistic regression). d. the dataset used in this study is unique in the population it covers, specifically within a region including various rural and mid-size urban centers, distinct from mailto:topacademicjournals@gmail.com top health sciences research journal vol.7, issue 1; january-febuary 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/thsrj; mail: topacademicjournals@gmail.com 11 | t o p h e a l t h s c i e n c e s r e s e a r c h j o u r n a l | https://topjournals.org/index.php/thsrj larger urban hospitals with a high volume of patients in close proximity. our risk score formula has the ability, unlike previously published scores, to predict potential cardiac patient readmission at the time of discharge (not after). as such, it has the potential for automation and uptake in clinic flow. input factors are readily available for patients and their readmission risk score can be easily calculated. the formula groups cardiac patients in to three groups: low risk; medium risk and high risk based on ranges of the risk score. the risk score is based t-test results and on chi-square values from logistic regression results. 7. conclusion the current study is novel in its approach to predicting and ultimately providing a prescriptive direction to healthcare decision-makers in examining cardiac readmissions with the introduction of a new algorithm. existing tools/models for predicting 30-day readmission and los have been limited. as previously highlighted, current industry standards such as the lace index are non-specific and rely solely upon clinical drivers with prediction rates hovering around 50% (cotter, bhalla, wallis, & biram, 2012). our findings not only provide increased ability to both predict those at-risk for readmission but also in our prediction of identifying those not at-risk adding to the literature in this area. this is particularly timely in the transition from fee for service to value-based healthcare in which there is an increasing responsibility to begin identifying and working to mitigate the determinants, whether clinical, biological, or social, contributing to health outcomes including readmissions. as such, this research has the potential to help reduce overall hospital readmission rates and allow hospitals to utilize their resources more efficiently to enhance interventions for high-risk patients by contributing to: 1) successful identification of significant risk factors that can predict cardiac patient readmissions; 2) development of a risk score for readmission; and 3) early identification of the at-risk population and introducing preventive healthcare measures (exercise, education, therapy etc.) to reduce hospital readmission rates prior to and following discharge. in alignment with current healthcare transition, this work assists not only in providing a direction towards cost reduction but importantly makes strides towards increased quality of life for cardiac patients through data-driven preventative efforts for at-risk identified populations. as shown in this study, readmission is not only affected by clinical indicators, but socioeconomic factors of patients as well. however, programs like hrpp hold healthcare providers accountable, making it necessary for the healthcare industry to leverage existing medical and social data to identify patients at risk and develop necessary interventions. data-driven methodologies such as the ones performed in this algorithm development are necessary to provide a framework for balancing resource utilization towards such patients with the risk of reduced payments. our algorithm uniquely collates predictors across both clinical and social determinants of health, specifically contributing to the social drivers crucial to readmissions as patients are discharged into their social environments. in our findings, two drivers viewed as proxies of social environments, are unique within the cardiac readmission research literature. drivers of patient no shows or missed medical appointments, include both patient behavior characteristics but also potential social determinants impacting means to attend appointments (i.e., lack of transportation, lack of social support able to provide transportation, poverty, distance to hospital). similarly, number of prescriptions provides a proxy for comorbid illnesses, drug interactions, and age which are mailto:topacademicjournals@gmail.com top health sciences research journal vol.7, issue 1; january-febuary 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/thsrj; mail: topacademicjournals@gmail.com 12 | t o p h e a l t h s c i e n c e s r e s e a r c h j o u r n a l | https://topjournals.org/index.php/thsrj crucial to patient engagement with their healthcare. as such, a risk score revealing these important socioeconomic drivers, along with clinical determinants, are poised to provide healthcare systems with actionable insights on how to intervene with patient populations shown to be at risk for readmission. this risk score formula, unique within in the published literature, provides an opportunity to identify high risk patients at the time of discharge. the analyses utilized not only allows us to score a patient at various levels of risk for readmission (predictive), it also provides information on the individual drivers for each score (prescriptive). this statistical approach will allow providers to compare and find the best fit on an individual level. on a population level of analytics this tool allows a look across the whole healthcare enterprise. in addition, once validated will allow for prescriptive analytics. this novel statistical approach proves to be a unique tool and a smart collaboration within in the healthcare space. limitations to the current study include a lack of data in potentially important drivers of readmission. we did not include data on emergency admissions or patient’s patterns of inappropriate utilization that may begin to reveal behavioral patterns around healthcare. other pertinent predictors of readmission seen in prior works including patient’s social support are unfortunately unavailable in electronic medical records and therefore not included in these analyses. further, only discharge data are used to develop the risk score for readmission. the statistical tests used in this study are association tests and they do not establish causality. since the dataset comes from hospital in the upper midwest, the patients are primarily caucasian. no chart review information is used in the score. future directions include refinement and validation of the current risk score. specifically, placing the score into a live clinical environment to assess real-life effectiveness. historically, impacts of regression to the mean (patient’s eventual regress to the mean without intervention) have clouded the influence of predictive ability, especially in assessments applying preand poststudies. we intend on circumventing any confounding factors by implementing our validation through control intervention environments. in collaboration with a large integrated healthcare delivery system we have the ability to evaluate the score with a relatively homogenous patient population where patients are separated by large distances. as such, any novel interventions such as score implementation in one setting and not another will not cross contaminate the control-intervention environments. metrics indicating predictive success will be available through emr data including decreased readmissions overtime. it is evident that prescriptive algorithms are the future for analytics in healthcare. past the promise of prediction, prescriptive approaches will fully engage providers in the use of big data and analytics. the current risk score with predictive and prescriptive capability provides a much-needed movement towards this work. references andel, c., davidow, s. l., hollander, m., & moreno, d. a. (2012). the economics of health care quality and medical errors. journal of health care finance, 39(1) 39. mailto:topacademicjournals@gmail.com top health sciences research journal vol.7, issue 1; january-febuary 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/thsrj; mail: topacademicjournals@gmail.com 13 | t o p h e a l t h s c i e n c e s r e s e a r c h j o u r n a l | https://topjournals.org/index.php/thsrj banoff, k. m., milner, k., rimar, j., greer, a. e., & canavan, m. (2016). assessment of a novel tool for identifying hospitalized patients with heart failure at risk for 30-day readmission, high cost, and longer length of stay. nursing economics, 34(4), 172. bradley, e., yakusheva, o., horwitz, l. i., sipsma, h., & fletcher, j. (2013). identifying patients at increased risk for unplanned readmission. medical care, 51(9), 761. centers for medicare & medicaid services (cms). (2012). readmissions reduction program. retrieved from http://go.cms.gov/1l93lh4). cotter, p. e., bhalla, v. k., wallis, s. j., &biram, r. w. (2012). predicting readmissions: poor performance of the lace index in an older uk population. age and ageing, 41(6), 784-789. de lissovoy, g. (2013). big data meets the electronic medical record: a commentary on “identifying patients at increased risk for unplanned readmission”. medical care, 51(9), 759-760. donzé, j., aujesky, d., williams, d., &schnipper, j. l. (2013). potentially avoidable 30-day hospital readmissions in medical patients: derivation and validation of a prediction model. jama internal medicine, 173(8), 632-638. falvey, j. r., burke, r. e., malone, d., ridgeway, k. j., mcmanus, b. m., & stevens-lapsley, j. e. (2016). role of physical therapists in reducing hospital readmissions: optimizing outcomes for older adults during care transitions from hospital to community. physical therapy, 96(8), 1125-1134. gruneir, a., dhalla, i. a., van walraven, c., fischer, h. d., camacho, x., rochon, p. a., & anderson, g. m. (2011). unplanned readmissions after hospital discharge among patients identified as being at high risk for readmission using a validated predictive algorithm. open medicine, 5(2), e104. judge, g. g., griffiths, w. e., carter hill, r., &lütkepohl, h. tsoung-chao lee (1985). the theory and practice of econometrics. new nork, ny: john wiley & sons. kansagara, d., englander, h., salanitro, a., kagen, d., theobald, c., freeman, m., &kripalani, s. (2011). risk prediction models for hospital readmission: a systematic review. journal of the american medical association, 306(15), 1688-2698 kasotakis, g., schmidt, u., perry, d., grosse-sundrup, m., benjamin, j., ryan, c., & bittner, e. a. (2012). the surgical intensive care unit optimal mobility score predicts mortality and length of stay. critical care medicine, 40(4), 11221128. mailto:topacademicjournals@gmail.com top health sciences research journal vol.7, issue 1; january-febuary 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/thsrj; mail: topacademicjournals@gmail.com 14 | t o p h e a l t h s c i e n c e s r e s e a r c h j o u r n a l | https://topjournals.org/index.php/thsrj kripalani, s., theobald, c. n., anctil, b., &vasilevskis, e. e. (2014). reducing hospital readmission rates: current strategies and future directions. annual review of medicine, 65, 471-485. ross, j. s., mulvey, g. k., stauffer, b., patlolla, v., bernheim, s. m., keenan, p. s., &krumholz, h. m. (2008). statistical models and patient predictors of readmission for heart failure: a systematic review. archives of internal medicine, 168(13), 1371-1386. rothman, m.j., rothman, s.i. &beals, j. (2013). development and validation of a continuous measure of patient condition using the electronic medical record. journal of biomedical informatics, 46(5), 837-848. rothman, m.j., solinger, a.b., rothman, s.i., & finlay, g.d. (2012). clinical implications and validity of nursing assessments: a longitudinal measure of patient condition from analysis of the electronic medical record. bmj open, 2(e000849), 1-6. snowdon, m. (2014) white paper: the four steps of population health management. optum tan, c., loo, g, pua, y., chong, h., yeo, w., ong, p., … allison, g. (2014). predicting discharge outcomes after total knee replacement using the risk assessment and predictor tool. physiotherapy, 100(2), 176181. the patient factor (2016). world health organization’s ranking of the world’s health systems/ august 16, 2016., retrieved from http://thepatientfactor.com/canadian-health-care-information/world-healthorganizationsranking-of-the-worlds-health-systems/ the world bank group. (2015). health expenditure per capita (current us$). the world bank. retrieved august 26,2015fromhttp://data.worldbank.org/indicator/sh.xpd.pcap?order=wbapi_data_value_2013+wbapi _data_value+w bapi_data_value-last&sort=desc tsai, t. c., joynt, k. e., orav, e. j., gawande, a. a., & jha, a. k. (2013). variation in surgical-readmission rates and quality of hospital care. new england journal of medicine, 369(12), 1134-1142. van walraven, c., dhalla, i., bell, c., etchells, e., stiell, i., zarnke, k., … forster, a. (2010). derivation and validation of an index to predict early death or unplanned readmission after discharge from hospital to the community. canadian medical association journal, 182(6), 551-557. wagener, g., minhaz, m., wang, s., panzer, o., wunsch, h., playford, h., &sladen, r. (2011). the surgical procedure assessment (spa) score predicts intensive care unit length of stay after cardiac surgery. journal of thoracic cardiovascular surgery, 142(2), 443-450. mailto:topacademicjournals@gmail.com http://thepatientfactor.com/canadian-health-care-information/world-health-organizations-ranking-of-the-worlds-health-systems/ http://thepatientfactor.com/canadian-health-care-information/world-health-organizations-ranking-of-the-worlds-health-systems/ http://thepatientfactor.com/canadian-health-care-information/world-health-organizations-ranking-of-the-worlds-health-systems/ http://data.worldbank.org/indicator/sh.xpd.pcap?order=wbapi_data_value_2013+wbapi_data_value+wbapi_data_value-last&sort=desc http://data.worldbank.org/indicator/sh.xpd.pcap?order=wbapi_data_value_2013+wbapi_data_value+wbapi_data_value-last&sort=desc http://data.worldbank.org/indicator/sh.xpd.pcap?order=wbapi_data_value_2013+wbapi_data_value+wbapi_data_value-last&sort=desc http://data.worldbank.org/indicator/sh.xpd.pcap?order=wbapi_data_value_2013+wbapi_data_value+wbapi_data_value-last&sort=desc top health sciences research journal vol.7, issue 1; january-febuary 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/thsrj; mail: topacademicjournals@gmail.com 15 | t o p h e a l t h s c i e n c e s r e s e a r c h j o u r n a l | https://topjournals.org/index.php/thsrj wang, h., robinson, r., johnson, c., zenarosa, n., jayswal, r., keithley, j., & delaney, k. (2014). using the lace index to predict hospital readmissions in congestive heart failure patients. bmc cardiovascular disorders, 14, 1-8. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 1; january-febuary 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 1 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe mathematical gains through physical strains: exercise and academic performance" 1dr. emily clark, ed.d and 2dr. samuel turner, ed.d. 1ed. d. assistant professor manhattan college, riverdale 2senior education student manhattan college, riverdale abstract: regular exercise, particularly aerobic and resistance training, has been linked to improved cognitive health and academic performance in students. this paper explores the potential of exercise to enhance math scores among school-age children, drawing on research that highlights the positive impact of physical activity on brain function and cell growth. the groundbreaking book "spark: the revolutionary new science of exercise and the brain" by ratey (2008) serves as a case study, demonstrating how a physical education program in the naperville central school district of illinois led to significant improvements in math, reading, and science scores for students who engaged in daily exercise. this research emphasizes the parallel between brain cells and muscle cells, highlighting that both require activity to grow and can atrophy with disuse. by examining the compelling evidence presented in "spark," this paper sheds light on the potential of exercise interventions to enhance academic performance in students. keywords: exercise, academic performance, cognitive health, brain function, math scores. introduction many studies have indicated that participating in regular exercise for the heart and lungs may be one of the most important factors for students to achieve good grades in math and reading. aerobic exercise and resistance training have been found to improve the cognitive health of the brain (ratey, 2008). according to ratey (2008) exercise sparks new brain cell growth. he believes in order to have our brains work at peak performance our bodies have to work hard. can this information help school age children improve their math scores? a good example of the power of exercise to boost brainpower was demonstrated in ratey’s (2008) groundbreaking book spark: the revolutionary new science of exercise and the brain. spark describes how a physical education class transformed students in the naperville central school district of illinois. students whodaily participated in a dynamic morning exercise program,while having access to exercise time throughout the school, day showed dramatic increases in their math, reading and science scores as a result. brain cells are similar to muscle cells. there is growth with use and atrophy with disuse. your brain on exercise exercise encourages your brain to work at optimum capacity by causing nerve cells to multiply andto strengthen neural interconnections. animal tests have illustrated that during exercise, nerve cells release proteins known as mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 1; january-febuary 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 2 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe neurotropic factors. one in particular, called brain-derived neurotrophic factor (bdnf), triggers other chemicals to promote neural health that directly benefits brain functions, including learning (ratey, 2008). gervaso (2014) states that exercise has such a positive effect on the nervous system. when an individual exercises they can think more clearly, perform better, and improve one’s morale.stimulating your nervous system will help an individual to function at a higher level. a study conducted by an education student at manhattan college set out to prove that exercise, specifically sprint workouts, could improve math competency as well as students’ confidence. motivating middle school students in mathematics is a challenge for many teachers today. adolescence marks the beginning of a downward trend in motivation and achievement in academics (ryan 2001). according to the new york city department of education, 75.5% of seventh grade english language learners (ells) scored a level 1, the lowest performance, on the 2013 new york state math test. only 8.6% of these students scored a level 3 or higher on the same math exam that year. students’ achievements in math and confidence in doing math can be greatly affected by their attitudes. this summer research study was initiated to help middle school students in new york city increase their math scores. research study the purpose of this study was to determine if exercise, specifically sprint routines, could improve math competency as well as students’ confidence with solving word problems. the study took place in an urban middle school in new york city. participants participants in the study included seven english language learners, five males and two females, who were in danger of failing mathematics. students were in grades six or seven. the school selected these seven students to receive tutoring because they scored a level 1, the lowest level of performance on the new york state mathematics test in the previous year. the seven students had repeated at least one grade level and previously attended summer school. the students were not receiving any additional support services at the school. procedures the researcher tutored the students in small group two or three times a week for forty minutes each day over an eight-week period. students worked in groups of two or three and were pulled from non-core subjects or activities, such as physical education and part of their lunch period, for tutoring. at least once each week during the tutoring session, students began with the sprint routine. instrument sprints are exercises used to strengthen mathematical computations while helping students gain confidence in their math abilities (ramos, 2011). the instrument used for this study was the math sprint worksheet that was part of a nine step routine. the worksheet consisted of 44 computation problems for part a and 44 similar computation problems for part b. sprint routine procedure participants began tutoring sessions completing a sprint worksheet once a week. students had 60 seconds to complete part a.the researcher assumed the role of an athletic coach in this routine. with each sprint routine, mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 1; january-febuary 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 3 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe the researcher would tell the students they had 60 seconds to complete as many of the exercises as they could. she told them they were not expected to complete all the exercises just as many as they could. she placed the exercise face down in front of them and told them to wait for the signal to begin. she used her cell phone as a timer and signaled the students with “on your mark, get set, go.” at the end of the 60 seconds, she signaled the students to stop by saying “pencils down”. if students completed all 44 problems before the minute, they stood at their place. the researcher then corrected the first part of the sprint worksheet with the class by reading the correct answers at a quick pace. students were directed to shout “yes” and punch out after each response they answered correctly, circle incorrect answers, and then write the number they answered correctly at the top of their worksheet. the researcher asked students to raise their hands if they had one or more correct, two or more correct, three or more correct etc. until no one raised their hand any more. within these small groups, the student who had the most correct was acknowledged. the researcher then gave students the opportunity to complete the remaining problems. before moving to part two of the sprint, the researcher involved students in some form of calisthenics such as jumping jacks, stretching exercises, or jogging in place. while students physically exercised they also participated in mental math exercises such as counting by multiples of fours, counting backwards from 50 by fives, skip counting from one inch to the smallest part of an inch. these combination physical and mental math exercises lasted for about one minute. students returned to their seats and prepared to take the second part of the sprint. students had 60 seconds to complete this sprint as well. the researcher corrected this part with the students following the same routine as in part a and had them mark the number of correct answers at the top of their worksheet. students also wrote how many more they had correct in the second part from the first part. the researcher asked the students to raise their hands if they improved by one or more, two or more, three or more etc. until no hands were raised. math achievement was based on how many more questions each student answered correctly on the second part. the student who had the greatest improvement from part a to part b was acknowledged. data collection procedures data was collected over the eight weeks of tutoring to determine if students’ sprint scores increased. the researcher collected the data from each student’s twopart worksheet. students were assessed on how many more problems were answered correctly on the second part of the sprint when compared to the first part. over the eight weeks of tutoring, students completed a total of seven sprint routines. sprints were used only when all students were present in the small groups. because of the high rates of absenteeism, the sprint routine could only be completed about once a week over the eight weeks. data in the first round of sprints, students’ scores ranged from 9 to 33 out of a possible score of 44 in part a. after the physical and mental calisthenics, students’ scores on part b ranged from 22 to 43. students noted an immediate improvement that provided a positive response from students. students were more receptive to the sprint exercise after they noted this improvement. sprints 2-7 revealed very similar results with increased or maintained math scores for every student between part a and part b. the results are found in table 1. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 1; january-febuary 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 4 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe table 1: student raw scores from sprints sprint 1 sprint 2 sprint 3 sprint 4 sprint 5 sprint 6 sprint 7 a b a b a b a b a b a b a b dominique 9 26 29 36 4 12 11 17 22 29 30 38 patrick 33 36 18 25 40 41 17 39 22 31 jessica 27 31 31 34 17 18 22 32 38 41 randy 27 43 23 26 27 30 13 15 38 38 robert 23 27 19 20 12 17 23 26 33 38 jefferson 10 22 18 18 6 13 7 9 22 26 29 37 leo 23 24 23 27 22 26 15 21 36 40 note. highest possible score: 44. students completed seven sprint exercises with two sprints of for the final sprint (sprint 7) the researcher repeated the first sprint exercise the students had taken during the first week of the tutoring session. the researcher wanted to compare students’ scores from the first week to the final week of tutoring. the results are presented in table 2. six of the seven students were present to complete the final routine of the sprint. data analysis in reviewing scores for each sprint, the data reveals that students improved or remained constant between parts a and b in each exercise. while in some instances there was great improvement between part a and part b such as patrick in sprint 4 with an increase of 22 correct answers, dominique and randy in sprint 1 with an increase of 17 and 16 points respectively, the median score improvement was 5.5 points. in two instances, jefferson in sprint 2 and randy in sprint 7, the scores between part a and part b remained unchanged. table 2: student growth in eight weeks sprint 1 sprint 7 a b a b dominique 9 26 30 38 patrick 33 36 jessica 27 31 38 41 randy 27 43 38 38 robert 23 27 33 38 jefferson 10 22 29 37 leo 23 24 36 40 note. highest possible score: 44. sprint 1 and 7 were the same sprint exercises distribute in comparing scores from part a in sprint 1 with scores from part b in sprint 7 the range of improvement was from 11 to 29 points. the median score improvement was 18.8 points with improvement shown for six of the seven students who were present for the final sprint exercise. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 1; january-febuary 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 5 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe discussion of the findings the purpose of this study was to determine if physical exercise and mental math exercise through sprints could improve math competency skills for seven middle school students. the data was gathered over an eight-week period in tutoring sessions with two or three students in each session. students completed part a of a sprint in 60 seconds, engaged in calisthenics and mental math exercises for another 60 seconds, and then had another 60 seconds to complete part b of the sprint. the data shows improvement in student performance of the math problems between parts a and b. the data also shows improvement in student math performance over the eight weeks of tutoring. these students were not receiving any additional support services other than their regular classroom instruction. research today on brain, mind, and body reveal significant links between movement and learning. brain compatible learning suggests incorporating math, movement, and physical education (reilly, buskist, and gross, 2012). this research with students’ participation in the math sprints showed some improvement in math scores from the first week of tutoring to the final week. students’ participation in the math sprints had no statistical significant effects on their math achievement; however students did progress in their fluency to solve problems accurately. these findings support previous studies that have found physical activity increased task performance (correa-burrows, burrows, orellana, & ivanovic, 2014; ratey, 2008). five of the seven students passed their grade requirements in mathematics for the year. two students would attend summer school and at the time of this report the researcher had not received the final results for passing for the two students attending summer school. students’ willingness to attempt the sprints also increased from the first week to the last. in the beginning the researcher had to coax the students to come to the tutoring sessions and then to work during the session. students who were taken from the physical education class for tutoring protested the most. randy commented: “it is the only class i’m good at and my team needs me.” students also complained that the sprints were too hard although the selected worksheets were from a fourth grade level, at least two levels below where the students should be performing. as students noted their own improvement with the sprints, they showed signs of confidence by challenging each other and commenting, “i’m going to be better today than you.” in the last few weeks of the tutoring, students asked if they could do the sprints. conclusions and recommendations exercise encourages the brain to work at a more optimum capacity. in conducting this study, the researcher assumed the sprint exercise was a possible way for students to develop math fluency. the data suggests that incorporating physical activity with mathematic computational exercises can make at least modest gains to students’ mathematical fluency.the data reveals positive growth for each of the seven students in the study. the limitations of this study that prevent generalization to a larger population include the small sample size. seven middle school students who were also english language learners were the participants in this study, and therefore the results cannot be generalized to other populations. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 1; january-febuary 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 6 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe in this study, the researcher used the math “sprints,” for which validity and reliability were established based on the sprint routine produced by the ramos group (ramos, 2011) or the davidson group (davidson, 2012). the researcher could not control this study for variables such as absenteeism, when students received tutoring and the impact of missing classes such as physical education or part of their lunch period, or students’ previous mathematical fluency. the researcher did not have prior information to determine the actual mathematical performance level of the students, other than knowing they had performed at the lowest level of the state test the previous year. the researcher selected sprints from a fourth grade level when she noted students were not able to successfully answer more than seven fifth grade math problems the first time she tried the sprint. recommendations based on the findings in this study it is recommended that: 1) the sprint routine is more frequently implemented in middle school math classes for greater impact. 2) the study is replicated with a larger group of middle school students and preferably with classes of students rather than just small groups. 3) various forms of calisthenics are used as an independent variable to determine if certain physical movements have greater impact on math learning. 4) research on sprint routines are expanded. references correa-burrows, p., burrows, r., orellana, y., & ivanovic, d. (2014). achievement in mathematics and language is linked to regular physical activity: a population study in chilean youth. journal of sports sciences, 32(17), 1631-1638. doi:10.1080/02640414.2014.910606 gerveso, j. (2014). intelligence: healthy brain results to a powerful mind.walla walla, wa:coffey. davidson, b. (2012). sprints. the davidson group: advancing elementary mathematics. retrieved from: http://teacherbilldavidson.com/sprintbooks/ ramos, r. (2011). sprints. the ramos group: elementary mathematics. retrieved from: http://ramosgroup.squarespace.com/sprints/ ratey, j. & hagerman, e. (2008). spark: the revolutionary new science of exercise and the brain. new york, ny: little, brown and company. reilly, e., buskist, c., & gross, m. k. (2012). movement in the classroom: boosting brainpower, fighting obesity. kappa delta pi record, 48(2), 62-66. doi:10.1080/00228958.2012.680365 ryan, a. r. (2001). the peer group as a context for the development of young adolescent motivation and achievement. child development 72(4) p/ 1135-1150. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 1 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe the scope of evolutionary explanations andrew werth department of biology, hampden-sydney college abstract: this paper explores the limits of evolutionary explanations (ees) in explaining human behavior. it begins by discussing the philosophical debate between daniel dennett and stephen jay gould on the scope of ees. dennett argues that ees are universal and can explain all aspects of the natural world, while gould argues that there are limits to ees, particularly in the realm of human behavior. the paper then considers three case studies that illustrate potential constraints on ees: the evolution of morality, the evolution of religion, and the evolution of art. the paper concludes that there are indeed limits to ees, but that these limits are not always clearcut and may vary depending on the specific question being asked. keywords: evolutionary explanations, human behavior, limits of ees, daniel dennett, stephen jay gould, morality, religion, art. introduction are evolution’s explanatory powers limitless or limited? according to philosopher daniel dennett (1995, 63), evolution is not only true but universal: the central organizing principle explaining all aspects of the living world. dennett likens darwinian theory to an uncontainable ‗universal acid.‘ evolutionary explanations, he declares, corrode every philosophical worldview they touch. people scramble (yet fail, in dennett‘s estimation) to keep darwin‘s dangerous idea at bay by constantly erecting new barriers while old ones are burnt through, as ―new waves of darwinian thinking‖ relentlessly erode temporary ―forces of containment.‖ as dennett states (1995, 63), ―darwin‘s idea had been born as an answer to questions in biology, but it threatened to leak out, offering answers—welcome or not—to questions in cosmology and psychology… if mindless evolution could account for the breathtakingly clever artifacts of the biosphere, how could the products of our own ‗real‘ minds be exempt from an evolutionary explanation?‖ yet as dennett trumpets the extraordinary power of evolutionary explanations, he reminds us of stephen jay gould‘s ‗nonoverlapping magisteria‘ or noma essay (1997, 21), which argues that evolutionary explanations must be strictly contained. contra dennett, gould claims that although evolution may be accepted as factual, firm boundaries must be respected. modern science offers evolution as the bedrock foundation underlying all features of living systems. evolutionary explanations (hereafter abbreviated ees) are presented as logical, mechanistic accounts that help us to understand why the natural world is the way it is. but are ees limited in explanatory scope and power? even those who otherwise willingly accept modern science sometimes balk at the sheer audacity of evolutionists to explain every mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 2 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe facet of nature, particularly human nature, in evolutionary terms. social scientists occasionally mock ees by affirming that, like any explanation that purportedly explains everything, they are effectively useless (dupré 2001, 74). there is nothing, they tease—no aspect of human behavior, even—that cannot be subsumed within and ultimately explained by evolution. surely there must be something evolution cannot explain. can darwinian theory explain every aspect of nature, or are there distinct, a priori limits to its epistemic utility? if so, are the limitations philosophical or scientific in nature? are they practical or theoretical, real or perceived? do limits arise from inadequacies of evolutionary theory itself, or merely from those who misunderstand or misappropriate it? what sorts of naturalistic questions might evolution not be able to answer? are humans exempt from ees? these questions carry profound significance for scientists, social scientists, and philosophers alike. following a historical introduction via two case studies, potential constraints on ees are considered. a third case study reinforces the conclusion that the stratagem to apply limits to ees 1) normally occurs in human context and 2) ultimately hinges upon one‘s acceptance or rejection of ontological materialism. case study 1: thomas henry huxley, darwin’s sometime supporter the accomplished nineteenth century anatomist and paleontologist thomas henry huxley (1824-1895) is best known today as charles darwin‘s colleague. darwin‘s keen mind and wit made him a fierce debater, but he shunned the spotlight and sought to downplay controversy; he privately fumed at critics but hesitated to take them on in public (browne 2002, 295). huxley, in contrast, cherished confrontation as ‗darwin‘s bulldog,‘ an outspoken champion of evolution. an eager and effective proponent, huxley defended darwin from detractors on several occasions, notably in the debate at oxford on june 30, 1860, against archbishop samuel ‗soapy sam ‘wilberforce (desmond and moore 1992, 492; hesketh 2009). yet huxley challenged darwin on key points. huxley admonished darwin for arguing that evolution must necessarily be slow and gradual, contending instead that lineages might evolve rapidly: ―you have loaded yourself with an unnecessary difficulty in adopting natura non facit saltum [nature does not make leaps] so unreservedly‖ (lyons 1999, 49). huxley would feel vindicated by today‘s acceptance of variable evolutionary rates in punctuated equilibrium (eldredge and gould 1972). still, huxley acknowledged that darwin, more than wallace, deserved credit for formulating the decidedly non-teleological, non-intuitive, yet remarkably simple idea of natural selection. upon first grasping this idea, huxley is said to have remarked, ―how extremely stupid not to have thought of that!‖ (desmond 1997, 41). one would suppose that as an ardent convert and supporter of this straightforward scheme, huxley would fully embrace darwinian theory, but in at least one notable way huxley broke with it. in his best known work, evolution and ethics (1894, 36), huxley tried to reconcile his dim view of a brutal, nasty nature ‗red in tooth and claw‘ with his idealistic view of humanity. how could something so good arise from something so bad? well trained, like darwin, in uniformitarian thinking, huxley recognized the universal, unalterable permanence of physicochemical laws according to which the world operates; he presumed these axiomatic ‗rules‘ of nature hold in all times and places. but in huxley‘s mind these rules must somehow have been subverted for ethics to develop mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 3 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe in our species. his selfperceived masterstroke was the metaphor of a garden which must ever be tended to stave off disrepair. according to irvine (1955, 414), huxley, an avid gardener, was inspired by voltaire‘s character candide, who avowed that ―il faut cultiver notre jardin‖ [we must all cultivate our own garden]. huxley readily embraced this directive. he recognized that only by the gardener‘s never-ending toil and constant energy input could inevitable decay—the entropy called for by thermodynamics—be postponed and ‗progress‘ made. so far, so good: darwin would object to nothing here. gardens evidently require constant care. but huxley‘s argument culminated by comparing humanity to the symbolic gardener. only by exercising similar toil, individually and collectively (as society and species), argued huxley, could humans improve their lot and avoid their bestial nature. only by removing wicked ‗weeds‘can we become moral creatures. huxley argued (1888) that we overcome a hobbesian nature solely via cultural practice. in short, huxley saw ethics as an unnatural innovation (without biological underpinning) triumphing over evolution. as primatologist frans de waal notes (2001, 344), this was a case of the bulldog biting his master. huxley‘s argument deliberately limited evolution‘s explanatory power. in de waal‘s words (344), ―since many people consider morality the essence of our species, huxley in effect said that what makes us human is too big for the evolutionary framework.‖ darwin‘s fiercest advocate would not bring himself to subscribe to a universally evolutionary position—huxley did not imagine a morality explicable in biological terms. as the figurative gardener‘s never-ending struggle attests, huxley felt ees could go only so far, despite darwin‘s unequivocal position (stated in the descent of man, 1871, 173) of continuity between evolution and human nature, including morality. by contrast, darwin‘s bulldog plainly recognized curbs to ees. although evolution is the foundation of modern biology—in dobzhansky‘s famous phrase, ―nothing makes sense in biology except in light of evolution‖ (1973, 125)—huxley‘s tenuous position (accepting ees for all of biology with the exception of human nature) is far from unique. in the century and a half since darwin‘s idea ascended, many scholars have jumped onto this middle-ground bandwagon. even pope john paul ii, in articulating the vatican‘s official position (1996, 1) by admitting the overwhelming empirical evidence for biological evolution, nonetheless attached strict limits to its relevance in understanding ‗the truth about man,‘ specifically the ‗ensoulment‘ of individual human beings. case study 2: john harlow, darwin’s unwitting (and unheard) supporter a similar story lies at the heart of a case the opposite of huxley‘s. it involves phineas gage (1823-1860), the railroad worker whose extraordinary tale is now widely known, in part because it is as gruesome as it is incredible, and because it has gained notoriety in studies of neuroanatomy and cognition (fleischman 2002; macmillan 2002; kean 2014). it is remarkable that gage was not killed by the iron tamping rod that blew a hole through his brain, and that he soon returned to work. neurologist antonio damasio (1994, 8) extensively described gage‘s ensuing personality change—from a pleasant, shrewd, ambitious, exemplary employee to a rash, foul-mouthed, unrestrained and unreliable man—and the role of the ventromedial prefrontal cortex in regulating behavior, largely by inhibiting impulsive behavior. less widely known is the role of dr. john martyn harlow of cavendish, vermont, who treated gage‘s wound the day of the injury (september 13, 1848) and followed his recovery the mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 4 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe rest of gage‘s life (mcmillan 2002, 106). harlow was riveted by gage‘s ability to survive his grievous injury and by its profound effect on gage‘s personality, although kean (2014, 353) casts doubts on the extent of this shift. harlow grew to appreciate the influence, if not explicit causal link, of brain on behavior. had he discovered the mythical ‗moral compass,‘ with the damaged frontal lobe relating directly to sociality (damasio 1994, 22)? harlow‘s work came in the decade following darwin‘s publication of origin, at a time when mental abilities were first ascribed to specific brain regions. paul broca and carl wernicke notably described language deficits in speech production and comprehension that could be traced to distinct brain loci (the inferior frontal and superior temporal gyri, respectively). together, broca and wernicke demonstrated an unambiguous link between brain and behavior. unlike these european academic anatomists, harlow was a country doctor. nonetheless, he believed he too had conclusive evidence of a connection between a precise brain region and its corresponding higher order function. damasio (1994, 85) cites harlow‘s story as ―the historical beginning of the study of the biological basis of behavior‖ (presuming one does not invoke once-popular but now-debunked ideas about physical traits in 18th century phrenology). however, the mind-brain link harlow explored (macmillan 2002, 114) involved not language but ethics: he speculated on the realm huxley argued was inexplicable in natural terms. in contrast to huxley, harlow suggested that morality—which darwin himself recognized in descent (1871, 102) as humanity‘s defining feature—was a material phenomenon amenable to scientific investigation. where huxley defined clear limits to ee, harlow saw none. yet whereas broca and wernicke achieved scientific success and popular acclaim, harlow‘s idea gained no support—at least, none until biologists at the close of the 20th century took up the battle flag and resumed harlow‘s fight. where the mighty huxley had circumscribed limits on evolution‘s explanatory power, harlow had tried, and failed, to break through. defining terms, past and present what constitutes an evolutionary explanation (ee)? as used here, the term explicitly refers to a scientific hypothesis offering an account of the form or function of any attribute—physical, biochemical, behavioral, etc.— of an organism or taxon (a group of related organisms at any level such as species or kingdom). in a sense an ee is a ‗just-so story‘purporting to explain how something in the natural world came to be. it provides a historical explanation—a logical inference based on empirical evidence—spelling out how a feature appeared and later predominated in a given environment. as such ees rely upon the classic algorithmic routine, outlined by darwin and wallace, of novel variants (mutations) appearing and being selected for or against, with new iterations occurring in succeeding generations. although our understanding of underlying genetic mechanisms has made huge strides, in essence ees are couched in the same terms darwin and wallace used 150 years ago. commonly known as natural selection, this process involves three step-wise stages: variation, selection, and inheritance. darwin and wallace were far from the first to propose organic evolution (non-constancy of species), but they formulated the causal, mechanistic explanation for how such change occurs. although ‗natural selection‘ can be taken as roughly synonymous for what is meant here by ee, other elements of selection, including sexual, directional, disruptive, purifying, stabilizing, and mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 5 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe artificial selection (human-induced selective breeding) also pertain. random change due to genetic drift can also occur, as will be discussed. nonetheless, when people refer to ‗darwin‘s theory of evolution,‘ natural selection is virtually always what they have in mind. though natural selection remains the centerpiece of modern evolutionary theory it is only one of darwin‘s many contributions that remain central today. indeed, darwin‘s theory is not a single idea but a suite of interconnected explanatory principles (hence darwin‘s ‗theories‘ would be a more appropriate name), including common ancestry, gradualness of change, adaptation (link between organism and environment), macroevolution (extension of adaptation to speciation and higher-level evolution), extinction, and convergent (analogous) evolution. note that darwin did not initially like the term ‗evolution,‘ partly because previous theorists, who described a progressive unfolding, offered no causal explanation for how it might occur (bowler 1975; desmond and moore 1992, 293). instead darwin described this process as ‗descent with modification.‘ only later and reluctantly did darwin use herbert spencer‘s phrase ‗survival of the fittest‘; he might have preferred ‗amplification of the aptest‘ (allchin 2007, 176), given that less fit organisms still survive, even if they have lower fitness and less genetic representation in succeeding generations. it must be emphasized that evolution and development are disparate phenomena (werth 2014, 9): the former links a chain of organisms by common descent, whereas development refers to programmatic changes during the life history of a single organism. individual organisms do not evolve. it is also important to distinguish true phyletic adaptation (heritable change in a lineage due to genotypic change) from acute or chronic change in an organism, such as acclimatization to altitude. such physiological accommodation, although often referred to as adaptation (and likewise fully explicable in causal, mechanistic terms), is not a scenario encompassed by ee. among darwin‘s advances were his emphasis on population-level thinking (herbert 1977; ridley 2003) and his characterization of variation not as a flaw to be brushed aside or explained away, but as a key element of ees in that they furnish the material sculpted by selection. the development of population genetics that led to the ‗modern synthesis‘of the 1940s paved the way for today‘s gene-centric focus on fitness, which expanded to include behavioral traits in all animals, including humans (i.e., sociobiology and evolutionary psychology, hereafter ep). although modern studies give greater emphasis to genetic fitness, the essential concept of survival and reproduction of parent and offspring remains unchanged since darwin and wallace. there is, however, debate over the level or levels at which selection acts, ranging from gene to individual organism to population (i.e., group selection; wilson 2012; pinker 2012). ees lie at the heart of biology. they are the central organizing principle making biology a bona fide science. evolution is universally accepted as factual by scientists and other scholars. despite tremendous popular opposition, no viable alternative explanatory framework has been proposed, nor has legitimate contrary empirical evidence been advanced. nevertheless, the question remains whether this explanatory framework is universal and all-powerful. can evolution explain all features of the living world? do evolutionary explanations fit basic tenets of science? mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 6 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe as scientific explanations, evolutionary scenarios are obliged to follow modern science‘s naturalism. ees depend on empirical data. they must be based on reliable, repeatable, objective evidence rather than mere claims or ideas. ees must be open to rejection or modification in the face of new evidence. they must be potentially falsifiable, and testability must be intersubjective: independent investigators must be able to challenge and support or disprove claims. ees are bound by rules of logic. crucially, ees must offer more than mere descriptions, for at heart science offers reasoned accounts for why things are as they are. further, such explanations must operate according to a causal, non-teleological mechanism; they involve proximate (initial mechanistic) rather than ultimate causes (in the sense of purpose). all explanation must involve wholly and solely natural, material, physical causes, as opposed to supernatural, immaterial, metaphysical phenomena. though evolution leads to ordered design via selection acting on variation generated by random mutation, there is never appeal to a telos or agency beyond nature. design occurs from the ‗bottom up‘rather than ‗top down‘ (dennett 1995, 75; shermer 2006, 65). evolution is a ‗theory‘in the strict scientific rather than common vernacular sense (i.e., a hunch or guess; kugler 2002, 341). further, ‗darwin‘s theory‘is an explanatory framework, not an ideology to be pinned to one man, as in the oft-pejorative phrase ‗darwinism.‘ even if darwin never developed this idea, which transformed biology from an assemblage of facts into a unified field of study, someone else would have, as wallace indeed did simultaneously. science, as a cumulative, collective, objective methodology focused on explanations of the physical world, is, ideally and in toto, ultimately independent of individual views (admittedly casting aside vast issues of philosophical realism and sociology of science). our understanding of evolution increases as a wealth of experimental and observational evidence accumulates. it might be argued that these basic stipulations (i.e., observability) constitute essential restrictions on ees. however, ees that do not fulfill these initial preconditions are scientifically invalid, so this claim is dubious at best. to the extent that ees represent bona fide science, they necessarily abide by such limits a priori. ees published in reputable, refereed publications (as admittedly not all ees are) are presumed to represent proper science; regrettably, this cannot be accepted as a given. one might argue that error bars, confidence intervals, and statistical findings also place limits on scientific explanations. however, these simply reinforce the provisional nature of ees, which are not infallible but instead change with evidence. do evolutionary explanations fit the real world, or merely a make-believe one? the best explanations are those with the fewest ontological posits, following the rule of parsimony (‗occam‘s razor‘). but does science actually tell us about nature, or does it only explain how data fit a hypothesis to be tested? does it just make simplified models that enable us to understand our perceptions of experiential phenomena in the natural world (godfrey-smith 2003, 187)? following dupré (2001, 10), holcomb (2002) argues science is limited because it merely models the actual universe, representing certain aspects of our world but not truly or totally characterizing it. is science merely a metaphor, and terms like ‗gravity‘ and ‗gene‘ linguistic placeholders signifying things we scarcely understand? mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 7 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe natural selection is nevertheless an exceedingly simple mechanistic relationship. darwin did not need to understand generation of variation to understand how selection operates, just as physicists cannot cleanly link newtonian mechanics with einstein‘s relativity to explain gravity. it may be that punctuated equilibrium, involving gaps in the fossil record and non-linear rates of morphological change, is more a post hoc descriptive account of why gaps exist than a causal chain explaining, in a predictive sense, why that pattern exists in nature (hume 1748). still, to what extent must scientific explanations give causal accounts, given darwin himself did not understand inheritance, and at what level of reduction must they attribute cause? do we explain natural selection in terms of populations, genes, or subatomic particles? do evolutionary explanations show causality? as godfrey-smith (2003, 191-2) argues, to explain something in science ―is to show how to derive it in a logical argument… to show that it is to be expected, to show that it is not surprising, given our knowledge of the laws of nature.‖ under the ‗covering law‘ model of modern deductive-nomological science (hempel 1965), to explain is to give an account of something, a reckoning of cause with a relationship of inference. however, an asymmetry problem exists in that whereas we derive conclusions from premises, we cannot always go back to premises from conclusions. when we predict something we show it is expected, even if it ultimately does not occur, whereas when we explain something ―we know that it has happened already, and we show that it could have been predicted, using an argument containing a law‖ (godfrey-smith 2003, 192). because of this unidirectionality not all explanations can be reversed, and not all good arguments are good explanations. this post hoc rationalization, which shermer (1997, 216) decries as hindsight bias or ‗monday morning quarterbacking,‘ is a frequent critique lodged against ee, where prediction, as in weather forecasting, is theoretically possible if extraordinarily complicated given the number of variables involved. but the inability to predict preceding physical states, given an initial set of conditions and well-understood laws of nature, is not a special problem for ees; such ‗overdetermination‘ is a broader issue for science generally. another issue is how well ees link specific events to general patterns, connecting diverse facts under a set of basic explanatory principles. in godfrey-smith‘s words (2003, 196), ―[scientists] try to develop general explanatory schemata that can be applied as widely as possible.‖ in this regard ee is wildly successful: darwin transformed natural philosophy from scattered anecdotes into modern biology. a basic principle unifies a huge range of natural phenomena—potentially, all such phenomena. do evolutionary explanations lack predictive power? because of science‘s predictive power, it is concerned with explaining not only what is but what might be. however, critics contend that ees are limited by historical contingencies. evolution might not really explain anything because it cannot specifically predict the sorts of things (structural, behavioral, etc.) that will evolve. vertebrates evolved with pectoral and pelvic limbs; this is why they have two sets of paired appendages. but why two? why not three? unlike newtonian mechanics or other areas of physical science, where one can calculate a precise end result given a set of initial conditions, ees seem to offer ad hoc, a posteriori accounts. although one can concoct ees to explain how any aspect of any organism came about, you can‘t predict a priori that x or y mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 8 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe will evolve. could one have expected that eyes or fins or leaves would evolve? nonetheless, the issue here concerns data, not theory. those who argue that ees are necessary but insufficient to explain life‘s diversity fail to acknowledge that given enough information, a biologist could explain specific diversity, just as a meteorologist could, with sufficient data, predict all weather. the argument is not that ees should be able to predict perfectly; rather, processes that appear stochastic may when better understood be seen as more deterministic. the central issue is that ees are at heart based on statistical probabilities—an inherent element of the algorithmic mechanism proposed by darwin and wallace. you need not predict who will win a tennis tournament to be certain someone will emerge as the winner, but knowing something about the competitors, you can offer a statistical argument for who is most likely to win. ees simply propose that some evolutionary paths are more likely than others, just as it is more likely that a top seed will defeat a #64 seed in a tennis match. the set of organisms that might evolve is infinite, yet one can predict future organisms given today‘s organisms and expected future conditions (e.g., climatic trends). this is the central conceit of books like dixon‘s after man (1981), which present, as its subtitle explains, a zoology of the future. such books are patently speculative, but the conjecture is based on science underlying ees. oddly enough, as mayr (2001, 277) noted, darwin was criticized by contemporaries for focusing on specific predictions and deductions rather than grand, abstract ideas. for darwin, ee fit philosophical as well as methodological naturalism. darwin‘s view allows for natural, material, physical explanations, as opposed to the supernatural, immaterial, metaphysical explanations so common outside science. ees do not rule out the possible existence of divine forces, but neither do they require one (kitcher 2007, 129). this stripped-down simplicity of ee is, for many critics, a steep hurdle to overcome, especially when compared to the stunning complexity of the living world. how could a simple, blind process result in so much complexity? how can the living world‘s beauty and harmony depend on a probabilistic process? this critique is typically offered not as a limitation on ees but as a refutation of them in the first place. a common criticism relating to predictive ability is that whereas ee may be seen as necessary it is insufficient in explanatory power. it can explain that the necks of giraffes and mice have seven cervical vertebrae, but not why mammals have 7 instead of 6 or 8. it can explain the prevalence of the pentadactyl hand as a bauplan for tetrapod vertebrates, but not why the common ancestor had five digits rather than some other number. however, this turns out to be a weak criticism at best; again, the real problem is of limited data, not underlying theory. given sufficient information, we should be able to explain, via abductive inference, when the next mass extinction will occur and which species will survive it. that ees are historical in nature does not preclude scientists from testing them critically (cooper 2002, 427). ees are open to the same falsification, via experiment and observation, as all scientific hypotheses. darwin predicted, given the presumed relationship between humans and apes, that fossils of early human ancestors would be found where chimpanzees and gorillas live, in africa. this has been borne out by copious evidence. another example involves the evolutionary link between birds and dinosaurs. based upon skeletal similarities in the wrist and hip, scientists predicted dinosaur reproduction was like that of modern archosaurs (crocodilians and birds), including mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 9 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe laying and brooding eggs in nests. the discovery of fossilized dinosaur eggs in nests confirmed this prediction. other ee-based predictions such as the stratigraphic and geographic distribution of fossil taxa have likewise been corroborated. a related issue arises from the reductionism vs. emergence conundrum in that many biological properties (e.g., life, consciousness) cannot easily be distilled—they emerge later, with higher levels of organization, as epiphenomena. again, the criticism is that something that explains everything explains nothing, and thus ee is a shady, fast-and-loose shell game rather than genuine science. closer inspection reveals that given a set of initial conditions, one could predict the evolution of photoreceptors to sense visual stimuli, or contractile tissues and locomotor structures for movement, or plant organs with photoreactive pigments and high surface area for photosynthesis. there is nothing shifty or underhanded going on, except that the final solution to these scenarios is pragmatically unpredictable: we can‘t easily foretell, with the data we have, which of various possible outcomes will come to pass. as physicist sean carroll writes (2016, 293), one can explain giraffes‘ long necks via natural or sexual selection, or by arguing that ―given the laws of physics, the initial state of the universe, and our location in the cosmos, collections of atoms in the shape of long-necked giraffes came into existence 14 billion years after the big bang.‖ this statement is true but not useful, carroll claims, as it lacks the predictive power of ees. are evolutionary explanations tautological? khan (2009) points to the ‗relentless tautologies‘offered by the evolutionary framework. he refers to the ‗ontological leap‘taken by staunch adherents to ee, particularly social scientists who purport to explain all facets of human art, religion, and history via ep. ‗survival of the fittest‘ is often unfairly painted as a tautology if one defines fittest as those that survive. however, because ee involves heritability of characters, natural selection does not merely imply that survivors survive. population genetics demonstrates and predicts when populations will or will not be altered by natural selection (shermer 1997, 143). genes conferring adult tolerance to lactose are likely to be selected for in groups of herders with ready access to milk, but not in populations without domesticated cattle, sheep, or goats. can evolution create? does it involve chance? a potential scientific complaint is that evolution cannot generate new forms because it is eliminative only, removing less fit individuals of a population. yet elimination can be creative; sculptors create by chiseling away. the ‗adaptationist program‘criticized in gould and lewontin‘s landmark ‗spandrels of san marco‘ paper (1979) might be seen as a limit to ee. chance contingencies are not explained by evolution, though they are often subsumed within ee, as lewontin and gould noted. not all organismal features are adaptations demanding a just-so story; some are historical accidents. adaptationism is a seductive siren, yet just because something makes sense as an adaptation doesn‘t mean it is an adaptation. crucially, as genes are linked, many features just ―come along for the ride‖ without being truly selected for. much genetic variation is also the result of stochastic drift; ‗neutral‘dna is unexpressed and thus not subject to selection. in this sense, as with external aspects of an mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 10 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe organism‘s phenotype, features might be attributed to chance events. this poses a potential limitation on the epistemic utility of ee. is evolution limited by material constraints? there appear to be constraints from basic physics (which, for example, limit arthropod size), from genetics/genomics (with a limited toolkit of conserved genes serving similar functions in a wide range of organisms), and from development. this is why, even though birds with aluminum wings or mammals with gore-tex coats would be highly favored, they do not exist (kardong 2012, 3). as schloss (2009, 41) notes, ees offer a scenario in which a bat wing or dolphin flipper evolved as variations on the mammalian forelimb, ―but to understand them fully requires concepts outside evolution, like aerodynamics and gravity.‖ schloss (2009, 41) opines that ―evolution is a search engine that combs possibility space, but to explain what it comes up with, we need to understand both the engine and the space.‖ why are there no organisms with wheels? natural selection would greatly favor wheels, or birds with aluminum or teflon wings or horses with six legs. such extrinsic (physical) constraints allow a crucial falsifiability to ees and predictions. as long (2013, 15) notes, ―physical models can‘t violate laws of physics,‖ whereas ―every computer model is doomed to succeed.‖ new evolutionary-developmental (‗evo-devo‘) biology seeks explanations incorporating intrinsic (genetic) limitations, helping to broaden ees‘ explanatory power. is evolution limited by irreversibility? another prospective scientific limit to ee lies in the irreversibility of evolutionary change. although it is supposed that random changes in dna (nucleotide substitutions) can ‗undo‘ earlier changes, ‗dollo‘s law‘ states that evolution moves in one direction only: organisms cannot return down a road they have traveled (e.g., losing and later regaining a trait). a study by bridgham et al. (2009) offers a potential mechanism for one-way evolution, involving mutations (even in ‗neutral‘ or ‗nonfunctional‘ dna sequences unexpressed in an organism‘s phenotype) that destabilize proteins. a simple genetic reversion would not necessarily ‗undo‘ destabilizing effects of the original change, which would require, without selection pressure, an exceedingly unlikely number of neutral mutations. this ‗one-way‘ path poses a limit, but reflection yields examples of major reversals. marine mammals arose from quadrupeds; in reverting to an aquatic existence, whales gave up the legs their ancestors evolved when the first terrestrial tetrapods emerged from the sea. the loss of prismatic enamel in cetacean teeth and loss of the complexly folded neocortex in manatee brains (kelava et al. 2013) are other examples of evolutionary reversal. do social norms or sanctions guiding human behavior impose limits? from the philosophical realm, another stipulation presents a likely limit on ees: the injunction against using scientific findings as a guide for moral behavior. to borrow a famous phrase attributed to galileo (1615), scripture ―teaches us how to go to heaven, not how the heavens go.‖ science is understood not to be used as a model teaching people how to lead their lives. however, this feeling is not universally shared. much ink has been spilled concerning ‗social darwinism‘ and whether it was justifiable to darwin and other scientists, but that is not what is meant here. rather, what if ees shed light on relationships between humans, or between humans and other mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 11 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe species, indeed all of nature? if we are morally obligated to yell ―fire!‖ when we smell smoke in a crowded room, then what if scientists possess superior smoke detectors? are they bound to share results of findings in ways that could potentially save lives? this is a key question that demands more space and attention than can be given here. it is essential to distinguish ideal science as an independent societal process from science as a flawed, subjective institution carried out by biased individuals. sociologists of science have studied, without arriving at a definitive conclusion (beattie 2007; dennett 2007), the ‗chicken-and-egg‘ question of whether people are prone to become scientists because of their philosophical and religious leanings or in contrast, if working as a scientist leads one to develop a secular worldview. science per se, as a literally atheistic process—where explanations involving supernatural causes are not allowed—is separate from scientists, many of whom practice diverse faiths. science has been ―permeated by groupthink, bias, and financial, political, and personal motivations‖ (bloom 2015), with false claims and faulty programs—from the third reich to marxism, with eugenics, phrenology, and stifled climate debate—because scientists are human too (guhin 2016). as neil degrasse tyson notes, ―in science, when human behavior enters the equation, things go nonlinear. that‘s why physics is easy and sociology is hard. nonetheless, this demarcation between ontological naturalism (which argues there are only natural phenomena, and that whatever exists or happens is therefore natural) and science‘s purely methodological naturalism poses perhaps the greatest potential curb on ees, especially for adherents of religious or other teleological worldviews. to the extent that science is limited in theory or practice by social restraints, these must be seen as limitations to evolutionary (and all other scientific) explanations. the general issue of whether science itself has limited explanatory power, especially where it abuts belief, has attracted scrutiny, most notably by bronowski (1956), snow (1959), and medawar (1984). to be clear, science does not presume naturalism; rather, science has provisionally concluded that naturalism offers the best picture of the world, based on objective empirical evidence (national academy of sciences 1998; plantinga 2011; carroll 2016). naturalism is therefore a strength of ees, not an a priori limitation. case study 3: alfred russel wallace and moral (ontological) limitations consider wallace as a counterpoint to huxley and harlow. a prominent naturalist who supported darwin and equaled him as natural selection‘s co-discoverer, wallace nevertheless eventually, like huxley, imposed his own limits on ees‘ utility. indeed, wallace is as widely known for his late-life departure from evolutionary theory as for his joint contribution to it. notably, wallace ultimately concluded, contra darwin, that evolution is teleological and anthropocentric. wallace was a remarkably productive scientist but a puzzling person. he saw himself an ‗utter skeptic‘ (slotten 2004, 232) and purely scientific thinker, but for half his life was a proponent of spiritualism, though he claimed attempts to contact ghosts in séances involved rational, scientific efforts, given that spirits would be sensed via material means such as sounds, movements, and temperature changes. wallace publicly claimed he sought to expose fraudulent mystics as sincerely as he sought to communicate with spirits from the beyond (shermer 2002, 179), but his embrace of mysticism cannot be overlooked. there is no disguising the fact that wallace, like huxley, held a different view of evolution‘s generative powers than darwin. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 12 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe whereas darwin argued that purely physicochemical phenomena could create new, diverse life forms but also, presumably, the first life itself—although evolution is strictly about change in organisms, not the initial appearance of life forms—wallace saw stark limits to evolution‘s explanatory capacity, espousing the familiar view that material causes are insufficient to explain how life and human cognition arose. he wrote (1889, 478) that nonmaterial (supernatural) causes in the ―unseen universe of spirit‖ were alone responsible for life‘s origins, for consciousness in ―higher animals,‖ and for man‘s great powers of reason. indeed, wallace proudly proclaimed these metaphysical goals as the very purpose of the universe. thus wallace drew the ire of huxley, who criticized this teleological stance (raby 2001, 291), and darwin himself, who wrote in a letter to wallace, ―i differ grievously from you, & i am very sorry for it… i hope you have not murdered too completely your own and my child‖ (darwin 1869, milner 2014, 2). wallace‘s writings and advocacy of spiritualism, mesmerism, and phrenology have dimmed his luster among modern biologists. despite a selfprofessed insistence on pure scientific thinking, wallace allowed supernatural causes to enter his explanatory framework. although wallace‘s myriad contributions to tropical biology and ecology remain seminal—as the father of bioegeography, his name persists in the eponymous wallace‘s line and wallace effect—in evolutionary theory he lingers mainly as footnote to darwin. students learn of wallace as the humble co-discoverer of natural selection, but the deeper they dig the more they see why darwin found reasons to shun him (shermer 2002, xviii). two points must be stressed here. first, given that we, as corporeal beings existing in the physical world, can perceive supernatural phenomena only when manifested as empirical events capable of being experienced by our senses, then they are of necessity rendered open to scientific interpretation and analysis. in short, we have no means of perceiving exclusively supernatural (rather than partly or wholly natural) phenomena, or of knowing whether supernatural things even exist—we sense phenomena only via natural means. supernatural things may well exist, but they have no place in science (thus science‘s methodological naturalism is better characterized as empiricism: knowledge is derived not from thoughts but from experience). second, teleological explanations are similarly ‗wrong‘ only in the sense that they are entirely unscientific. in non-scientific contexts (including religious faiths) teleology can be valuable. are humans exempt from evolution? are we bound by determinism? astute readers will notice a common thread in the stories of huxley‘s garden, harlow‘s brain, and wallace‘s ghost. all involve a single species: our own. aside from possible philosophical and scientific objections to ees noted earlier, all concerns relate to humans alone. we impose limits only upon ourselves. consider the fundamental importance of this observation. no one who accepts ees claims that any aspect of a bird, butterfly, or banana is not amenable (in theory) to evolutionary interpretation. creationists aside, scientists do not argue that a paramecium, pine tree, or porcupine requires a special explanation for its morphology or behavior beyond that outlined by darwin. only when a spotlight is turned on our species do we search for additional answers; only then do we explain via ultimate mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 13 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe causes. we present ourselves as the first and last exhibit in the list of limits on ee. aside from arguments that we have ‗outstripped‘evolution (gluckman and hanson 1996, 126), we object for religious or moral reasons. to reiterate, important questions about the origin of life do not properly fall under the purview of ee. ees deal with organismal modifications over time; life‘s appearance is a different question. this is not an attempt to hedge or dodge the issue. any scientific account of life‘s origin must unquestionably adhere to the ‗rules‘ of science outlined earlier, including an empirical, natural, non-teleological position (opposite wallace‘s supernatural explanation). again, historical explanations are amenable to the scientific methods of observation and experiment, and offer the same predictive power (cooper 2002, 430). in short, darwin presented humans as animals. his view is often construed as—though it was not intended to be—an affront to human dignity and an assault on the doctrine of human exceptionalism and supremacy. if we are just animals, then what keeps us from behaving like animals? how can we exhibit morality? we now study the biological basis of ethics. morality has evolutionary roots (allchin 1999), contradicting huxley‘s claim that ethics must be an exception to evolution. primatologists like de waal (2001) argue that moral rudiments exist in other primates, particularly chimpanzees and bonobos. social apes live in tight groups, with a central social life focused on status in the dominance hierarchy and with violent, sometimes even murderous, impulses. perhaps not surprisingly, people traditionally viewed apes as aggressive, brutal fighters. but de waal and colleagues (e.g., pinker, 2002) highlight clear trends in apes toward peacemaking and reconciliation. they challenge the prevailing hobbesian (or huxleyian) view that we are born ruthless and selfish, and that without culture we remain that way. critics of ee frequently argue humans are no longer bound by the same selective processes that govern evolution of other species, whether because so much change in human populations stems from cultural rather than genetic evolution (pagel 2012), or simply because, as o‘hear (1997, 49) writes, ―our reflectiveness and our rationality‖ allow us to ―take on goals and ideals which cannot be justified in terms of survival-promotion or reproductive advantage.‖ we are not bound, as ep generally holds, by our stone age past; we make conscious decisions that differ from subconscious desires. we employ such decision-making every time we use birth control, avoid eating desirable calorie-laden foods, submit to painful medical procedures, and aid our enemies (burnham and phelan 2012; cochran and harpending 2009). humans alone are seen as transcending biological predispositions, with powers of reason, selfreflection, and cultural transmission that enable us to create new environments, subvert nature‘s tyranny, and exempt ourselves from nature‘s inexorable processes (midgely 1985; o‘hear 1997; ratcliffe 2005). gluckman and hanson (2006, ix) argue that ees do not apply to us because our bodies and behavior are no longer subject to natural selection. following a different tack, others argue that humans are exempt from natural selection‘s grasp due to our genetic engineering, particularly the way we can at least potentially alter germline dna and thus transcend selection. the use of viral vectors to introduce dna could yield ‗accelerated evolution that surmounts natural processes. philosophers of science (dupré 2001, 132; holcomb 2002; ruse 2010) use the term metaphysical pluralism in criticizing ep as extending beyond the explanatory reach of evolution and science in general. critics (midgley mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 14 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 1985; freese 2008) disparage ep as faulty (scientifically, philosophically, ideologically) for its emphasis on determinism, mechanism, reductionism, neo-social darwinism, and vulgar adaptationism. they accuse ep of embodying bad metaphysics for its scientific imperialism and antienvironmentalism, and for uncritically accepting explanations offered to fit into an evolutionary framework, sometimes with little empirical evidence or with evidence manifestly molded to fit this procrustean bed. an admitted problem with ep, and a difference with other sciences, is that it too often projects wildly speculative conjectures with little hard evidence. whereas peerreviewed science (taken collectively) hesitates to postulate inferences not backed by hard data, ep seems in many cases eager to offer far-reaching conclusions (such as about human mating or love of music) without nuanced subtlety. this is leveled as a practical criticism, not a theoretical one. ep explanations need not be limited. rather, excited writers (often journalists, not sociobiologists) are often guilty of speculating beyond the scope of what limited data imply. this revisits the problem of insufficient information, as well as whether branches of science differ methodologically or in the physical reality they reveal. are they genuinely, following wilson‘s model of consilience (1998), points along the spectrum of a larger whole, revealing related aspects of a single truth? holcomb (2002) criticizes such ‗nothing-butism‘ or ‗one-size fits all‘ explanations as metaphysical monism. o‘hear (1997, 214) offers a cogent argument that many aspects of our species, particularly moral reasoning and consciousness, are ―undarwinian‖ or ―not explicable in terms of darwinian drives.‖ he claims ―we seek truth for its own sake‖ (1997, 204) with no benefit to survival and reproduction, though this is debatable. as with all organisms, just because traits do not exhibit clearly adaptive ‗purpose‘ does not mean they did not or could not have originated evolutionarily. darwin was the first to advance a unified, non-teleological theory of evolution that did not seek refuge in aristotelian final causes. darwin‘s concept of descent involved no movement toward a goal. unlike huxley, darwin viewed nature as ever-changing but not necessarily improving, or progressing. this was a novel, unpalatable view. in mayr‘s words (1964, xvi), ―darwin postulated a brute, mechanical, soulless universe, depending on the whims of accident.‖ darwin zealously argued that survival is not a matter of mere happenstance: it is a statistically predictable property of an organism‘s makeup. however, darwinism seems to rule out choice and free will. as genetic creatures, aren‘t our features, and by extension our lives, predetermined? evolutionists are quick to distinguish the crucial difference between determinism (―the future is written‖) and potentiality: many paths lie open, some likelier than others. [some religions involve predestination to a greater extent than geneticists would claim.] in this context one must note that ‗evolution‘ literally refers to unrolling or unfolding, as of a scroll already written but not yet open to view; thus the word evolution itself carries an indelible stamp of teleology on which so much human thinking is predicated. ever since darwin biologists have debated the extent to which biological change reflects adaptation to an unpredictable, randomly changing environment, or whether evolution reflects goal-directed progress, as of the unfolding of a grand scheme. although huxley is justifiably famous for his formative views on agnosticism, he is also known for espousing a popular view of progress. then as now, the notion of divinely guided, theistic mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 15 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe evolution was a popular middle ground in which people could keep their science and square it with theological worldviews. conclusion: limits lie in the eyes (and worldview) of the beholder according to lore (zimmer 2001, ix), an upper-class victorian lady is said to have remarked, upon the publication of the origin of species, ―let us hope this is not true; but if it is, let us hope it will not be generally known.‖ alas, for this woman and millions of like-minded critics, evolutionary theory is now as universally accepted by scientists as it is widely known by non-scientists, with a deep, enduring, alluring power. as dennett predicted, evolution has spilled beyond the natural sciences to the social sciences, threatening (some would say) to account for seemingly every aspect, large and small, of humankind, as it has for all other living creatures. the explanatory power of evolutionary accounts might seem limitless. science emerges from curiosity and reflects our innate striving to apply an organizing framework to everything we experience. ‗science‘derives from the latin verb ‗to know,‘ yet although science is our most powerful tool to understand our universe, there is much science cannot answer, including the biggest questions we ask. this baffles opponents of evolution who misunderstand that science seeks explanations about the natural world, but relies on empirical evidence and addresses naturalistic questions. it cannot speak to supernatural claims. it is not suitable for addressing questions about existence, knowledge, or meaning. it cannot tell us how we should behave or what our purpose in the world should be. at heart, fundamental objections to evolutionary explanations fall into two categories: misunderstanding of the nature of science and ideological or ontological protest to evolutionary implications. if ees follow basic rules of science (viz. are based on empirical evidence, are falsifiable and predictive, and do not presume a teleological stance), there are no inherent limits qua science. to the extent that one deals with phenomena subject to empirical analysis, there may be no inherent boundaries to evolution‘s explanatory powers. it is potentially applicable to all facets of the natural world, including human culture. in the end, ees, like any scientific explanations, go only so far as science takes us. for people who feel science can answer everything—that all natural phenomena, including aspects of humanity, can be adequately explained via physical causes—there are no inherent limits to evolutionary explanations. but for the many who feel otherwise, ees have distinct limits. no one should underestimate the brute force of evolution in providing clear, consistent, consilient explanations of the natural world, but none should overestimate the case for science likewise. many who accept evolution‘s factual nature hold differing views as to its explanatory power. this was true of key figures in the development and propagation of darwin‘s theory of evolution, and will likely hold true for the foreseeable future. the teleological predisposition that lies at the heart of most objections to evolution are so deeply seated in us— both culturally and biologically (through countless generations of neurological hardwiring)—as to be virtually unshakeable. studies repeatedly show (kelemen and rosset 2009) that even when we consciously try to break the teleological paradigm, we subconsciously revert to this heuristic. as intentional creatures, it is our nature to presume agency, to seek reason and purpose in everything. this is not to say no such meaning exists in the world mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 16 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe around us— there may well be. but that remains an open question beyond the scope of science. the point is that our default presumption is that there must necessarily be meaning. for most people, religion is the surest path to the meaning we crave, and herein lies the greatest potential curb to ee, for if there is a grand ‗meaning to it all‘ (beyond that which we impose ourselves), this scheme has the potential to exist outside the observable bounds of nature, and thus to be outside the reach of evolutionary explanation. if we wish to believe in a wholly materialistic universe, with nothing exempt from ordinary laws of nature, then we can easily imagine an unalloyed, invincible, omnipotent evolutionary framework—the ‗universal acid‘ of dennett‘s metaphor—that truly explains everything in nature. but this is a massive ‗if,‘ and for most people an impossibly difficult step. the biggest, surest limit to evolutionary explanation is not to be found in the study of nature but rather in the study of ourselves, for it is a limit we willingly or unwillingly yet all too easily apply. sheldrake (2012) vigorously critiques modern science‘s unquestioned stance of mechanistic materialism. haught (2009) likewise argues that some scientists uncritically conflate ees with a materialist or physicalist worldview such that ―what emerges is not pure science but a belief system.‖ haught charges that although evolutionary biology is sound, it creeps unwarranted and unprovoked beyond science into ―realms of belief.‖ at issue is darwin‘s legacy, unintended or not, of extending methodological naturalism to ontological naturalism, a flashpoint of debate for philosophy. if scientists uncritically accept a wholly material worldview as their starting point, their results will be biased, haught (2009) argues. recall the essential uniformitarian legacy of darwin in applying scientific investigations and findings to all times and places, not excluding any portions of the material universe. but is there more to the universe than matter and energy? in haught‘s view, ees are about more than science, as they are inherently ―antithetical to religion,‖ excluding the potential for metaphysical explanations. does darwin make sense only in a materialist setting? is ee predicated on a materialist worldview? obviously not, as many people prefer theistic evolution or progressive creationism. others, including astronaut john glenn, see no problem squaring their faith with science (reid 2016): ―i don‘t see that i‘m any less religious by the fact that i can appreciate the fact that science just records that we change with evolution and time. the crux of the debate is whether one can be a serious evolutionist without being a materialist. this is a question outside science, which we may never answer to everyone‘s satisfaction. given that faith does not depend on empirical evidence, this will not soon if ever be resolved in any formal, final way. like all scientific explanations, evolutionary explanations cannot extend into the realm of belief. this is undoubtedly their strongest, surest ‗limit.‘ ultimately it boils down to the worldview one adopts. acknowledgments i dedicate this paper in memory of my late colleague diana rhoads, who never ceased to provide inspiration and tough questions, always in the spirit of graceful cooperation and learning. for a steady stream of feedback i am grateful to colleagues in biology (bill shear, mike dougherty, michael collins, douglas allchin), chemistry (herb sipe), philosophy (marc hight, patrick wilson), religion (jeff vogel, mike utzinger, jerry carney, john david ramsey), and literature (jim arieti, lowell frye). references mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 17 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe allchin, d. (2007). a more fitting analogy. the american biology teacher 69, 174-176. barbour, i. (1998). religion and science. london: scm press. beattie, t. (2007). the new atheists: the twilight of reason & the war on religion. london: darton, longman, and todd. bloom, p. (2015). scientific faith is different from religious faith. the atlantic 417357. bowler, p. (1975). the changing meaning of ―evolution.‖ journal of the history of ideas 36, 95-114. bridgham, j.t., ortlund, e.a., & thornton, j.w. (2009). an epistatic ratchet constrains the direction of glucocorticoid receptor evolution. nature 461, 515-519. bronowski, j. (1956). science and human values. new york: messner. browne, j. (2002). charles darwin: a biography, vol. 2: the power of place. new york: knopf. burnham, t., & phelan, j. (2012). mean genes: from sex to money to food, taming our primal instincts, 2e. new york: perseus. carroll, s. (2016). the big picture: on the origins of life, meaning, and the universe itself. new york: dutton. cooper, r. (2002). scientific knowledge of the past is possible. american biology teacher 64, 427-432. cochran, g., & harpending, h. (2009). the 10,000 year explosion: how civilization accelerated human evolution. new york: basic books. damasio, a. (1994). descartes‘ error: emotion, reason, and the human brain. new york: picador. darwin, c. (1869). april 14 letter to a.r. wallace. cambridge: darwin correspondence project (cited 2014 may 26). http://www.darwinproject.ac.uk/letter/entry-6706 darwin, c. (1871). the descent of man, and selection in relation to sex. london: john murray. dennett, d. (1995). darwin‘s dangerous idea: evolution and the meanings of life. new york: simon & schuster. dennett, d. (2007). breaking the spell: religion as a natural phenomenon. new york: penguin. desmond, a. (1997). huxley: from devil‘s disciple to evolution‘s high priest. new york: basic books. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 18 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe desmond, a., &moore, j. (1992). darwin: the life of a tormented evolutionist. new york: w.w. norton & co. de waal, f. (2001). the ape and the sushi master: reflections of a primatologist. new york. basic books. dixon, d. (1981). after man: a zoology of the future. london: st. martin‘s press. dobzhansky, t. (1973). nothing in biology makes sense except in the light of evolution. american biology teacher 35, 125129. dupré, j. (2001). human nature and the limits of science. oxford: oxford univ. press. eldredge, n., & gould, s.j. (1972). punctuated equilibria: an alternative to phyletic gradualism. in t.j.m. schopf, ed., models in paleobiology, pp. 82-115. san francisco: freeman. fleischman, j. (2002). phineas gage: a gruesome but true story about brain science. new york: hmh books. freese, j. (2008). the limits of evolutionary psychology and the open-endedness of social possibility. sociologica 2008(3, novdec.), doi:10.2383/28768. gluckman, p., & hanson, m. (2006). mismatch: why our world no longer fits our bodies. oxford: oxford univ. press. galileo, g. (1615). letter to the grand duchess christina. godfrey-smith, p. (2003). theory and reality: an introduction to the philosophy of science (science and its conceptual foundations series. univ. of chicago press. gould, s.j. (1997). non-overlapping magisteria. natural history 106, 6-22. gould, s.j., & lewontin, r. (1979). the spandrels of san marco and the panglossian paradigm: a critique of the adaptationist programme. proc. r. soc. lond. b biol. sci. 205, 581-598. guhin, j. (2016). a rational nation ruled by science would be a terrible idea. new scientist 2096315. haught, j.f. (2009). theology, evolution, and the human mind: how much can biology explain? zygon 44, 4. hempel, c.g. (1965). aspects of scientific explanation: and other essays in the philosophy of science. free press. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 19 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe herbert, s. (1977). the place of man in the development of darwin‘s theory of transmutation. journal of the history of biology 10:155-227. hesketh, i. (2009). of apes and ancestors: evolution, christianity, and the oxford debate. toronto: univ. of toronto press. holcomb, h.r. (2002). review of human nature and the limits of science, by john dupré, oxford university press. notre dame philosophical reviews. 2002.06.05 hume, d. (1748). an enquiry concerning human understanding. reprinted 1993 hackett publishing. huxley, t.h. (1888). the struggle for existence in human society. collected essays 9:195-236. huxley, t.h. (1894). evolution and ethics. reprinted 1989. princeton: princeton univ. press. irvine, w. (1955). apes, angels, and victorians: the story of darwin, huxley, and evolution. new york: mcgraw-hill. kardong, k. (2012). vertebrates 6e. new york: mcgraw-hill. kean, s. (2014). the tale of the dueling neurosurgeons: the history of the human brain as revealed by true stories of trauma, madness, and recovery. new york: little, brown. kelava, i., lewitus, e., & huttner, w. (2013). the secondary loss of gyrencephaly as an example of evolutionary phenotypic reversal. frontiers in neuroanatomy 7, 16. kelemen, d., & rosset, e. (2009). the human function compunction: teleological explanation in adults. cognition 111, 138-143. kitcher, p. (2007). living with darwin: evolution, design, and the future of faith (philosophy in action). oxford univ press. khan, r. (2009). social scientists should steer clear. the guardian, 13 february 2009. http://www.guardian.co.uk/commentisfree/belief/2009/feb/13/charles-darwin-evolution kugler, c. (2002). darwin‘s theory, mendel‘s laws: labels and the teaching of evolution. american biology teacher 64, 341-351. lyons, s.l. (1999). thomas henry huxley: the evolution of a scientist. new york: prometheus. macmillan, m. (2002). an odd kind of fame: stories of phineas gage. new york: bradford. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 20 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe mayr, e. (1964). introduction to on the origin of species, facsimile of the first edition. new york: atheneum. mayr, e. (2001). what evolution is. new york: basic books. medwar, p. (1984). the limits of science. new york: harper collins midgley, m. (1985). evolution as a religion: strange hopes and stranger fears. routledge. milner, r. (2014). three birds of a feather: darwin, wallace, and attenborough. reports of the national center for science education, 34, 1-5. national academy of sciences. 1998. teaching about evolution and the nature of science. washington, dc: national academy press. o‘hear, a. (1997). beyond evolution: human nature and the limits of evolutionary explanation. oxford: oxford univ. press. pagel, m. (2012). wired for culture: origins of the human social mind. new york: w.w. norton. pinker, s. (2002). the blank slate: the modern denial of human nature. new york: penguin. pinker, s. (2012). the false allure of group selection. edge, june 19 2012. plantinga, a. (2011). where the conflict really lies: science, religion, and naturalism. oxford: oxford univ. press. pope john paul ii. (1996). message to the pontifical academy of sciences: on evolution, delivered 22 october 1996. raby, p. (2001). alfred russel wallace: a life. princeton: princeton univ. press. ratcliffe, m. (2005). an epistemological problem for evolutionary psychology. international studies in the philosophy of science 19, 47–63. reid, a. (2016). john glenn: defender of both faith and evolution. ncse.com/blog 12 december 2016. ridley, m. (2003). evolution 2e. oxford: oxford university press. ruse m. (2010). science and spirituality: making room for faith in the age of science. cambridge univ press mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.6, issue 4; july-august 2021; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 21 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe schloss, j. (2009). totally, for a martian. in does evolution explain human nature?, pp. 40-43. west conshohocken, pa: john templeton foundation. sheldrake, r. (2012). science set free. new york: deepak chopra books. shermer, m. (1997). why people believe weird things: pseudoscience, superstition, and other confusions of our time. new york: henry holt. shermer, m. (2002). in darwin's shadow: the life and science of alfred russel wallace, a biographical study on the psychology of history. oxford: oxford univ. press. shermer, m. (2006). why darwin matters: the case against intelligent design. new york: times books. snow, c.p. (1959). the two cultures and the scientific revolution. cambridge: cambridge univ. press. slotten, r.a. (2004). the heretic in darwin‘s court: the life of alfred russel wallace. new york: columbia univ. press. wallace, a.r. (1889). darwinism: an exposition of the theory of natural selection with some of its applications. london: macmillan. werth, a.j. (2014). vestiges of the natural history of development: historical holdovers reveal the dynamic interaction between ontogeny and phylogeny. evolution: education and outreach 7, 1-11. wilson, e.o. (1998). consilience: the unity of knowledge. vintage. wilson, e.o. (2012). the social conquest of earth. new york: w.w. norton. zimmer, c. (2001). evolution: the triumph of an idea. new york: harper. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 3; may-june 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 8 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe network pharmacology of natural medicine in oral mucosal lesions: a comprehensive review prof. zhang ming 1department of endodontics, the first affiliated hospital of xinjiang medical university/ stomatology hospital, urumqi, china abstract: oral mucosal lesions (oml) pose a significant global public health challenge, impacting countless individuals worldwide. this comprehensive review explores the various facets of oml, encompassing conditions such as oral candidiasis, oral lichen planus, recurrent aphthous ulcer, oral leukoplakia, and oral squamous cell carcinoma. the multifaceted etiology of oml is examined, shedding light on genetic susceptibility, immune dysfunction, viral and bacterial infections, food allergies, and nutritional deficiencies as contributing factors. with a rich history of natural medicine use in china, this article delves into the potential of chinese medicinal compounds in oml treatment. recent scholarly research has led to the identification and study of chemical components within traditional chinese medicine, highlighting their anti-inflammatory, analgesic, antioxidant, antibacterial, and wound healing properties. natural products derived from plants have demonstrated remarkable potential in oml treatment, offering diverse structures, multi-target effects, high activity, and low toxicity. keywords: oral mucosal lesions, oral candidiasis, oral lichen planus, recurrent aphthous ulcer, oral leukoplakia, oral squamous cell carcinoma, chinese medicine, natural products, etiology, traditional medicine. 1. introduction oral mucosal lesions (oml), also known as oral soft tissue diseases, are a series of diseases or conditions affecting the oral mucosa and soft tissue. it was rated as one of the major global public health problems by the world health organization (who) in 2003 and is the most common health problem faced by individuals worldwide [1].oml covers a wide variety of diseases, mainly including oral infectious diseases, such as oral candidiasis (oc);oral mucous mottling diseases, such as oral lichen planus (olp);oral mucosal ulcerative lesions, such as recurrent aphthous ulcer (rau);oral precancerous lesions, such as oral leukoplakia (olk);oral cancer or tumor, such as oral squamous cell carcinoma (oscc), etc. the etiology of oml is very complex, with the in-depth study of scholars in recent years, it is found that genetic susceptibility, immune dysfunction, viral and bacterial infection, food allergy, vitamin and trace element deficiency and many other factors are closely related to the occurrence of oml[2]. in china, the use of natural medicine has a long history. with the vigorous research and promotion of chinese medicine by scholars this year, the chemical components of chinese medicine contained in chinese medicine mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 3; may-june 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 9 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe compound are also widely studied by scholars. so far, many natural products have been used in the treatment of oral mucosal diseases because of their good anti-inflammatory, analgesic, antioxidant, antibacterial and wound healing ability. a large number of studies have shown that bioactive substances derived from plants have great potential in the treatment of oml, and natural products may be the best and most valuable resources for multitarget drugs due to their multiple advantages of diverse structure, multi-target, high activity and low toxicity [1,3]. natural medicine has great advantages in the treatment of oral mucosal diseases. however, unlike western medicine, traditional chinese medicine is not based on a single component of natural medicine. therefore, it is difficult to systematically explain the mechanism of action of traditional chinese medicine. it is the key to analyze the overall active ingredients and mechanism of action of natural medicines [4]. the concept of "network pharmacology" was first proposed by the british pharmacologist hopkins in 2007, and it is defined as a branch of pharmacology, which uses the disease-gene-target-drug network method to analyze the relationship between drugs, diseases and targets, the characteristics of multi-level networks, and the huge data analysis system. it coincides with the characteristics of "multicomponent, multi-target and multi-path" treatment of diseases in traditional chinese medicine, so network pharmacology has certain advantages in discovering targets of natural drugs [5,6]. at present, the commonly used databases of network pharmacology include drugbank, stitch and tcm chemical information database, which cover drug molecular data. pubchem, chembl, kegg and target databases related to active pharmaceutical ingredients; gene related databases such as omim; protein related databases such as hprd, biogrid and dip; and a database of molecular interactions such as hprd, bind, dip, happi, mint, string, and pdzbase. the aforementioned database can be used to find the necessary information, in addition to this, we also need appropriate analytical tools such as cytoscape, pajek, visant, guess, widas, pa tika, pa tika web and cadlive, among which, in the field of tcm natural medicine research, cytoscape, guess, pajek and visant are currently the most widely used network analysis software [7]. therefore, the use of network pharmacology system to comprehensively analyze the mechanism of action of multi-component drugs has been widely used in the study of natural medicine treatment of diseases. this paper reviewed the representative application of network pharmacology research in the treatment of common oral mucosal diseases by natural drugs. we summarized and analyzed the representative articles published on domestic and foreign websites that used network pharmacology to explain the potential pharmacological mechanism of natural drugs in the treatment of oral mucosal diseases. to provide a reference for the experimental study of natural medicine prevention and treatment of oral mucosal diseases. 2. explore the treatment of mucosal diseases by natural medicine prescriptions based on network pharmacology oral lichen planus (olp) is a chronic inflammatory disease of oral mucosa mediated by t lymphocytes, often manifested as white reticulate mucosa lesion. li yueyue [8] et al. combined tcmsp database, genecards database and omim database to construct the "disease-active ingredients-target" diagram, and obtained 15 active ingredients in compound gypenoside capsules, including gypenoside components, brevetin, quercetin and mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 3; may-june 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 10 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe rhamnetin. it was found that these active ingredients could interact with 54 potential targets related to oral lichen planus. ppi network analysis, go functional enrichment analysis, kegg pathway enrichment analysis and molecular docking analysis were used. it was found that compound gyantulan capsule may play a role in the treatment of olp by regulating endocrine resistance, mitogen-activated protein kinase signaling pathway, hypoxia inducible factor 1 signaling pathway, cytokine cytokine receptor interaction and other signaling pathways. deng qianlan et al[9]screened 169 active ingredients from huashuixing yuqingreet recipe through tcmsp, batbat-tcm and uniprot databases, and obtained key ingredients such as quercetin, luteolin, han baicalin and kaempol after intersecting with olp disease targets. by constructing ppi network, it was found that the treatment of olp with huashuxing yuqingreai prescription involved many pathways such as inflammation, infection, metabolism and tumor, among which the interleukin-17 (il-17) signaling pathway and tnf signaling pathway were closely related to the occurrence of oral lichen planus. some scholars[10] analyzed the treatment of olp with huoxue huayu prescription based on network pharmacology. it was found that the main active components included quercetin, kaempferol, stigasterol, etc. it was found that the main active components included quercetin, kaempferol, stigasterol, etc. core action targets include il-1β,ptgs2(cox-2),mao, etc. kegg analysis showed that activating blood circulation to remove blood stasis could affect neurotransmitter metabolism, cytomegalovirus infection, age-rage and other pathways. oral ulcers are secondary lesions characterized by loss of oral mucosal tissue, often including local traumatic ulcers, recurrent aphthous ulcers (rau), viral and bacterial infections, allergic reactions, adverse drug reactions, or systemic diseases. kouyanqinggranule,(kyqg) which was collected in the 2020 edition of chinese pharmacopoeia, is mainly used in the treatment of inflammatory diseases of mouth and throat, such as rau, oral leukoplakia, olp, etc. some scholars[11] used network pharmacology to screen multiple targets of kyqg in the treatment of oral ulcer diseases, and a total of 47 key targets were selected through network analysis, mainly involving three functional modules of inhibiting inflammatory response, regulating immune response and inhibiting oxidative stress. the realization of these functions mainly depends on the tnf signaling pathway and hif-1 signaling pathway. it was found that kyqg could significantly inhibit the levels of cycoperoxidase-2 (cox2), matrix metalloproteinase-9 (mmp9) and tumor necrosis factor-α (tnf-α) in serum of rats with oral ulcer. li xueli [12] explored the mechanism of action of yatongting drip pill for treating oral ulcers based on ingredient-target interaction, and identified 19 ingredients of piperlongi and 13 ingredients of clove. yatong stop dropping pills in piperine, quercetin, kaempferol and other compounds, through the expression of cdk2, cdk4, fos, hif-1, mapk8 (jnk), tgf-β,it affects cell cycle, p53, foxo, mapk, toll-like, hif-1, erbb, neurotrophin, tgf-beta, t cell, b cell, camp and other signaling pathways, and produces effects on regulating cell cycle, immune response, apoptosis, etc. final treatment of mouth ulcers. ma xuan et al [13] explored the effect of sipayi solid giva solution on recurrent aphthous ulcer (rau) through network pharmacology, and found that the core components contained in it, such as galic acid, can act on genes such as tnf and ifn-γ, and then regulate multiple signaling pathways such as nf-κb and hif-1, thus playing a role in the treatment of rau. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 3; may-june 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 11 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe oral submucous fibrosis (osf) is a chronic inflammatory oral mucosal disease with insidious, progressive, and potential deterioration. the clinical manifestations of osf are mainly cheek and soft palate whiteness and progressive mouth opening limitation. at present, the pathogenesis of osf is not clear, mainly related to longterm chewing of betel nut, immune dysfunction, genetic susceptibility and dietary habits. zhu keke et al[14] explored the network and molecular mechanism of action of taohong siwu decoction in treating osf based on the method of network pharmacology. the active components of taohong siwu decoction and its therapeutic targets for osf were analyzed by combining multiple databases. according to cytoscape and r software and bioinformatics analysis, 42 targets of taohong siwu decoction for treating osf were obtained. quercetin, kaempferol, ferulicacid, paeoniflorin, luteolin and baicalein may be the main active components of taohong siwu decoction in the treatment of osf. it can act on jun, hmox1, mapk family, mmp family and other targets, and participate in biological processes such as cytokine activity, cytokine receptor binding, growth factor activity and dna-binding transcriptional activation activity.hif-1 signaling pathway, nf-κb signaling pathway, mapk signaling pathway, wnt signaling pathway and tgf-β signaling pathway are used to treat osf. compound salvia miltiorrhiza dropping pills also have certain clinical efficacy in treating osf[15]. through database analysis, the key active ingredients of compound salvia miltiorrhiza dropping pills are luteolin, perillyl alcohol, salviol b, tanshinone ⅱa, ginsenoside rh2, xuexueoxalic acid, etc.core targets include mapk3, mapk1, hras, jun, vegfa, ptpn11, egfr, il6, mapk8, tnf and other key targets, which mainly act on cancer-related signaling pathways, pi3k-akt signaling pathway, and microrna-related pathways to exert biological activities. behcet syndrome (bd) is a systemic, chronic, progressive, and recurrent disease of the immune system that is closely associated with genetic factors (such as the hla-b51 gene), bacterial or viral infections, and immune dysfunction. it often invades many organs including the mouth, eyes, skin and muscles and joints, mainly manifested by recurrent oral ulcers, genital ulcers, skin damage and ocular iritis. the main compounds of sanwu huangqin decoction and their corresponding action targets were searched by tcmsop and tcmid database. the target of behset disease was searched by genecards database. network visualization via string database and cytoscape software; go and kegg sets were analyzed for intersection targets using david database. moreover, the regulation effect of sanwu huangqin decoction on core target genes was verified by constructing bd mouse model[16]. hand-foot and mouth disease (hfmd) has been the highest incidence of class c infectious diseases since it was included in class c infectious diseases in 2008.hfmd occurs mostly in school-age children under 5 years old, and its clinical symptoms are mainly fever, rash or herpes on the hands, feet, mouth and other parts, and severe cases can lead to death. cao zhiming et al[17]also found through network pharmacology that coptis and coptis can act on targets such as ins, tp53 and il6 to regulate signaling pathways such as pi3k-akt, p53, apotosis and nf-κb to treat hfmd. geranicin, ginkgo biflavone and isoginkgo biflavone may be the active components of ev71 resistance. cheilitis, similar to the "lip wind" and "tight lips" documented in chinese medicine literature. clinical symptoms can be divided into allergic contact cheilitis, photolinear cheilitis, exfoliative cheilitis, glandular mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 3; may-june 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 12 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe cheilitis, granulomatous cheilitis and so on. the specific manifestations are dry desquamation, itching, burning pain, swelling, exudation and scab on the lip mucosa. ren xuewen et al[18] used tcmsp and tcmid to screen the effective compounds and targets of compound comfrey oil. the disease target of cheilitis was selected by searching genecards and omim database, and the intersection of disease and drug target was selected by r language. the drug-compound target-disease interaction network was constructed by cytoscape software. the ppi network was built using string platform, and the bioconductor software package was used to perform go function enrichment and kegg pathway analysis. among them, the 21 active ingredients screened play a key role in targeting il-6, stat3 and tnf, and are mainly enriched in several signaling pathways such as agerage, fssas and tnf, playing anti-inflammatory and regulating cell proliferation and apoptosis. 3. explore the treatment of mucosal diseases by single medicinal plants based on network pharmacology dictinum skin has the efficacy of clearing heat and detoxifying, dewetting and relieving itch, etc., which can be used in the treatment of skin mucosal diseases. liu shiwei et al. [19] selected the pharmacodynamic components and target of dictinum skin through tcmsp database and swiss target prediction database, and predicted the target related to olp disease through gene cards database. the intersection of drugs and disease targets was established, and a "drug-ingredient-target-disease" network was constructed, and it was found that dichotoma can play a role in the treatment of olp through multiple targets and pathways such as il-4 and il-17. oral squamous cell carcinoma (oscc) is one of the most common cancer types in the world, accounting for more than 90% of oral malignancies. oscc usually presents as a persistent hemorrhagic ulcer or ulcer, often developed from precancerous lesions such as white spots and erythema. liu [20] studied the treatment of oral squamous cell carcinoma (oscc) with tripterygium vine through network pharmacology combined with molecular docking model, and analyzed the key targets of tripterygium vine in the treatment of oscc as stat3, tnf, jun, tp53 and akt1 through ppi network topology. topological analysis of the "drug component-targetdisease" network showed that kaverol, triptolide, triptolide, tangerine and epicatecin were the core active components, which mainly affected the proliferation, apoptosis, invasion and migration of oscc, and the pi3kakt signaling pathway was the key signaling pathway. through the network pharmacological analysis of tripterygium in the treatment of olp, wu et al. [21] found that the core active components of tripterygium included tripterygium lactone, kauniol, and cephalotin, and the key targets included tumor necrosis factor, serine/threonine protein kinase 1, and the major pathways involved were tnf signaling pathway and il-17 signaling pathway. in addition, based on the effects of tripterygium wilfordii on pain, swelling, detoxification, blood circulation and circulation, the research group also used network pharmacological means to predict the main active ingredients of tripterygium wilfordii and their pharmacological properties and mechanism of action in the treatment of recurrent aphthous ulcer (rau), and found that the main ingredients that play a role in the treatment of rau still include kauniol and tangerine.in addition, triptolide is also included, and the main signaling pathways are tnf signaling pathway, toll-like receptor pathway, and t cell receptor signaling pathway. from this we can see that network pharmacology can reveal the mechanism of "different diseases of the same treatment" in the study of oral mucosal diseases in traditional chinese medicine. in other words, network pharmacology can elucidate the mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 3; may-june 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 13 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe mechanisms of the same strategy to treat different diseases through the target-pathwayorgan network of the same drug. oral leukoplakia (olk) is a kind of white plaque occurring in the oral mucosa. it is the most common potential malignant oral lesion. the pathological feature of oral leukoplakia is abnormal proliferation of epithelioid cells, which is a precancerous lesion with a cancer risk of about 0.6% to 20%. the clinical classification of olk can be divided into homogeneous and heterogeneous lesions. the selection of effective ingredients for olk treatment from natural medicines is currently a hot topic in disease prevention research [22].by means of network pharmacology, molecular docking and experimental evaluation, hou fanfan et al. found that the main active component of anti-olk in radix flax was radix flax glycoside; kegg pathway analysis revealed that pi3k/akt was the key pathway for its action; ppi analysis showed that akt1, vegfa, egfr, hif1a and ptgs2 were the main target genes. based on the above predicted results, in vitro experiments were conducted to further prove that baicalin can inhibit the proliferation of dok cells, induce apoptosis, block cell cycle, and inhibit the mrna expression level of central genes by inhibiting pi3k/akt pathway [23]. compound salvia miltiorrhiza dripping pills have a certain effect in the treatment of oral submucous fibrosis, in which salvia miltiorrhiza, as the main active component of the prescription, plays a great role, but its mechanism has not been fully clarified. therefore, cai et al[24]found through network pharmacology that active components of salvia miltiorrhizae may inhibit osf by targeting cytokinemediated signaling pathways, apoptosis and il-17 signaling pathways. 4. explore the effective components of monomer for the treatment of mucosal diseases based on network pharmacology quercetin, as a natural flavonoid, has a variety of biological activities and is widely distributed in nature. quercetin often exists in the flowers, fruits, roots and leaves of many common plants. quercetin is mainly stored in the form of quercetin and hypericin, and has many pharmacological effects such as antioxidant, antiinflammatory, anti-tumor and immune regulation [25]. the above-mentioned compound gantulan capsule, huashui xingyu qingrefang, huoxue huayu decoction, yatong stopping tiao pill and taohong siwu decoction all contain quercetin, which has good effects on various diseases. zhao et al [26] combined network pharmacology with experimental verification to predict and verify the key anti-olp targets of quercetin.66 quercetin -olp common targets were analyzed from different databases, ppi networks were constructed, topology analysis and mcode cluster analysis were performed for common targets, and key targets such as tp53, il-6 and ifn-γ were identified. the key signaling pathways of active oxygen metabolism, il-17 and age-rage were enriched by go and kegg analysis. in vitro experiments have also confirmed that quercetin interferes with th1/th2 balance by acting on il-6 and ifn-γ, regulates the immune system, and then treats olp, laying a foundation for the clinical application of quercetin. total paeoniflorin is extracted from the dried root of paeoniflorin. it is a general name of a group of glycosides including paeoniflorin, paeoniflorin, benzoyl paeoniflorin, hydroxy paeoniflorin and paeoniflorin. it has antiinflammatory, analgesic and immunomodulatory effects. lou et al[27]obtained five major chemical components mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 3; may-june 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 14 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe of total glucosides of paeony through network pharmacological screening. the biological processes in go enrichment analysis mainly involved the positive regulation of rna polymerase ii promoter transcription, the positive regulation of nf-κb transcription factor activity, inflammatory response, and apoptosis process. the molecular functions are mainly involved in metal endopeptidase activity, lipopolysaccharide binding, zinc ion binding, etc. the cellular components mainly involve nuclear, extracellular space and plasma membrane. the target of kegg pathway enrichment analysis plays a role in the treatment of oral lichen planus by regulating signaling pathways such as tlr, tnf, proteoglycans, pi3k-akt and nod-like receptors. 5. discussion based on the published literature, this paper reviews the application of network pharmacology in the treatment of oral mucosal diseases with natural drugs. through the interdisciplinary application of holistic biological network analysis and integration, network pharmacology reveals the correlation between drugs and targets, and elucidates the synergistic mechanism of the active ingredients of natural medicines in traditional chinese medicine formulations. network pharmacology optimizes known chinese medicine compounds or effective ingredients for diseases, and evaluates their clinical efficacy and functions, providing theoretical basis for the development of multi-target therapies and providing a good condition for promoting the development of chinese medicine. references salehi b, lopez-jornet p, pons-fuster lópez e, et al. plant-derived bioactives in oral mucosal lesions: a key emphasis to curcumin, lycopene, chamomile, aloe vera, green tea and coffee properties [j]. biomolecules, 2019, 9(3). lin d, yang l, wen l, et al. crosstalk between the oral microbiota, mucosal immunity, and the epithelial barrier regulates oral mucosal disease pathogenesis [j]. mucosal immunol, 2021, 14(6): 1247-1258. zhang l, han l, wang x, et al. exploring the mechanisms underlying the therapeutic effect of salvia miltiorrhiza in diabetic nephropathy using network pharmacology and molecular docking [j]. biosci rep, 2021, 41(6). yang hy, liu ml, luo p, et al. network pharmacology provides a systematic approach to understanding the treatment of ischemic heart diseases with traditional chinese medicine [j]. phytomedicine, 2022, 104: 154268. lu f, wang d, li rl, et al. current strategies and technologies for finding drug targets of active components from traditional chinese medicine [j]. front biosci (landmark ed), 2021, 26(9): 572-589. [6] sun r, xu g, gao d, et al. to predict anti-inflammatory and immunomodulatory targets of guizhi decoction in treating asthma based on network pharmacology, molecular docking, and experimental validation [j]. evid based complement alternat med, 2021, 2021: 9033842. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 3; may-june 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 15 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe zhou z, chen b, chen s, et al. applications of network pharmacology in traditional chinese medicine research [j]. evid based complement alternat med, 2020, 2020: 1646905. li yy, zhang b, chen hj. mechanism of compound jiaogulan capsule on the treatment of oral lichen planus based on network pharmacology and molecular docking [j]. journal of guangdong pharmaceutical university, 2020, 36(04): 530-536. qianlan d, yueting lu, lijuan y, et al. mechanism of huashi xingyu qingre recipe in treating oral lichen planus based on network pharmacology and clinical trial verification [j]. j tradit chin med, 2022, 42(2): 304313. yang q, lai rf, liu xn. study on the mechanism of huoxue huayu prescription in treatment oral lichen planus based on geo data mining and network pharmacology [j]. journal of stomatology, 2022, 38(05): 465470. chen p, yao h, yuan q, et al. discovery of the possible mechanisms in kouyanqing granule for treatment of oral ulcers based on network pharmacology [j]. bmc complement med ther, 2020, 20(1): 258. li xl. effect and mechanism of yatong stopping dropping pill in treating oral ulcer [d]; tianjin university of traditional chinese medicine, 2021. ma x, fan cy, ji zh, et al. identification of chemical components of xipayi mouth rinse fluid and its mechanism in the treatment of recurrent aphthous ulcer based on network pharmacology [j]. china pharmaceutical industry, 2022, 31(02): 41-45. zhu kk, zhou r, chen m, et al. molecular mechanism of taohong siwu decoction on treatment of oral submucous fibrosis based on network pharmacology [j]. review of chinese medicine, 2020, 26(13): 129133. zhang n. study on the mechanism of action of compound danshen dropping pills in the treatment of oral submucous fibrosis by network pharmacology and molecular docking [d];shanxi medical university, 2021. piao yz, sun dn, zhang y, et al. network pharmacology approach on the mechan ism of sanwu huangqin decoction in treating behce’t s disease [j]. journal of hainan medical college, 2020, 26(09): 677-685. cao zm, wu qf. study on the effect of coptis and dried ginger on treating hand, foot and mouth disease based on network pharmacology [j]. chinese patent medicine, 2021, 43(04): 1052-1057. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 3; may-june 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 16 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe ren xw, li yw, cai ll, et al. network pharmacological study on the mechanism of compound oleum lithospermi in the treatment of cheilitis [j]. world of traditional chinese medicine, 2020, 15(14): 20362042. liu sw, huang xj, li jl. a study on the action mechanism of cortex dictamni on oral lichen planus based on network pharmacology [j]. chinese medicine clinical research, 2021, 13(34): 8-12. liu y. study on network pharmacology and molecular docking of tripterygium wilfordii in treating oral squamous cell carcinoma [d]; shanxi medical university, 2021. wu zy, zhao j, wang c, et al. prediction of the pharmacological characteristics and therapeutic mechanism of tripterygium wilfordii in treating oral lichen planus based on network pharmacology [j]. prevention and treatment of oral diseases, 2021, 29(12): 809-819. hou ff. study on network pharmacologic analysis and experimental study of scutellaria in the treatment of oral leukoplakia [d]; shanxi medical university, 2021. hou f, yu z, cheng y, et al. deciphering the pharmacological mechanisms of scutellaria baicalensis georgi on oral leukoplakia by combining network pharmacology, molecular docking and experimental evaluations [j]. phytomedicine, 2022, 103: 154195. cai x, zhang h, li t. multi-target pharmacological mechanisms of salvia miltiorrhiza against oral submucous fibrosis: a network pharmacology approach [j]. arch oral biol, 2021, 126: 105131. [25] zhao zb. study on immune intervention of quercetin in oral lichen planus based on network pharmacology and experimental analysis [d];nanjing medical university, 2021. zhao z, wang l, zhang m, et al. reveals of quercetin's therapeutic effects on oral lichen planus based on network pharmacology approach and experimental validation [j]. sci rep, 2022, 12(1): 1162. lou yt, tao r, li yz, et al. study on the mechanism of action of total glucosides of paeony in the treatment of oral lichen planus based on network pharmacology [j]. chinese patent medicine, 2022, 44(03): 10051010. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 35 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe a systematic review and meta analysis of randomised controlled trials evaluating the effectiveness of mobile phone text messaging as a supportive intervention in the maintenance of glucose control emmanuel o. chukwu1 and olive c. ibeto2 1medical unit, diana princess of wales hospital, grimsby, united kingdom 2department of public health, university of chester, united kingdom abstract background: poorly managed diabetes results to unbearable complications, at high expense to the health system. mobile phone text messaging can be an ideal platform in rendering self-management care to diabetic patients, which in essence improves the blood glucose control. the main aim of this study is to evaluate systematically, the effectiveness of mobile phone text messaging as a supportive intervention in the maintenance of glucose control. methods: various databases such as cochrane library, pubmed, medline, embase were searched following a timeline between the 1st of january 2004 to 1st of august 2019. reference list from significant studies as well as included studies were reviewed for additional studies. randomised controlled trials (rct) evaluating the effect of text messaging on haemoglobin concentration were well utilised in this review. results: seven studies were included in the investigation for this review, having met the inclusion criteria. reports from five of the studies stated that the intervention group had significant decrease in haemoglobin concentration, when compared to the control arm. it was observed from the meta-analysis that the impact of mobile phone text messaging (mptm) on glucose control was effective (md = -0.53, 95% ci= -0.75, 0.30, p < 0.00001). conclusion: mobile phone text messaging can render supportive care towards improving health outcomes amongst diabetic patients. this can be achieved by enhancing the individual’s knowledge and self-efficacy, which would significantly assist in self-management. keywords: systematic, review, meta-analysis, randomised, trial, controlled, effectiveness, mobile phone, supportive, intervention, maintenance, glucose, control introduction diabetes mellitus (dm) is a known long-lasting disease that badly affect lots of individuals globally, which result to significant mortality, morbidity and excessive utilization of resources in health care facilities (whoworld health organization, 2020). this disease condition has continuously placed unmatched pressure on the health care schemes globally (lin et al, 2020; kitsiou, pare, jaana, & gerber, 2017). the incessant and mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 36 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe predictable increase in the incidence of dm in addition to the expenses resulting from the lasting effects of this disease condition, have drawn the mind-sets of the health care providers and the policy makers on focussing on how best to enhance diabetes care and patient’s outcomes, utilising selfmanagement interventions (powers et al., 2017). dm is a known chronic ailment that occurs as a result of the inability of the pancreas to produce adequate insulin or when the body finds it difficult utilising effectively, the insulin produced (american diabetes associationada, 2010). the chronic increase in the blood sugar level which results from uncontrolled diabetes leads to lasting damage effect and the inability of some vital organs in the body to function. this effect includes possible loss of vision (retinopathy), renal failure (neuropathy), and neuron disorder (neuropathy) (liu et al, 2020; lotfy, adeghate, kalasz, singh, & adeghate, 2017). this disease condition has been among the most common longlasting diseases experienced all over the world and has gradually remained on the increase in terms of prevalence and significance (khan et al, 2020). dm can be viewed as a group of metabolic diseases traditionally associated with high levels of glucose in the blood that causes problems in insulin production and insulin use, or both (ada, 2010). recently, who announced the gradual rise in the prevalence of dm over the past years, around the world (who, 2019). the international diabetes federation (idf) global estimate showed that approximately 415 million adults were living with diabetes mellitus in 2015 with a projected increase of about 642 million by the year 2040 (ogurtsova et al., 2017). developing and under developed countries are the hardest hit by the burden from the disease condition, as approximately 80% of dm cases occur in these nations (zhang et al., 2010). it has been stated from researches that 14.2 million adults in africa between the age range of 20 and 79 years are diabetic, and are estimated to rise to 34.2 million by 2040 (mbanya, motala, sobngwi, assah, & enoru, 2010). notwithstanding, the high prevalence of dm recorded about 193 million individuals representing that up to half of the population living with dm are unaware of their condition (fan, 2017). continentally, the approximated prevalence of dm is in africa was 3.8%, 10.7% in the north and middle east of africa, 7.3% in europe, 11.5% in the caribbean and northern america, 9.6% in the central and southern part of america, 9.1% in the south-eastern part of asia, and 8.8% in the western pacific (fan, 2017). high populated countries such as the united states, china, and india, have continually being on the increase in terms of prevalence of individuals living with dm (who, 2016). in the united kingdom (uk), there is a 6% prevalence of dm among individuals between 20 and 79 years (diabetes uk, 2018). similarly, the american diabetes association (ada), in 2011 estimated that 25.8 million adults and children were being diagnosed with dm (control & prevention, 2011). the two major types of dm include type 1 and type 2 dm (who, 2019). type 1 dm which was once identified as insulin dependent diabetes or juvenile diabetes occurs as a result of the pancreas producing little or no insulin (who, 2018). type 1 dm, according to the who is not preventable. type 2 dm occurs as a result of the body’s inability to effectively utilise insulin. it occurs more in adult; however recent studies indicated that type 2 dm is now also increasingly found amongst children and adolescents (who, 2018). majority of the diabetic patients globally, fall under the category of type 2 dm. unlike type 1 dm, type 2 dm is highly preventable (who, 2019). other specific types of dm include gestational dm, which is mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 37 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe characterised by increased blood glucose level in pregnancy. the major clinical manifestations of the disease condition include polyuria (excessive urine), polydipsia (excessive thirst), polyphagia (excessive hunger) and weight loss (ada, 2011). identification of hyperglycaemia plays an important factor in the diagnosis of dm. the international expert committee suggested that the diagnosis of diabetes be made based on the measurement of the haemoglobin (hba1c), which in effect signifies the lasting blood glucose concentration (gillett, 2009). the diagnostic criteria include hba1c greater than or equal to 6.5% (48mmol/mol), or fasting plasma glucose greater than or equal to 7.0mmol/l (126mg/dl) or 2hr plasma glucose greater than or equal to 11.1mmol/l (200mg/dl) (sacks et al., 2011). research methods research aims and objectives this study was aimed at extracting a pooled estimate of rcts comparing the effectiveness of mobile phone text messaging intervention in combination with normal standard care as compared with standard care alone for glycaemic control in diabetes management. this study achieved the principle aim by accomplishing the following objectives; i. critically reviewed conducted rcts that focused on mobile phone text messaging as an intervention for improving healthcare service delivery. ii. critically reviewed conducted rcts that focused on mobile phone text messaging as an intervention for improving glycaemic control in diabetes self-management. iii. analysed the identified and included rcts using statistical tools such as standard deviation, p-values, and confidence interval, to evaluate the intervention under study seeking for evidence of significant effectiveness. iv. provided recommendations based on rejected or accepted proposed hypothesis on the best possible approaches towards providing an excellent healthcare service. research question this review, just like other studies aims to provide an answer to a theoretical question. in meeting up the aim of carrying out a systematic review, the research question to be focussed on, was stated as: is mobile phone text messaging effective as a supportive intervention in the maintenance of glucose control? research hypothesis this study includes both null and alternative hypothesis. the null hypothesis states that there is no effect or improvement in glucose control amongst diabetic patients that utilised mptm in comparison to individuals on standard treatment only. alternative hypothesis states that a significant effect was observed in the glucose control of the patients that used mptm in comparison to individuals who were on standard treatment only. inclusion criteria • the criteria include that all studies utilised must be randomised controlled trials conducted within a time frame of 15 years 01/01/2004 to 01/08/2019. rcts were used in this study because of its quality in terms of assessing and evaluating therapeutic efficacy, hence right for answering the research question (stern et al., 2014). mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 38 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe • the participants in this research were diagnosed of diabetes mellitus. type 1 or type 2 dm to be specific. studies utilised in this study assessed the effectiveness of mptm amongst type1 or type 2 dm, and the comparator is the use of standard diabetic care only. • studies utilising hba1c in measuring glucose control, prior and after the intervention were included. • ages of participants in this study were between 8 and 75 years old. exclusion criteria they include the following: • all trials that were not randomized controlled trials. • trials conducted on other types of dm except type 1 or type 2 dm. • trials that compared mptm with other health conditions apart from type 1 and 2 dm. • studies that compared mptm and other information technology interventions were not included. • studies including pregnant women were not included. it was vital to exclude such studies as the research design for this review majorly concentrates on comparing the use of mptm and standard care with the use of standard care only. incomplete and ongoing studies were excluded from this review too. studies included the randomized controlled trial studies utilized in this review were conducted in, new zealand, egypt, philippines, south korea, scotland, mexico, and iran, evaluating the effectiveness of mptm in combination with standard care, and standard care alone. comparative rcts are regarded as gold standard for accessing the effectiveness of public health interventions using systematic review methodology. seven randomised control trials were selected for this review after a systematic search. studies selected used literate participants that owned mobile phones, and are able to speak, read, and understand text messages in english language. these studies used standard care only as a comparator, studies with clinically certified diabetic patients whose hba1c levels are greater than 7%. were used. studies that were accessed to be of low quality were also excluded from this study. pico model for defining the clinical research question pico model can be defined as a format used for developing an accurate clinical research question before commencing a research (eriksen & frandsen 2018; methley et al, 2014). pico which means participants, intervention, comparator, and outcome, was used to describe this study as following; description of participants the participants in this study were group of individuals, selected randomly from different trials to participate in attesting to the effectiveness of mptm intervention. the individuals involved were all diabetic patients undergoing treatment, between 8 and 75 years of age. both males and female were included, provided they are being diagnosed of dm, with hba1c > 7%. type of intervention mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 39 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe intervention in research is referred as a treatment regimen allocated to research participants with the aim of evaluating and assessing the effectiveness of a particular treatment/intervention (eriksen, 2020; higgins & green, 2011). the intervention in focus for this systematic review was mobile phone text messaging plus standard care. comparator in this study, the comparator is the use of standard care only. amongst various studies utilised in this review, the comparators were stated as usual care, standard care or conventional care, but for the interest of uniformity in this review the comparator will be addressed as standard care (sc). however, they all have the same meaning. standard care includes diabetic medications, glucose monitoring, medical advice and follow up appointments. evaluation of outcome the primary outcome in this review, which is of great interest to the reviewer is an improved glucose control., which will be measured by the glycosylated haemoglobin (hba1c). the hba1c test signifies the average blood glucose level of an individual (ada, 2014). however secondary outcomes include those outcome measures that will be useful to those in authority such as the decision and policy makers. the secondary outcomes could include: cost effectiveness of the intervention, health related quality of life, perceived social support, improved self-care behaviours and improved self-efficacy. this study however focussed on the primary outcome. search strategy an effective search strategy is very vital, because it helps in gathering appropriate articles needed to meet with the inclusion criteria (stern et al., 2014; wager & wiffen, 2011), therefore a systematic and detailed search is essential. a well conducted search strategy gives a brief summary of the process, on how trials useful in a systematic review are selected (parahoo, 2014). boolean operators like “and”, “or” were utilized in identifying distinct studies needed in a review. three major factors were employed in this review’s search strategy, which are • using a reproducible method, • being specific in selecting the appropriate article required to answer the study question and • avoiding time wastage and sensitivity in terms of data protection. the manual and electronic methods were adopted in identifying articles needed for the review (parahoo, 2014). a precise database known as the cochrane database of systematic review (cdsr) was searched before conducting this systematic review, for rcts and systematic reviews evaluating the effectiveness of mptm towards maintaining glucose control amongst patients with dm. electronic search was also thoroughly conducted in other useful databases which include pubmed, cinahl, clinical trials.gov, medline, cochrane library, embase and database of abstracts of reviews of effect (dare). additionally, databases such as biosis was used in sourcing for articles shown in conferences. the latin american and caribbean health sciences (lilacs) was also included in the search for studies that met the criteria needed. keywords such as “text messaging”, “sms”, and “diabetes mellitus”, “mobile phone text messaging and glucose control” were used while conducting the search strategy. the summary of search strategy was outlined in table 4.1 below. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 40 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe table 4.1 preliminary study selection database searched search terms date assessed number of studies identified by liberal search of database time period/language restriction. cinahl “mobile phone text messaging” and “diabetes mellitus” and “randomised controlled trials 10/09/2019 1 01/01/2004-01/01/2019 no language restriction pubmed “mobile phone text messaging” and “diabetes mellitus” and “randomised controlled trials” 10/09/2019 72 01/01/2004-01/01/2019 no language restriction medline “mobile phone text messaging” and “diabetes mellitus” and “randomised controlled trials 10/09/2019 3 01/01/2004-01/01/2019 no language restriction cochrane central register of controlled trials “mobile phone text messaging” and “diabetes mellitus” and “randomised controlled trials 10/09/2019 70 01/01/2004-01/01/2019 no language restriction mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 41 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe lilacs “mobile phone text messaging” and “diabetes mellitus” and “randomised controlled trials 10/09/2019 2 01/01/2004-01/01/2019 no language restriction health technology assessment “mobile phone text messaging” and “diabetes mellitus” and “randomised controlled trials 10/09/2019 100 01/01/2004-01/01/2019 no language restriction web of science core collection “mobile phone text messaging” and “diabetes mellitus” and “randomised controlled trials 10/09/2019 3 01/01/2004-01/01/2019 no language restriction ongoing studies “mobile phone text messaging” and “diabetes mellitus” and “randomised controlled trials 10/09/2019 3 01/01/2004-01/01/2019 no language restriction other sources “mobile phone text messaging” and “diabetes mellitus” and “randomised controlled trials 10/09/2019 3 01/01/2004-01/01/2019 no language restriction total 257 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 42 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe study selection process to reduce chances of selection bias, this review adopted the guidelines stated by the centre for review and dissemination (2009) and in combination with the guidelines set by cochrane handbook of systematic review (higgins & green, 2011). the selection criteria for this systematic review was outlined under the eligibility criteria. the systematic selection process first involved the electronic search for articles on the database with consistency in view of the research question and the eligibility criteria. titles, abstracts and reference were evaluated towards selecting articles that conform with the research question. rctts that were not consistent in answering the research question were excluded from the review, following a comprehensive systematic screening. studies that met the inclusion criteria were selected. full text of the articles was recovered and used for the systematic selection process and future analysis. methodological quality of the potentially included studies were accessed using the standards set by consolidated standard of reporting trials (consort) statement of checklist also known as cochrane collaboration risk of bias tool (schulz, altman, & moher, 2010). this ensured that articles accessed as low quality of methodology were not included in the review. the preliminary study selection process for this systematic is presented in figure 4.1 using a preferred reporting items for systematic reviews and meta-analyses (prisma) flow diagram for systematic review. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 43 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 44 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 45 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe figure 4.1 prisma table (moher et al., 2009). mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 46 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe table 4. 2: features of the included studies study population intervention/duration comparator outcome sms education for the promotion of diabetes selfmanagement in low& middle-income countries: a randomized controlled trial in egypt. abaza and marschollek, 2017. 90 type 2 dm patients in an egyptian hospital aged 12-69 years. daily text messages and weekly reminders for diabetes care plus standard care for 12 weeks standard care glycosylated haemoglobin effectiveness of text message based, diabetes self-management support programme (sms4bg): randomised controlled trial. dobson et al., 2018 366 type 1 or type 2 dm patients from new zealand. aged 16 years and above tailored package of text messages for diabetes selfmanagement plus standard care for 9 months standard care glycosylated haemoglobin an mhealth sms-based intervention improves glycaemic control in hispanics with type 2 diabetes. fortmann et al., 2017 126 type 2 dm hispanic patients in san diego. aged 16-75 years. dulce digital text messages plus standard care for over 6 months standard care glycosylated haemoglobin mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 47 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe a randomised controlled trial of sweet talk, a text messaging system to support young people with diabetes. franklin et al., 2006. 126 type 1 dm patients in scotland. aged 8-18 years conventional therapy plus sweet talk messages for 12 months. conventional therapy glycosylated haemoglobin impact of distance education via mobile phone messaging on knowledge, attitude, practice, and self efficacy of patients with type 2 diabetes mellitus in iran. goodarzi et al., 2012. 100 type 2 dm patients in iran, aged above 30 years four text messages weekly plus standard care for 12 weeks standard care glycosylated haemoglobin a randomised controlled trial of a nurse short message service by cellular phone for people with diabetes. kim, 2006 60 type 2 dm patients in south korea. aged 18-50 years internet based intervention using short message service (sms) plus standard care for 12 weeks standard care glycosylated haemoglobin use of short message services (sms) for the management of type 2 diabetes mellitus: a randomised controlled trial. tamban et al., 2013. 104 diabetic patients in philippines. aged 19 -50 years 3 sms per week plus standard care for 6 months standard care glycosylated haemoglobin mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 48 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 49 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe quality assessment it is important that quality of included studies is assessed when conducting a systematic review, because it determines if and to what extent, the results from studies were unduly influenced by the study designs selected (mcdonagh, peterson, raina, chang, & shekelle, 2013; smith & noble, 2014). this was achieved by recording the strength and weakness of all included studies. therefore, it is essential to adopt the use of critical appraisal skill program (casp) tool in minimising bias. this tool is essential in conducting an appropriate methodological quality assessment of included studies (voss & rehfuess, 2013). this study used casp tools in evaluating the methodological quality and standards of rcts used for this study. while conducting an evaluation and appraisal on the methods, the quality and design included in the review and variations observed in the results are summarised and entered as limitations of the study as recommended (higgins & green, 2011). table 4.3 demonstrates how each study included in the review was assessed utilising casp tools table 4.3: methodological quality assessment for included studies using casp checklist tool for rcts casp checklist item yes= y. can’t tell = c. no= n name and year of study publication 1 2 3 4 5 6 7 8 9 10 11 abaza &marschollek, 2017 y y y y y y changes in hba1c were measured. the difference in the hba1c concentration between the patients at the intervention and control arm was not significant p=0.406 y y y mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 50 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe dobson et al., 2018 y y y n y y changes in hba1c were measured. the reduction in hba1c was significantly higher in the intervention arm compared to the control arm. p=0.007 y y y fortmann et al., 2017 y y y n y y changes in hba1c were measured. the reduction in hba1c was significantly higher in the intervention arm compared to the control arm p=0.03 y y y franklin et al., 2006 y y y c n y changes in hba1c were measured. there was no change in hba1c between the patients at the intervention and control arm. p=0.99 y y y goodarzi et al., 2012 y y y c y y changes in hba1c were measured. the reduction in hba1c was significantly higher in the intervention arm compared to the control arm p=0.024 y y y kim, 2006 y y y c y y changes in hba1c were measured. the reduction in hba1c was significantly higher in the intervention arm compared to the control arm p=0.005 y y y mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 51 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe tamban et al., 2013 y y y y y changes in hba1c were measured. the reduction in hba1c was significantly higher in the intervention arm compared to the control arm p=0.04 y y y data extraction studies analysed in this review were the selected studies, whose primary outcomes measured differences in haemoglobin concentration (hba1c) between participants at the intervention and the control arm. below is a standardized table illustrating the studies utilised in the review. extraction of significant data that were beneficial for the study was done. features of the data extracted were the sample size, details of the participants, characteristics of the review and measurement of both the outcome and intervention. this study stated the various locations at which participants were selected, though it was randomly picked. the participants were from countries of various continents, namely: new zealand, egypt, the philippines, south korea, scotland, mexico, and iran. the intervention utilised (mptm) was briefly summarized in the table. the comparison between the mptm (intervention arm and standard care (control arm) were stated as well. the rev man software was utilised in entering the extracted data. this was done because revman software produces a forest and funnel plot utilised in interpreting the results. the metaanalysis was done using the application of a fixed effect model. fixed effect model was used because majority of the included studies were quite similar especially in terms of sample size. standard deviation was used in measuring the estimated effect., since the measured outcome (hba1c) was presented in a continuous form. furthermore, heterogeneity was interpreted in the studies with the value i2 (higgins & green, 2011). mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 52 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe table 4.4: summary of data extraction from studies. study enrolled patients study duration study design region of study age of the participants location type of intervention health status loss to follw up outcome measure abaza &marschollek, 2017 90 12 weeks rct egypt 12-69 years university of science and technology hospital cairo egypt. daily text messages and weekly reminders for diabetes care plus standard care diabetes mellitus 17 glycosylated haemoglobin dobson et al., 2018 366 9 months rct new zealand 16 years and above primary and secondary health centres across new zealand. tailored package of text messages for diabetes selfmanagement plus standard care type 1 or 2 diabetes mellitus 12 glycosylated haemoglobin fortmann et al., 2017 126 over 6 months rct san diego 16-75 years federal health centre, san diego dulce digital text messages plus standard care type 2 diabetes mellitus 17 glycosylated haemoglobin franklin et al., 2006 126 12 months rct scotland 8-18 years tayside clinic scotland conventional therapy plus sweet talk messages type 1 diabetes mellitus 67 glycosylated haemoglobin mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 53 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe goodarzi et al., 2012 100 12 weeks rct iran above 30 years karaj diabetes association, iran. four text messages weekly plus standard care type 2 diabetes mellitus 19 glycosylated haemoglobin kim, 2006 60 12 weeks rct south korea 18-50 9years endocrinology department in a tertiary care hospital, south korea internet based intervention using short message service (sms) plus standard care type 2 diabetes mellitus 9 glycosylated haemoglobin tamban et al., 2013. 104 6 months rct the philippines 19-50 university of the philippines general hospital 3 sms per week plus standard care diabetes mellitus 22 glycosylated haemoglobin table 4.5: study outcome data study nos of patients that completed the study intervention/control study design outcome (sd mean difference/95% ci) abaza &marschollek, 2017 73 daily text messages and weekly reminders for diabetes care plus standard care / standard care rct hba1c -0.10[-1.11, 0.91] mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 54 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe dobson et al., 2018 354 tailored package of text messages for diabetes selfmanagement plus standard care/ standard care rct hba1c -4.90[-8.22, -1.58] fortmann et al., 2017 109 dulce digital text messages plus standard care/ standard care rct hba1c -0.90[-1.51, -0.29] franklin et al., 2006. 59 conventional therapy plus sweet talk messages/conventional therapy rct hba1c -0.20[-1.07, 0.67] goodarzi et al., 2012 81 four text messages weekly plus standard care/ standard care rct hba1c -0.50[-1.01, 0.01] kim, 2006 51 internet based intervention using short message service (sms) plus standard care/ standard care rct hba1c -0.80[-1.32, -0.28] tamban et al., 2013 82 3 sms per week plus standard care/ standard care rct hba1c -0.30[-0.69, 0.09] mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 55 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe data analysis data analysis during systematic review involves the collection, summary, and combination of all included studies, to make informed decision based on their findings. (higgins & green, 2011). data were analysed using both descriptive and narrative analysis, to synthesise data into an important piece of information. the analysis started with a descriptive summary of the included studies (table 4.2), data extracted were inputted into a review manager (revman) 5.3 software as recommended by the cochrane collaboration, as an essential tool for analysing extracted result during a systematic review for the effectiveness of public health intervention. this software was developed in consultation with cochrane methodologist and reviewers to support standards and guidelines for systematic reviews. therefore, it is regarded as a gold standard for analysis of data for effectiveness of a public health intervention (higgins & green, 2011). data inputted into the revman software were automatically synthesized into graphical form with statistical tools which include chi-square, p-value and i2. these tools were applied to test the significance of the intervention as stated by the cochrane intervention (higgins & green, 2011). these graphical representations were in the form of forest and funnel plots. incomplete or missing data were taken into consideration when conducting this systematic review. this was to prevent manipulation of results which in itself is a bias. the problems associated with incomplete or missing data were solved by ensuring that only studies with complete data for each analysis were used for the analysis of outcomes of interest. assessment of heterogeneity while conducting this review, the assessment of heterogeneity was conducted on the studies included. all the studies selected in this review were thoroughly assessed of heterogeneity.heterogeneity can be referred to as disimilarities in the articles utilised in the review. these differences could be in the form of statistical, clinical or methodological variation (centre for reviews and dissemination, 2009; furlan, pennick, bombardier, & van tulder, 2009; higgins, 2013). methodological heterogeneity deals with variations in the methodologies utilised in the independent studies which includes allocation concealment, blinding and disimilarities witnessed in the definition and assessment of outcomes. statistical heterogeneiity on the other hand recommends that the incuded studies are likely to lack the ability to estimate same quantity, though ststistical heterogeneity is known to evolve from methodological variety, nevertheless, the above ststement fails to conclude on the ideology of occurrence of variation on the true intervention effect. finally, clinical variations, are intervention effects arising as a result of variations in the study settings, patient’s features and the value of the intervention utilised (centre for reviews and dissemination, 2009; tacconelli, 2010). the revman software was used to test for heterogeneity during data analysis and the reuslts were interpreted in the result section. results of the research this review evaluated 257 published articles in assessing the effectiveness of mptm on glucose control. this was achieved through a comprehensive search carried out in various electronic data bases as stated in table mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 56 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 4.1. following the exclusion of certain studies, due to duplication and inability in meeting up the criteria designed for the included studies, 10 studies met the standards for the inclusion criteria, though only seven papers were utilised as three studies were later excluded as a result of missing data. this systematic review and meta-analysis were then conducted using seven studies. prisma flow chart was used to illustrate the process at which eligible studies were selected (see fig 4.1) characteristics of the seven included studies were illustrated in table 4.2. the dates, at which the included studies were published ranged from 2004 to 2019. a total of 809 patients diagnosed with either type1 or type 2 dm were included in the studies, though majority were type 2 dm patients. this review had 407 patients in the experimental group and 402 at the intervention arm. the participants included in the study ranged between the ages of 8 and 75 years. both male and female were included. studies were carried out in different regions of the world, including africa, asia, southern america and europe. out of the seven included studies, three studies had a study duration of 12 weeks(abaza & marschollek, 2017; goodarzi et al., 2012; kim, 2007), whiles the remaining three studies had a duration of 9, 12 and 6 months respectively (dobson et al., 2018; franklin, waller, pagliari, & greene, 2006; tamban et al., 2014), except one study that was not very specific, however, the author stated the study duration as over 6 months (philis-tsimikas, fortmann, garcia, ruiz, & schultz, 2016). seven studies utilised sms as an interactive approach in terms of sending and receiving information to and from the patients. however, one of the studies utilised websites as well as sms in sending and receiving data from participants (kim, 2007). two studies reported insignificant differences in hba1c between the control and intervention arm (abaza & marschollek, 2017; franklin et al., 2006). nevertheless, none of the studies reported a significant difference in hba1c, favouring the control group. based on quality assessment, two of the published included studies were at high risk for internal bias (dobson et al., 2018; philis-tsimikas et al., 2016), however internal validity is acceptable in circumstances of low to moderate risk. moreover, a study by wood et al., (2017) sated that, in terms of assessing outcomes such as hba1c, absence of blinding has little or no chances of influencing the outcome. standard deviation was used in measuring the estimated effect, assessing the hba1c concentration (primary outcome). as a continuous data, the analysis was done at 95% confidence interval. the seven included studies in the review, all had hba1c as their primary outcome. the meta-analysis was conducted on all the included studies, with the aim of producing a pooled effect. during the assessment of heterogeneity, the chi square test was (chi2=11.67). i-squared was less than 50% (i2 = 49%), indicating less heterogeneity. while comparing the mean differences between the control and intervention group. an overall value of mean difference (md) generated was stated as 95% ci =-0.53 [-0.75, -0.30]. the test for overall effect was significant, which was stated as (z=4.50; p<0.00001). well detailed meta-analysis including the funnel and forest plot were displayed in figures 5.11 and 5.12. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 57 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe figure 5.11: forest plot comparing mptm +sc with sc and hba1c as primary outcome. figure 5.12: funnel plot comparing mptm +sc with sc and hba1c as primary outcome. based on the illustration of the funnel plot demonstrated in figure 5.12., all the studies displayed on both sides of the plots were distributed symmetrically and captured within the precision of pooled effect however it was mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 58 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe observed that the study by dobson et al., 2018 laid outside the symmetry of precision as it contributed the lowest weight to the meta-analysis. a second meta-analysis was also conducted excluding studies with large sample size. a total of 407 participants were recorded with 200 at the experimental group and 207 at the control group. the second analysis reported the following results, which was stated as md = 95% ci =-0.50 [-0.73, -0.28]. and chi2= 4.98, i2= 0%, z= 4.31 at p < 0.00001. this in essence indicates that the heterogeneity was likely high in the first meta-analysis as a result of high variation of sample size presented in study by dobson et al., 2018. due to the limited available studies that met the inclusion criteria, the work by dobson et al was also utilised in carrying out the investigation for this review not minding the high sample size which was different from the rest of the studies. figure 5.13: forest plot comparing mptm +sc with sc and hba1c as primary outcome. (this diagram excludes the study with large sample size. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 59 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe figure 5.14: funnel plot comparing mptm +sc with sc and hba1c as primary outcome. (this diagram excludes the study with large sample size risk of bias of the selected studies the included studies for this systematic review investigated for risk of bias using the revman as recommended by the cochrane collaboration. the assessment of risk of bias was conducted using descriptive analysis. the summary of the occurrence of all types of bias across the included studies are represented below (figure 5.2) as produced by revman software. the risk of bias analysis was based on the reviewer’s judgement on what was reported on the included studies. based on the summary of risk of bias assessment, it was indicated in the graph, that blinding of personnel and participants had the greatest risk as two studies were indicated to be at high risk(dobson et al., 2018; philis-tsimikas, fortmann, garcia, ruiz, & schultz, 2016), while 3 studies were unclear as the reviewer failed to mention whether blinding of participants and personnel were actually carried out during the course of the study(v. l. franklin et al., 2006; goodarzi et al., 2012; kim, 2007). however, all the include studies posed low risk to selection, detection, attrition and reporting bias. as this systematic review included only rcts, it was essential that all studies included were first judged for random sequence generation before other bias domains were investigated. there was no other type of bias detected in any of the included studies. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 60 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe figure 5. 1 the risk of bias summary of each study included in this systematic review based on the reviewer’s judgement for each bias domain. figure 5. 2 the risk of bias graph. the risk of each bias domain is presented in percentage based on the reviewer’s judgement, across all included studies. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 61 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe findings of meta-analysis the first meta-analysis involved all the included studies, while the second metaanalysis excluded a study with large sample size. the results obtained from the meta-analysis were illustrated in the funnel plots and forest plots. heterogeneity and p value were utilized in interpreting the results in the plot. the result from the metaanalysis conducted on the studies indicated that mobile phone text messaging was effective in the maintenance of glucose control. a total of 809 participants were generated as the sample size from the pooled effect and were randomised in to mptm +sc group and sc group. the mean difference (md) of the analysis indicated that the proposed intervention (mptm + sc) was effective in the maintenance of glucose control amongst diabetic patients (md=0.53, 95% ci= -0.75, -0.30, p < 0.00001). a statically significant result was generated from the overall pooled effect, with a p value less than 0.05 and a confidence interval with narrow width. hence disproving the null hypothesis with a prediction of the results, occurring by chance. this indicates the effectiveness of the intervention in reducing the hba1c concentration amongst diabetic patients. all the studies with the exception of two (abaza & marschollek, 2017; franklin et al., 2006) did not cross the line of no effect. nevertheless, the 95% ci was continuously at the left side, hence favouring the intervention. it was indicated in the result, that the two studies that crossed the line of no effect individually also had a mean difference less than one, thereby favouring the intervention. however, both studies were statically insignificant with p values greater than 0.05. irrespective of the statically insignificance of the studies, it was observed in the study by franklin et al., that though there was no decrease in the hba1c between the intervention and control group. patients verbalised that the intervention improved their self-management skills and demonstrated their interest to continue with the intervention. also, the study by abaza and colleagues indicated that majority of the participants at the intervention arm had decreased hbaic. due to the statically insignificance of the result, the effectiveness of the study will be termed to have occurred by chance. the illustrated funnel plot generated from the seven studies indicated absence of publication bias. the utilised studies were distributed symmetrically around the pooled md. the statically significance stated as p <0.00001, supports the alternate hypothesis that proposed the effectiveness of mptm in the maintenance of glucose control amongst dm patients. this in essence states that the intervention helped in reducing the hba1c level, which in effect improved the glucose level of the patients. heterogeneity which was stated as 12 =49%, was suspected be that high as a result of higher sample size in the works of dobson et al., when compared to the rest of the utilised studies. heterogeneity was therefore re assessed in a second meta-analysis by excluding the study of dobson which had higher sample size, than the rest of the studies. the result from the second meta-analysis indicated also statically significant p values with a 0 percent heterogeneity, as against the initial 49% heterogeneity. the result was stated as (md= -0.50, 95% ci= (-0.73, -0.28), p < 0.0001). the funnel plot indicated symmetrical distribution of studies around the pooled effect hence disproving the chances of publication bias. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 62 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe discussion this systematic review focused on the work done to assist diabetic patients to manage their disease condition, improve behavioural and health outcomes using mobile phone text messaging (mptm) intervention. disease conditions such as diabetes requires the maintenance blood sugar levels and other related clinical and physiological measurements to tolerable levels through monitoring and management with consistent self-care routines (jarvis, skinner, carey, & davies, 2010). it was vital to note the increased use of mobile phone interventions in healthcare service delivery due to the fact that majority of individuals own a phone. as stated in the literature review, several studies have evaluated its impact as an intervention to improve various treatment regimens and management in healthcare delivery. these studies have demonstrated many positive trends, though few significant findings were reported. mobile phones as a management tool was used to enable an effective and timely flow of accurate and precise short information flow between the patients and the healthcare service providers. in some of the included studies, text messaging was used to facilitate management advice and support in between healthcare centre appointments. while in other studies, text messaging was used to deliver regular and timely alerts, and reminders to achieve the desired objective. all the included studies measured hba1c before and after intervention and showed a significant decrease in hba1c values. results of this systematic review showed that educational interventions through the provision of personalized advice and support, regular and timely alerts, and reminders delivered through mobile phones may assist to manage diabetes and other related clinical and physiological complications thereby improve health outcomes. reports from different studies suggested that that as low as 1% reduction in glycosylated haemoglobin can result in 37 % reduction in risk of mortality as well as micro vascular disorders (stratton et al., 2000). this review therefore highlighted the positive and significant evidence for rendering healthcare interventions that concentrated on managing diabetes through mobile phone text messaging service. the results of the review in line with various analysed literature (as stated on the literature review) indicated that interventions obtained through text messaging were very beneficial in terms of positively influencing the health outcome of patients. summary of effectiveness a study is said to be statistically significant, when the p value is less than 0.05, with a 95% confidence interval and a narrow width that fails to cross the line of no effect (ellis & steyn, 2003). the meta-analysis conducted proves the evidence that mptm is statically significant in the maintenance of glucose control. the interpretation is that mobile phone text messaging in addition to standard care is more effective in reducing the hba1c levels among diabetic patients compared to standard diabetic care only. based on the generated result in this review, results of certain studies that are in consistent with this review’s intervention were compared below. a systematic review carried out by saffari and colleagues in 2014, evaluated the effectiveness of text messaged based programme in maintaining glucose control amongst type 2 diabetic patients. the intervention utilised in this study was text message programme plus standard care. the average age of the participants in the study was 53 years mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 63 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe .10 studies were analysed in this review. participants at the intervention arm received text messages created in a tailored package called diabetes self-management education. the result of the study in consistence with this review indicated a significant reduction of hba1c in the experimental group, when compared to the control group. the overall value was stated as (smd= -0.595; p<0.001 (saffari et al., 2014). this indicates that the intervention was effective and statistically significant, as the p value was less than 0.05. the study recorded a total of 50% reduction in hba1c concentration. in contrast, a trial by franklin and colleagues in 2006, included 126 young type 1 diabetic patients recruited in scotland between the ages of 8 and 18 years. patients at the intervention arm received conventional therapy (which for the uniformity of this study was termed standard care) plus text messages form sweet talk software for 12 months. the messages contained personalised tailored messages and precise prompts to the patient’s gender, age and insulin routine. there was no reduction in the hba1c concentration at the end of the study. this was observed in both the intervention and control arm with a p value of 0.99 indicating that the study was not statically significant. however, reports from the study stated that 82% of the participants confirmed that the sweet talk messaging improved their self-management system and requested to keep receiving the messages (franklin et al., 2006). however, factors such as sample size and study duration could have affected the significance of the result. the last study whose result was analysed in comparison with the result of this review was a meta -analysis conducted by liang and colleagues in 2010. the study demonstrated also the effect of mobile phone intervention in the maintenance of glucose control. unlike this review, liang’s study engaged other forms of mobile technology asides text messaging. twenty-two trials were utilised in the study with a total of 1657 participants. at the end of the study, it was indicated that mobile phone intervention utilised for diabetes self-management decreased the hba1c level by 0.5% with a 95% confidence interval (0.3, -0.7) and a p value of 0.02(liang et al., 2010). the intervention in essence was effective and the p value which was less than 0.05 signified the statistical significance of the study. in comparison with standard care alone, it is evident that addition of mptm to the standard diabetic care significantly improved the haemoglobin concentration amongst type 1 or type 2 dm patients. the pooled analysis of various studies demonstrated the reduction of hba1c utilizing the proposed intervention. the result of this review is therefore in consistent with studies in line with the effectiveness of text messaging in improving health outcome. application of evidence and future research a systematic approach was adopted in selecting and analysing the studies that demonstrated the evidence of the effectiveness of mobile phone text messaging in the maintenance of glucose control, though limitations were inevitable. a precise focus was taken in to consideration. hence, the studies utilised were limited to just studies in which interventions were rendered solely by the means of text messaging. the application of the evidence provided by this systematic review is in ensuring that accurate and timely sms reminders and updates are incorporated into the currently known diabetes management practices to ensure higher efficiency of selfmanaging mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 64 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe diabetes by patients. only one study, out of all the studies, had a combination of other means of data transmission (internet). thereby minimising the difficulties that would have been associated with the assessing the effectiveness of text messaging, when combined with other multifaced interventions. however, majority of the available literature on mhealth are based on complex interventions, combining text messaging with various forms of technology. most of the studies in this review with the exception of the study by dobson et al had comparatively low sample sizes. judging by the fact that none of the data from the studies were collected beyond twelve months, makes it difficult to draw a conclusion on the long-lasting effect of the proposed intervention (mptm) in the maintenance of glucose control. bearing in mind that diabetes mellitus is a long-term illness, there is need for studies with longer duration of follow ups. though the included studies were carried out in various continents of the world, and considering the increasing rate of network coverage in addition to mobile phone ownership. the developing and underdeveloped nations should be well considered especially in terms of creating awareness on phone-based applications. however, this study made available a beneficial overview and also described essential gaps in knowledge encountered in this field, which values more research. limitations of the review this review also had limitations like lack of blinding, small sample size and short duration in some of the included studies. the small number of significant findings could be due to the small sample sizes and short durations of the included studies. however, reports from studies suggested that lack of blinding has low chances of influencing outcomes such as haemoglobin concentration (wood et al., 2017). the included studies did not make any note of power calculations, as such the overall generalizability of the data in relation to the populations is limited in scope. furthermore, because the selection of studies and judgement of bias was conducted by just one reviewer, it may be seen as been prone to bias from the reviewer. finally, one of the major limitations of this review was that the assessment outcomes report was not done at a more general level so as to allow for major comparison across studies. this review focused solely on hba1c, which was commonly monitored by all the included studies. this was because all other related condition with specific factors to diabetes were not completely addressed by the included studies. as a result of this, these factors were not fully discussed in this systematic review. conclusion mobile phone is considered as the most accessible in the world, while text messaging on the other hand, is also seen as the most commonly utilised means of mobile communication. various researchers in public health have sought to explore and make the most out of the proposed communication modality. text messaging interventions were designed to provide evidence that will result to enhanced health outcome and improved health behaviour. the findings from the seven studies in this review illustrated that mobile phone text messaging has a significant effect on glucose control. furthermore, factors such as sample size, duration of intervention and level of hba1c can influence the effectiveness of an intervention. there is need for more researches to be carried out on various mobile application and mhealth educational means, on patients with different diseases not just dm. there is also mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 65 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe need for more researches on homogenous studies with higher sample sizes and longer duration, by so doing, there will be enhanced generalizability of findings. references abaza, h., & marschollek, m. (2017). sms education for the promotion of diabetes self-management in low & middle income countries: a pilot randomized controlled trial in egypt. bmc public health, 17(1), 962. doi:10.1186/s12889-017-4973-5 american diabetes association. (2010). diagnosis and classification of diabetes mellitus. diabetes care, 33(supplement 1), s62-s69 centre for reviews and dissemination. (2009). systematic reviews: crd's guidance for undertaking reviews in health care. universit of york: centre for reviews and dissemination. control, c. f. d., & prevention. (2011). national diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the united states, 2011. atlanta, ga: us department of health and human services, centers for disease control and prevention, 201(1), 2568-2569. dobson, r., whittaker, r., jiang, y., maddison, r., shepherd, m., mcnamara, c., . . . murphy, r. (2018). effectiveness of text message based, diabetes self management support programme (sms4bg): two arm, parallel randomised controlled trial. bmj (clinical research ed.), 361, k1959. doi:10.1136/bmj.k1959. diabetes uk. (2018). know diabetes, fight diabetes. retrieved 12th may,2019 from https://www.diabetes.org.uk/ ellis, s., & steyn, h. (2003). practical significance (effect sizes) versus or in combination with statistical significance (p-values): research note. management dynamics: journal of the southern african institute for management scientists, 12(4), 51-53. eriksen, m. b., & frandsen, t. f. (2018). the impact of patient, intervention, comparison, outcome (pico) as a search strategy tool on literature search quality: a systematic review. journal of the medical library association : jmla, 106(4), 420–431. https://doi.org/10.5195/jmla.2018.345 fan, w. (2017). epidemiology in diabetes mellitus and cardiovascular disease. cardiovascular endocrinology & metabolism, 6(1), 8-16. franklin, v. l., waller, a., pagliari, c., & greene, s. a. (2006). a randomized controlled trial of sweet talk, a text-messaging system to support young people with diabetes. diabetic medicine, 23(12), 1332‐1338. doi:10.1111/j.1464-5491.2006.01989.x furlan, a. d., pennick, v., bombardier, c., & van tulder, m. (2009). 2009 updated method guidelines for systematic reviews in the cochrane back review group. spine, 34(18), 1929-1941. mailto:topacademicjournals@gmail.com https://www.diabetes.org.uk/ https://doi.org/10.5195/jmla.2018.345 https://doi.org/10.5195/jmla.2018.345 american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 66 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe gillett, m. j. (2009). international expert committee report on the role of the a1c assay in the diagnosis of diabetes: diabetes care 2009; 32 (7): 1327–1334. the clinical biochemist reviews, 30(4), 197. goodarzi, m., ebrahimzadeh, i., rabi, a., saedipoor, b., & jafarabadi, m. a. (2012). impact of distance education via mobile phone text messaging on knowledge, attitude, practice and self efficacy of patients with type 2 diabetes mellitus in iran. journal of diabetes and metabolic disorders, 11(1). doi:10.1186/2251-65811110 higgins, j. (2013). green s. cochrane handbook for systematic reviews of interventions. version 5.1. 0. the cochrane collaboration; 2011. in. jarvis, j., skinner, t., carey, m., & davies, m. (2010). how can structured self‐management patient education improve outcomes in people with type 2 diabetes? diabetes, obesity and metabolism, 12(1), 12-19. khan, m., hashim, m. j., king, j. k., govender, r. d., mustafa, h., & al kaabi, j. (2020). epidemiology of type 2 diabetes global burden of disease and forecasted trends. journal of epidemiology and global health, 10(1), 107–111. https://doi.org/10.2991/jegh.k.191028.001 kim, h.-s. (2007). a randomized controlled trial of a nurse short-message service by cellular phone for people with diabetes. international journal of nursing studies, 44(5), 687-692. kitsiou, s., pare, g., jaana, m., & gerber, b. (2017). effectiveness of mhealth interventions for patients with diabetes: an overview of systematic reviews. plos one, 12(3), e0173160. liang, x. h., wang, q. q., yang, x. l., cao, j., chen, j. c., mo, x. b., . . . gu, d. f. (2010). effect of mobile phone intervention for diabetes self-management support on glycemic control: a meta-analysis. cardiology, 117, 120‐. doi:10.1159/000320851 lin, x., xu, y., pan, x., xu,j., ding,y., sun, x,. song, x., ren, y. & shan, p. (2020). global, regional, and national burden and trend of diabetes in 195 countries and territories: an analysis from 1990 to 2025. sci rep 10, 14790. https://doi.org/10.1038/s41598-020-71908-9 liu, j., ren, zh., qiang, h., wu, j., shen, m., zhang, l., & lyu, j. (2020). trends in the incidence of diabetes mellitus: results from the global burden of disease study 2017 and implications for diabetes mellitus prevention. bmc public health 20, 1415. https://doi.org/10.1186/s12889-020-09502-x lotfy, m., adeghate, j., kalasz, h., singh, j., & adeghate, e. (2017). chronic complications of diabetes mellitus: a mini review. current diabetes reviews, 13(1), 3-10. mbanya, j. c. n., motala, a. a., sobngwi, e., assah, f. k., & enoru, s. t. (2010). diabetes in sub-saharan africa. the lancet, 375(9733), 2254-2266. mailto:topacademicjournals@gmail.com https://doi.org/10.2991/jegh.k.191028.001 https://doi.org/10.2991/jegh.k.191028.001 https://doi.org/10.1038/s41598-020-71908-9 https://doi.org/10.1038/s41598-020-71908-9 https://doi.org/10.1038/s41598-020-71908-9 https://doi.org/10.1186/s12889-020-09502-x https://doi.org/10.1186/s12889-020-09502-x american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 67 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe mcdonagh, m., peterson, k., raina, p., chang, s., & shekelle, p. (2013). avoiding bias in selecting studies. in methods guide for effectiveness and comparative effectiveness reviews [internet]: agency for healthcare research and quality (us). methley, a. m., campbell, s., chew-graham, c., mcnally, r., & cheraghi-sohi, s. (2014). pico, picos and spider: a comparison study of specificity and sensitivity in three search tools for qualitative systematic reviews. bmc health services research, 14, 579. https://doi.org/10.1186/s12913-0140579-0 moher, d., liberati, a., tetzlaff, j., & altman, d. g. (2009). preferred reporting items for systematic reviews and meta-analyses: the prisma statement. annals of internal medicine, 151(4), 264-269. ogurtsova, k., da rocha fernandes, j., huang, y., linnenkamp, u., guariguata, l., cho, n. h., . . . makaroff, l. (2017). idf diabetes atlas: global estimates for the prevalence of diabetes for 2015 and 2040. diabetes research and clinical practice, 128, 40-50. parahoo, k. (2014). nursing research: principles, process and issues: macmillan international higher education. philis-tsimikas, a., fortmann, a., garcia, i., ruiz, m., & schultz, j. (2016). dulce digital: a randomized controlled sms intervention for latinos with type 2 diabetes. diabetes technology and therapeutics., 18, a98. doi:10.1089/dia.2016.2525 powers, m. a., bardsley, j., cypress, m., duker, p., funnell, m. m., fischl, a. h., . . . vivian, e. (2017). diabetes self-management education and support in type 2 diabetes: a joint position statement of the american diabetes association, the american association of diabetes educators, and the academy of nutrition and dietetics. the diabetes educator, 43(1), 40-53. sacks, d. b., arnold, m., bakris, g. l., bruns, d. e., horvath, a. r., kirkman, m. s., . . . nathan, d. m. (2011). guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus. clinical chemistry, 57(6), e1-e47. saffari, m., ghanizadeh, g., & koenig, h. g. (2014). health education via mobile text messaging for glycemic control in adults with type 2 diabetes: a systematic review and meta-analysis. primary care diabetes, 8(4), 275-285. schulz, k. f., altman, d. g., & moher, d. (2010). consort 2010 statement: updated guidelines for reporting parallel group randomised trials. bmc medicine, 8(1), 18. smith, j., & noble, h. (2014). bias in research. evidence-based nursing, 17(4), 100-101. stern, c., jordan, z., & mcarthur, a. (2014). developing the review question and inclusion criteria. ajn the american journal of nursing, 114(4), 53-56. mailto:topacademicjournals@gmail.com https://doi.org/10.1186/s12913-014-0579-0 https://doi.org/10.1186/s12913-014-0579-0 https://doi.org/10.1186/s12913-014-0579-0 american journal of medical and physical education vol.1, issue 1; july 2023; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 68 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe stratton, i. m., adler, a. i., neil, h. a. w., matthews, d. r., manley, s. e., cull, c. a., . . . holman, r. r. (2000). association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (ukpds 35): prospective observational study. bmj, 321(7258), 405-412. tacconelli, e. (2010). systematic reviews: crd's guidance for undertaking reviews in health care. the lancet infectious diseases, 10(4), 226. tamban, c., isip-tan, i. t., & jimeno, c. (2014). use of short message services (sms) for the management of type 2 diabetes mellitus: a randomized controlled trial. journal of the asean federation of endocrine societies, 28(2), 143. voss, p. h., & rehfuess, e. a. (2013). quality appraisal in systematic reviews of public health interventions: an empirical study on the impact of choice of tool on meta-analysis. j epidemiol community health, 67(1), 98-104. wager, e., & wiffen, p. j. (2011). ethical issues in preparing and publishing systematic reviews. journal of evidence-based medicine, 4(2), 130-134. who (2018),top ten causes of death retrieved 24th march 2019 from world health organisation https://www.who.int/en/news-room/fact-sheets/detail/the-top-10-causes-of-death who. (2016). global report on diabetes. retrieved from 9, 2018, from world health organization http://apps.who.int/iris/bitstream/handle/10665/204871/9789241565257_eng.pdf who. (2018). diabetes. retrieved december 4, 2018 from world health organization https://www.who.int/news-room/fact-sheets/detail/diabetes who. (2020). diabetes. retrieved august 16, 2022 from world health organization, https://www.who.int/newsroom/fact-sheets/detail/diabetes who. (2019, may 4). about diabetes. retrieved january 1, 2019 from world health organization, https://web.archive.org/web/20140331094533/http://www.who.int/diabetes/action_online/basics/ yoshii, a., plaut, d. a., mcgraw, k. a., anderson, m. j., & wellik, k. e. (2009). analysis of the reporting of search strategies in cochrane systematic reviews. journal of the medical library association: jmla, 97(1), 21. zhang, p., zhang, x., brown, j., vistisen, d., sicree, r., shaw, j., & nichols, g. (2010). global healthcare expenditure on diabetes for 2010 and 2030. diabetes research and clinical practice, 87(3), 293-301. mailto:topacademicjournals@gmail.com https://www.who.int/en/news-room/fact-sheets/detail/the-top-10-causes-of-death https://www.who.int/en/news-room/fact-sheets/detail/the-top-10-causes-of-death http://apps.who.int/iris/bitstream/handle/10665/204871/9789241565257_eng.pdf https://www.who.int/news-room/fact-sheets/detail/diabetes https://www.who.int/news-room/fact-sheets/detail/diabetes https://www.who.int/news-room/fact-sheets/detail/diabetes https://www.who.int/news-room/fact-sheets/detail/diabetes https://www.who.int/news-room/fact-sheets/detail/diabetes https://www.who.int/news-room/fact-sheets/detail/diabetes https://web.archive.org/web/20140331094533/http:/www.who.int/diabetes/action_online/basics/ https://web.archive.org/web/20140331094533/http:/www.who.int/diabetes/action_online/basics/ american journal of medical and physical education vol.7, issue 3; may-june 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 1 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe perceived organizational support as a stress buffer for collegiate coaches' work stressors and turnover intentions 1elodie marie wendling, 2john david smith, 3sarah ann williams 1phd adjunct instructional professor, university of florida 2professor of american history, college of liberal arts & sciences 3international human rights analyst, university of copenhagen, faculty of law abstract the competitive nature of sports coaching exposes coaches to numerous stressors, including long hours, nonconventional work schedules, and travel demands. these stressors can lead to work-family conflict, which can in turn increase turnover intentions. this study examined the buffering effects of job resources (i.e., social support, supervisor support, and role clarity) on the relationship between work-family conflict and turnover intentions in collegiate coaches. the results showed that job resources buffered the negative relationship between work-family conflict and turnover intentions. keywords: sports coaching, work-family conflict, turnover intentions, job resources, social support, supervisor support, role clarity. introduction given the fiercely competitive nature of sports coaching, elite coaches are exposed to numerous stressors and unique challenges in their occupation (olusoga et al., 2009). in addition to normal life-stressors, being a collegiate coach is known for long hours that regularly extend into nights and weekends (graham & dixon, 2014). operating in a performance-oriented environment with non-conventional work schedules and unique lifestyles with extensive travel demands, coaches may be at risk of mental health concerns and high turnover rates (frey, 2007; taylor et al., 2019). the stressful working environment and low job security can in fact contribute to coaches’ illbeing (olusoga et al., 2009; stebbings et al., 2012) and lead to burnout (karabatsos et al., 2006), decreased life and job satisfaction (dixon & sagas, 2007), and higher rates of turnover (frey, 2007; knight et al., 2015). given the importance of work in people’s lives, challenges encountered at work may spillover into their personal life, which may considerably influence their well-being and quality of life (bowling et al., 2010). indeed, coaches have reported ample times how the demands of their job interfered with their family life, making workfamily conflict one of the most significant strains experienced by coaches (stebbings et al., 2012; taylor et al., 2019). furthermore, the interference of work on their family may cause them to leave the athletic department they work for (inglis et al., 1996) or even their coaching career altogether (bruening & dixon, 2007; frey, 2007). although significant research has focused on stress and work-family conflict in the coaching profession, the examination of stress protective mechanisms that are grounded on a well-established stress theory and that would serve as buffers against the negative influences of work-family conflict on turnover intentions remains scant and is of primary focus in this study. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 3; may-june 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 2 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe as a seminal theory of stress, the conservation of resources (cor) theory (hobfoll, 1989) has been prominently used to examine work-family role conflict in the organizational psychology literature (grandey & cropanzano, 1999; halbesleben et al., 2012; jawahar et al., 2007). the management of resources is critical to experiencing stress in the cor theory, given that the fundamental principle of this theory is about the gain and los of key resources, the latter of which may trigger stress (hobfoll, 1989). four types of resources were identified as key to acquire, maintain, and protect, including objects (e.g., housing, transportation, luxury clothes), conditions (e.g., marriage, seniority, status), personal characteristics (e.g., self-esteem, mastery), and energies (e.g., time, money, knowledge). the availability of these resources is essential to survive, define one’s self, achieve our goals, and gain more resources. thus, the actual or potential loss of valued resources or the lack of expected resource gain after investing in one’s own resources would be experienced as stressful (hobfoll, 1989, 2002). according to cor theory, certain resources, such as social support and psychological resources, may have stressbuffering properties that serve to protect existing resources from being lost and even enable resource gain, which would enhance individuals’ stress resiliency (hobfoll, 2002, 2011). while we intended to examine how collegiate coaches’ stress related to their work and ensuing work-family conflict affect their turnover intentions, the primary purpose of this study was to investigate the extent to which organizational support served as a buffer against turnover intentions caused by role conflicts. despite the importance of social support in managing role stressors and acting as a stress resiliency, social support was not included in any of the four categories of resources in cor theory due to the external nature of this resource that, although valuable to acquire and retain other key resources, individuals cannot directly possess (hobfoll, 2002). thus, investigating the moderating effect of a key type of workplace social support by examining the extent to which perceived organizational support is a useful external resource when coaches are faced with workfamily conflict may be critical toward helping coaches develop a sustainable and successful career with enhanced well-being in their lives. in addition, managerial implications of this study are of crucial importance to athletic departments that are concerned about the well-being of their coaches and the organizational costs associated with coaches leaving their universities (dixon & bruening, 2007; ryan & sagas, 2009). acquiring a better grasp of the mechanisms contributing to and alleviating employees’ turnover rates can help organizations reduce the loss of human expertise, experience and relationships, as well as the time, money, and effort required to recruit and train new employees (mitchell et al., 2001). given the importance of coaches’ interpersonal influence on their athletes (lee &chelladurai, 2018), this study may also benefit the development of athletes, as coaches experiencing lower work-life conflict have better interpersonal behaviors toward their athletes (stebbings et al., 2012). finally, fewer changes on coaching staffs can enhance the stability and quality of athletic programs (raedeke et al., 2002; zoroya, 2020), which in turn facilitates athletes’ recruitment and development (o’connor & bennie, 2006; shipherd et al., 2019). 2. theoretical framework 2.1 college coaching work stressor-strain relationship in cor theory cor theory posits that stress is not solely caused by the actual loss of valued resources, but also by the potential loss of resources or lack of resource gain after using one’s own resources (hobfoll, 1989). working in a culture emphasizing sacrifice and dedication, elite coaches can experience various job stressors, including extreme pressure to win and related job insecurity, excessive and nontraditional work hours, significant time and emotional demands, media attention and community involvement, the scarcity of coaching job openings and increased competition for jobs, just to name a few (graham & dixon, 2014, 2017; schenewark & dixon, 2012; taylor et al., 2019; weight et al., 2015). as stated by dixon and bruening (2007), the coaching profession is a “multimailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 3; may-june 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 3 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe faceted, high paced work setting full of practices, recruiting, off-season workouts, administrative duties, and teaching responsibilities [that have] created an environment where only those willing to work twelve hours days, six days a week, for fifty weeks a year can thrive” (p. 384). these extensive job expectations combined with toxic working conditions are ripe for increasing job stress that may compel coaches to prioritize their work over their family, triggering higher work-family conflict. as defined by greenhaus and beutell (1985), work-family conflict is “a form of inter-role conflict in which the role pressures from the work and family domains are mutually incompatible in some respect” (p. 77). in an attempt to fulfill their work-related responsibilities, coaches may not only experience work role stress caused by the actual loss of valued resources, but they may also feel the pressure to invest more of their already fewer resources to adequately fulfill their family role. often times, trying to meet the obligations of both roles seems to be unrealistic due to the incompatibility of these expectations (graham & dixon, 2017). in addition, coaches may experience work role stress due to the potential loss of their job, which strongly depends on the success of their team. they may also not garner the resources they expected after using their own valuable resources. the sacrifice of personal and family relationships coaches are willing to make to meet the demands of their team does not guarantee them to have a success on the field or court. such resource drain may leave coaches with fewer resources available to meet family demands (schenewark & dixon, 2012). hence, based on the cor theory and previous findings (boyar et al., 2003; eby et al., 2005; grandey & cropanzano, 1999), work role stress is expected to relate to work interfering with fulfilling family demands. as a result, the following hypothesis was tested: hypothesis 1: work role stress experienced by coaches directly and positively relates to their work-family conflict. being unable to satisfy family demands, coaches may decide to change their situation to protect their family role. as valued resources are lost while juggling both work and family roles, college coaches’ resources may end up being so depleted that they may indeed decide to leave their athletic department or career to protect or replace threatened resources. additional loss of resources caused by work-family conflict may cause the resources of coaches to become so scarce that leaving the university they work for or even renouncing their coaching career may be the only option to eliminate this resource drain. previous organizational studies demonstrated support that work-family conflict is linked to turnover intentions (boyar et al., 2003; carr et al., 2008; eby et al., 2005; greenhaus et al., 1997, 2001; hewlett & luce, 2005; karatepe & azar, 2013; netemeyer et al., 1996). similarly, research examining the work-family conflict coaches experience found evidence of coaches’ intentions to leave the athletic department they work for (bruening & dixon, 2007; dixon & bruening, 2007; inglis et al., 1996) or even leave their coaching career altogether (bruening & dixon, 2007; dixon & bruening, 2005, 2007; frey, 2007; schenewark & dixon, 2012). the following hypotheses were advanced based on this literature and theory, as coaches experiencing work-family conflict may seek to eliminate resource depletion by exhibiting the intentions to leave their organization and/or the occupation of coaching: hypothesis 2a: coaches’ work-family conflict directly and positively relate to their intentions to leave the athletic department they work for. hypothesis 2b: coaches’ work-family conflict directly and positively relate to their intentions to leave their coaching career altogether. drawing on hobfoll’s (1989) cor theory, we will review in the next section the moderating effect of organizational support on the relationship of work-family conflict and turnover intentions. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 3; may-june 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 4 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 2.2 the stress-buffering role of perceived organizational support in cor theory one’s social relations may have stress-reducing and resistance properties (kenrick et al., 2010). not only can these key social resources serve as an instrumental function of protecting existing resources and obtaining additional resources, but they can also act as a self-defining function of protecting and maintaining one’s identity (hobfoll et al., 1990). while a supportive work environment can diminish resource loss caused by work-family conflict, such a support can also enable resource gain by alleviating the source of stress and facilitating goal achievement (hobfoll, 2002, 2011). indeed, individuals’ perceived organizational support may have neutralizing effects that can contribute to individuals’ stress resistance, which would enable employees to better withstand resource loss caused by work-family conflict. in this study, perceived organizational support was defined as the extent to which employees perceive that “the organization values their contributions and cares about their wellbeing” (eisenberg et al., 1986, p. 504). in addition to employers’ appreciation of their employees’ contributions and care for their employees’ well-being, we included the financial component of supportive resources for work including the financial support athletic departments provide in terms of not only the financial budget assigned to the team but also the compensation provided to coaches. existing organizational studies have shown the critical role of organizational support in lessening workfamily conflict (allen, 2001; byron, 2005; french et al., 2018; kossek et al., 2011; mesmer-magnus & viswesvaran, 2005; michel et al., 2011). while evidence that a supportive organizational culture helps decrease work-family conflict has been observed numerous times in the existing literature, the mitigating impact of organizational support on the negative effects that work-family conflict has on organizational outcomes is less prevalent. previous organizational research on work-family conflict has tested the moderating effects of social support or organizational support on various stressors-strain relationships. for instance, frese (1999) found that the relationship between various work stressors and psychological dysfunctioning was weaker at higher levels of social support. in addition, previous work observed that supervisor support moderated the effect of working hours on workfamily conflict (fox & dwyer, 1999; fu & shaffer, 2001). on the family side of the work-family interface, aryee and colleagues (1999) found that spousal support weakened the relationship between parental overload and family-work conflict. finally, jawahar and colleagues (2007) observed that perceived organizational support mitigated the negative effect of role conflict on emotional exhaustion. within the coaching literature, dixon and sagas (2007) demonstrated the importance of providing organizational support to college coaches to help diminish the negative effect of work-family conflict, while kim and cunningham (2005) found that college coaches perceived organizational support had a moderating effect on the relationship between work experiences and jobsatisfaction. despite the dearth of empirical evidence testing the stressbuffering role of perceived organizational support, hobfoll (2002, 2011) clearly delineated the critical role of social resources on individuals’ stress resiliency and thereby, this important moderating relationship merits attention. serving as a stress resiliency resource, the support provided by the athletic department may help coaches cope with stress and minimize resource loss because it can help lessen the occurrence of and perceived severity of work-family conflict. such a support may counteract the diminishment of resources that coaches invest in to satisfy the demands of their job and family, enabling them to preserve or even gain valuable resources. given that organizational support can assist coaches with acquiring the necessary resources to recover from resource depletion resulting from workfamily conflict, we developed the following two hypotheses, as we expected that increases in coaches perceived organizational support would buffer against increases in turnover intentions when experiencing increased workfamily conflicts: hypothesis 3a: the expected positive relationship between work-family conflict and organizational turnover intentions is moderated by organizational support, such that higher levels of support from the athletic department mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 3; may-june 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 5 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe are expected to weaken the relationship between coaches’ work-family conflict and their intentions to leave the department. hypothesis 3b: the expected positive relationship between work-family conflict and occupational turnover intentions is moderated by organizational support, such that higher levels of support from the athletic department are expected to weaken the relationship between coaches’ work-family conflict and their intentions to leave their coaching career. given that coaches have limited control over how much support they can receive from the athletic department they work for, this study aims to highlight the important role athletic departments have in improving coaches’ retention and supporting their coaching staff by buffering the negative effects of work-family conflict on turnover intentions. establishing a supportive organizational culture can enable athletic departments to avoid incurring replacement costs and ultimately improve the quality of the athletic programs they offer to their athletes (ryan & sagas, 2009; shipherd et al., 2019). 3. methods 3.1 participants and procedures data for this study was collected utilizing a survey design as a part of a larger ongoing study that has aimed to assess the quality of employment of college coaches. the larger study selected participants using a stratified random sample of 800 ncaa head coaches across all three ncaa divisions (400 from men’s teams and 400 from women’s teams). for this study, we used 253 completed surveys from respondents who reported to be married or live with a significant other and/or had at least one child living with them under the age of 18 years old to ensure of the relevance of the work-family conflict measure. two rounds of data collection were conducted and resulted approximately in a response rate of 43%. in testing for any possible response biases between the first round and second round of respondents, we found no significant mean differences between the two groups on any of the variables of interest. in terms of demographics, the average age of the participants was 43 years old, and the median age was 42 years old, ranging from 23 to 73 years old. further, the sample was comprised of 76% male respondents (n=192) and 24% female respondents (n=61). the racial and ethnic composition of the sample was composed of 92.5% whites, 5% african americans, 1.3% hispanics, and 1.2% others. to measure the level of education, we asked the coaches to self-report their “highest level of education” ranging from a high school education to a doctorate. most of the participants had a master’s degree and/or doctorate degree (59.3%) or a bachelor’s degree (36.4%). 3.2 measures all four variables were measured using existing scales and rated on a 7-point likert-type scale ranging from 1 (strongly disagree) to 7 (strongly agree). the measures for this study were as follows: organizational and occupational turnover intentions. we used the six items developed by meyer and colleagues (1993), of which three items were modified to measure coaches’ intentions to leave their athletic department and the other three items were also adapted to assess coaches’ intentions to leave the coaching profession. sample items include “i will likely search and apply for a job with another team in the next year” for organizational turnover intentions, and “i frequently think about leaving the coaching profession” for occupational turnover intentions. work-family conflicts. a five-item work-family conflict scale developed by netemeyer et al. (1996) was used to measure the amount of interference the coaching job puts on coaches’ home life. this measure has been previously used in numerous studies and has demonstrated satisfactory validity and reliability (see fields, 2002). mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 3; may-june 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 6 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe sample items include “things i want to do at home do not get done because of the demands my job puts on me” and “the amount of time my job takes up makes it difficult to fulfill family responsibilities”. work role stress. four items from the job stress scale (parker & decotiis, 1983) was used to measure work role stress, including “i have too much work to do and too little time to do it in”, “i feel like i never have a day off”, “my job gets to me more than it should”, and “sometimes when i think about my job i get a tight feeling in my chest”. perceived organizational support. the moderating variable, organizational support considered as a key job resource in the theoretical model, was measured with eight items including four items from the perceived organizational support scale (eisenberger et al., 1986) that were modified to assess support from the athletic department administration. in addition, we measured the financial support for their team by creating two items that assess coaches’ satisfaction with their budget for the team, and we adapted two items from the satisfaction with pay developed by chelladurai and ogasawara (2003). items used for this study were as follows: “my athletic department administration would ignore any complaints from me” (reverse-coded item), “my athletic department administration really cares about my well-being”, “my athletic department administration cares about my general satisfaction at work”, “my athletic department administration takes pride in my accomplishments at work”, “i am satisfied with how my teams budget compares to the budgets of similar teams at other colleges/universities”, “i am satisfied with the adequacy of the budget for my team”, “i am satisfied with my pay compared to the amount of work i do”, and “i am satisfied with how my pay compares with those with similar jobs at other colleges/universities”. 3.3 data analysis descriptive statistics were obtained using spss statistics 25, and measurement and hypothesized models were tested via partial least squares structural equation modeling (pls-sem) using the smartpls (version 3.3.2) software. this well-established analytical method has been conducted in the psychology literature (e.g., westman et al., 2017), and in career-related research (e.g., hsieh & huang, 2014; ren & chadee, 2017; waters, 2004). as a nonparametric method, pls-sem is recommended for testing continuous moderator influences (hair et al., 2017), as is the case here. a two-stage analytical procedure was followed as delineated by hair and his colleagues (2017): (1) we tested the measurement model to assess the psychometric properties of the measures used in this study; (2) we analyzed the structural model to test our hypotheses and determined the significance of path coefficients performing a bootstrapping method with 5,000 resamples. we controlled for the exogenous effects of age and gender, given that previous research demonstrated their direct effects on work-family conflict, occupational and organizational turnover intentions (cunningham & sagas, 2002; griffeth, hom, & gaertner, 2000; parasuraman, 1982). 4. results 4.1 measurement model means, standard deviations, loadings range, composite reliability, and average variance extracted (ave) for each study variable are reported in table 1. the internal consistency of the measures was assessed using the composite reliability values, which all exceeded 0.70 and thereby demonstrated satisfactory reliability of the measures (hair et al., 2017). we evaluated the convergent validity of the variables using the loadings of the items and ave values. the loadings of 17 items out of the 23 items used in this study were higher than 0.70, and the other six items exceded the value of 0.60, which is still adequate to retain for the análisis (chin et al., 2008). in addition, all ave values mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 3; may-june 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 7 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe exceded the recommended threshold of 0.50, which showed satisfactory convergent validity of the variables (fornell & larcker, 1981). table 1. descriptive statistics and psychometric properties of the constructs constructs number of items m sd loadings range cr ave 1. work role stress 4 4.03 1.30 0.68-0.79 0.84 0.56 2. work-family conflicts 5 4.72 1.41 0.86-0.93 0.95 0.80 3. organizational turnover intentions 3 2.67 1.48 0.86-0.87 0.90 0.76 4. occupational turnover intentions 3 2.85 1.49 0.72-0.91 0.88 0.72 5. organizational support 8 4.04 1.19 0.60-0.84 0.88 0.50 notes: scale reliability: composite reliability (cr)> 0.70; convergent validity: ave > 0.50 and loadings> 0.60 discriminant validity of the variables was examined using the fornell-larcker criterion analysis and the heterotrait-monotrait (htmt) analysis. in table 2, we reported in bold and placed on the diagonal the square root values of the ave of each variable, and the bivariate correlations of the variables are presented in the off-diagonal. following the fornell-larcker criterion analysis, we were able to demonstrate adequate discriminant validity given that each variable shared more variance with its corresponding items than with any other variables used in the model. furthermore, the results of the htmt ratio of correlations, presented in table 3, provided additional evidence that each variable in this study was empirically distinct, given that all htmt values did not exceed the conservative threshold of 0.85 (henseler et al., 2015), and the confidence interval results of htmt statistic from the bootstrapping did not contain the value of 1 for all combinations of variables. therefore, the measurement model used in this study showed satisfactory reliability and validity. table 2. fornell-larcker criterion analyses for discriminant validity and correlation matrix constructs 1 2 3 4 5 1. work role stress 0.748 2. work-family conflicts 0.692** 0.894 3. organizational turnover intentions 0.340** 0.387** 0.872 4. occupational turnover intentions 0.292** 0.338** 0.534** 0.849 5. organizational support -0.276** -0.293** -0.501** -0.342** 0.707 notes: bold-faced numerals on the diagonal represent the square root of the average variance extracted while the off-diagonal values are correlations. discriminant validity: square root of the ave values are all greater than correlation coefficients. * p < 0.05; ** p < 0.01 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 3; may-june 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 8 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 4.2 structural model first, we verified whether collinearity issues were not present in this model. the variance inflation factor (vif) values of all the items used in this study did not exceed the threshold value of five (hair et al., 2017), which confirmed that this model did not have collinearity issues. we then tested the statistical significance of hypothesized direct and moderating effects using the bootstrapping method of 5,000 iterations. in addition, we assessed the effect size of the relationships using 𝑓2as recommended by hair et al. (2017), given that some path estimates may have small effects in spite of being statistically significant, which would not merit much practical implications. we used cohen’s (1988) guidelines to determine the effect size of the direct effects. as expected, the relationship between work role stress and work-family conflicts was significant and had a large effect size ( = 0.696; p < 0.001; 𝑓2 = 0.924). thus, hypothesis 1 was supported. statistically significant relationships were found between work-family conflict and organizational turnover intentions as well as betweenwork-family conflict and occupational turnover intentions, and an effect size in between small and medium effects was observed for both relationships ( = 0.265; p < 0.001; 𝑓2 = 0.103; = 0.259; p < 0.001; 𝑓2 = 0.076, respectively). thus, these results provided support for hypotheses 2a and 2b. 4.2.1 moderation analysis the two-stage approach as delineatedby chin and colleagues (2003) was followed to test the moderating effects. a significant and negative interaction effect of organizational support on the relationship between workfamily conflict and organizational turnover intentions was found ( = -0.095; p < 0.05), supporting hypothesis 3a. the effect size of this interaction term was considered between a medium and large effect (𝑓2 = 0.018), as indicated by kenny’s (2016) guidelines. this result demonstrated that higher levels of organizational support weaken the relationship between work-family conflict and organizational turnover intentions, while lower levels of organizational support strengthen the relationship between work-family conflict and organizational turnover intentions. finally, the moderating effect of organizational support on the relationship between workfamilyconflict and occupational turnover intentions was not significant. thus, hypothesis 3b was not supported. results of the structural model are summarized in figure 1. in addition, we reported the predictive accuracy ( ) and relevance (𝑄2) of the predictors on the endogenous variables. the 𝑅2 for work-family conflict was moderate with 49.4% of the variance being explained by work role stress. a moderate predictive power was also observed for organizational turnover intentions, with 40.5% of the variance being explained by all the other variables in the model, except occupational turnover intentions. finally, 22.9% of the variance in occupational turnover intentions was explained by all the other variables in the model, except organizational turnover intentions. in terms of the predictive relevance, the stone-geisser’s 𝑄2 values for the dependent variables (geisser, 1974; stone, 1974) were generated using the blindfolding procedure for an omission distance of seven. results yielded 𝑄2 values of 0.389 for work-family conflict, 0.285 for organizational turnover intentions, and 0.149 for occupational table 3. heterotrait monotrait (htmt) analysis. constructs 1 2 3 4 5 1 . work role stress 2 . work family conflicts 0.835 3 . organizational turnover intentions 0.417 0.426 4 . occupational turnover intentions 0.373 0.382 0.635 5 . organizational support 0.352 0.334 0.592 0.416 note: shaded boxes are the standard reporting format for htmt procedure. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 3; may-june 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 9 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe turnover intentions, which are all higher than the threshold value of 0, demonstrating acceptable predictive relevance for all 5. discussion while the purpose of this study was to investigate the impact of coaches’ stress related to their job and ensuing work-family conflict on turnover intentions, this study also extended previous coaching research by providing support for the stress-buffering effect of perceived organizational support. given the importance of the coaching staff in achieving collegiate athletic departments’ goals, and the numerous work-stressors attached with the coaching profession, it is critical to identify stress protective mechanisms that are drawn from a seminal theory of stress such as cor to alleviate stress and role conflicts and improve coaches’ retention. not only did many of the present findings support hobfoll’s (1989) cor theory, but they also provided empirical evidence to the existing literature that coaches experiencing job stress and conflicts between work and family may decide to leave the athletic department and/or their career as a coach altogether. more importantly, the result of the moderating effect of perceived organizational support highlighted the critical role athletic departments have in either contributing to or alleviating coaches’ turnover rates. indeed, when coaches believed that their athletic department valued their contributions, cared about their well-being, and that they were provided with satisfying financial support, they were less likely to look for another collegiate coaching job even though their work interfered with their ability to fulfill family demands. conversely, if these beliefs of being valued, cared for and financially supported were not present, coaches’ intention to leave their athletic department was enhanced when they were unable to fulfill their family role(s) because of the demands of their job. given that the stressful nature of the coaching profession may be difficult to change and that the extensive demands of their job would likely interfere with family duties (knight et al., 2015), it is crucial that athletic departments show their appreciation for the sacrifice coaches make for their team, show concern for the wellthree dependent variables (hair et al., 2017). notes: moderating effect; * p < 0.05; ** p < 0.01; *** p < 0.001 figure 1. structural model. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 3; may-june 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 10 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe being of their coaches and provide satisfying team budget and compensation to coaches. doing so would help reduce the loss of key human resources in athletic departments and the related costs of recruiting and training new coaches. it would also help maintain stability in an athletic program (raedeke et al., 2002), improve interpersonal relationships between coaches and athletes (jowett & poczwardowski, 2004; knight et al., 2015) and enhance athlete psychosocial development (shipherd et al., 2019). interestingly, perceived organizational support did not significantly weaken the impact of work-family conflict on coaches’ intention to leave their career as a coach. such a result can be interpreted from a theoretical standpoint using cohen’s and wills’ (1985) buffering hypothesis and frese’s (1999) extension of this hypothesis. cohen and wills (1985) argued that social support may serve as a buffer when there is a “reasonable match between the coping requirements and the available support” (p. 314). frese (1999) further extended this buffering hypothesis conceptually and empirically to dependent variables. testing the buffering effect of social support, his findings demonstrated that “the social types of dysfunctioning (i.e., social anxiety and irritation/strain) were more highly affected by the buffers than were psychosomatic complaints and depression” (frese, 1999, p. 187). thus, there may have been a lack of relevance of the type of supportive resource we used in this study to help neutralize stress and protect existing resources to better withstand resource loss caused by coaches’ workfamily conflict. in other words, appreciating coaches’ work, caring for their well-being, and providing satisfying financial resources may not be pertinent when coaches decide to leave their coaching career due to their work interfering too much with their family life. such a support may not be instrumental when coaches intend to renounce their coaching career to eliminate the resource drain caused by juggling work and family roles. given that, in this scenario, coaches are quite willing to lose their coaching role to protect their family role, such a support being related to their work may be perceived as having less utility when mitigating resource depletion related to their family life. this finding implies that the type of support athletic departments provide to their coaching staff must be expanded beyond work to also include family obligations. indeed, family-friendly athletic administrations that offer flexible work arrangements can help reduce work-family conflict (bruening & dixon, 2007), but they can also encourage coaches to develop a sustainable career with enhanced well-being in their lives. 5.1 limitations and future research this study is not free from limitations and as such, care should be taken when interpreting the results. the sample, although deemed representative of the population under study, was collected as part of a larger study and through a cross sectional survey design; thus, the temporal nature of the relationships between job stress, workfamily conflict, and perceived organizational support is unknown. further, bias could have been present in that is likely that some of these coaches responded to this questionnaire during their primary season while others were in their off-season. additional work utilizing standardized timing of data collection and longitudinal design across a coach’s season could thus be fruitful and more explanatory than the present contribution. additional avenues of future research are also merited based on the unique findings of the study. for example, the significant moderating effect of organizational support on the relationship between work-family conflict and organizational turnover demonstrates the importance of support in facilitating coaching retention. given the abundance of literature that has demonstrated the relationship between perceived organizational support on a number of important employees and organizational level outcomes (e.g., see rockstuhl et al. 2020 for a recent review), additional work analyzing the role of support on similar outcomes of importance in the coaching profession seems justified. for example, further work examining the role that organizational support for coaches (individually and collectively as a staff) can have on other critical outcomes such as affective organizational commitment, psychological well-being, and even performance, could prove fruitful to the coaching science literature. finally, the results of our study explained by the buffering hypothesis justify a call for future studies to mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 3; may-june 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 11 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe examine the role of different kinds of support (e.g., career support, social support) to build theoretically on the stress-buffering mechanisms of perceived supports, and to provide more targeted practical recommendations to organizations and coach developers. references allen, t. d. (2001). family-supportive work environments: the role of organizational perceptions. journal of vocational behavior, 58, 414-435. aryee, s., luk, v., leung, a., & lo, s. (1999). role stressors, interrole conflict, and well-being: the moderating influence of spousal support and coping behaviors among employed parents in hong kong. journal of vocational behavior, 54, 174–178. bowling, n. a., eschleman, k. j., & wang, q. a. (2010). a meta-analytic examination of the relationship between job satisfaction and subjective well-being. journal of occupational and organizational psychology, 83, 915–934. boyar, s. l., maertz, c. p., pearson, a., w., & keough, s. (2003). work-family conflict: a model of linkages between work and family domain variables and turnover intentions. journal of managerial issues, 15, 175-190. bruening, j. e., & dixon, m. a. (2007). work-family conflict in coaching ii: managing role conflict. journal of sport management, 21, 471–496. byron, k. (2005). a meta-analytic review of work-family conflict and its antecedents. journal of vocational behavior, 67, 169-198. carr, j. c., boyar, s. l., & gregory, b. t. (2008). the moderating effect of work-family centrality on workfamily conflict, organizational attitudes, and turnover behavior. journal of management, 34, 244-262. chelladurai, p., & ogasawara, e. (2003). satisfaction and commitment of american and japanese collegiate coaches. journal of sport management, 17, 62-73. chin, w. w., marcolin, b. l., & newsted, p. r. (2003). a partial least squares latent variable modeling approach for measuring interaction effects: results from a monte carlo simulation study and an electronic-mail emotion/adoption study. information system research, 14, 189–217. chin, w. w., peterson, r. a., & brown, p. s. (2008). structural equation modelling in marketing: some practical reminders. journal of marketing theory and practice, 16, 287-298. cohen, j. (1988). statistical power analyses for the behavioral sciences (2nd ed.). hillsdale, nj: erlbaum. cohen, s., & wills, t. a. (1985). stress, social support, and the buffering hypothesis. psychological bulletin, 98, 310-357. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 3; may-june 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 12 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe cunningham, g. b., & sagas, m. (2002). the differential effects of human capital for male and female division i basketball coaches. research quarterly for exercise & sport, 73, 489-495. dixon, m. a., & bruening, j. e. (2005). perspectives of work-family conflict in sport: an integrated approach. sport management review, 8, 227–253. dixon, m. a., & bruening, j. e. (2007). work-family conflict in coaching i: a top-down perspective. journal of sport management, 21, 377–406. dixon, m. a., & sagas, m. (2007). the relationship between organizational support, work-family conflict, and the joblife satisfaction of university coaches. research quarterly for exercise and sport, 78, 236-247. eby, l., casper, w., lockwood, a., bordeaux, c., & brinley, a. (2005). work and family research in io/ob: content analysis and review of the literature (1980-2002). journal of vocational behavior, 66, 124-197. eisenberger, r., huntington, r., hutchison, s., & sowa, d. (1986). perceived organizational support. journal of applied psychology, 71, 500-507. fields, d. l. (2002). taking a measure of work. thousand oaks, ca: sage. fornell, c., & larcker, d. f. (1981). evaluating structural equation models with unobservable variables and measurement error. journal of marketing research, 18, 39–50. fox, m. l., & dwyer, d. j. (1999). an investigation of the effects of time and involvement in the relationship between stressors and work–family conflict. journal of occupational health psychology, 4, 164–174. french, k. a., allen, t. d., dumani, s., & shockley, k. m. (2018). a meta-analysis of work-family conflict and social support. psychological bulletin, 144, 284-314. frese, m. (1999). social support as a moderator of the relationship between work stressors and psychological dysfunctioning: a longitudinal study with objective measures. journal of occupational health psychology, 4, 179– 192. frey, m. (2007). college coaches’ experiences with stress – “problem solvers” have problems, too. the sport psychologist, 21, 38-57. fu, c. k., & shaffer, m. a. (2001). the tug of work and family: direct and indirect domain-specific determinants of work–family conflict. personnel review, 30, 502–522. geisser, s. (1974). a predictive approach to the random effects model. biometrika, 61, 101-107. graham, j. a., & dixon, m. a. (2014). coaching fathers in conflict: a review of the tensions surrounding the work– family interface. journal of sport management, 28, 447–456. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 3; may-june 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 13 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe graham, j. a., & dixon, m. a. (2017). work-family balance among coach-fathers: a qualitative examination of enrichment, conflict, and role management strategies. journal of sport management, 31, 288–305. grandey, a., & cropanzano, r. (1999). the conservation of resources model applied to work–family conflict and strain. journal of vocational behavior, 54, 350–370. greenhaus, j. h., & beutell, n. j. (1985). sources of conflict between work and family roles. academy of management journal, 10, 76–88. greenhaus, j. h., collins, k. m., singh, r., & parasuraman, s. (1997). work and family influences on departure from public accounting. journal of vocational behavior, 50, 249-270. greenhaus, j. h., parasuraman, s., & collins, k. m. (2001). career involvement and family involvement as moderators of relationships between work-family conflict and withdrawal from a profession. journal of occupational health psychology, 6, 91-100. griffeth, r. w., hom p. w., & gaertner, s. (2000). a meta-analysis of antecedents and correlates of employee turnover: update, moderator tests, and research implications for the next millennium. journal of management, 26, 463488. hair, j. f., hult, g. t. m., ringle, c. m., & sarstedt, m. (2017). a primer on partial least squares structural equation modeling (pls-sem) (2nd ed.). los angeles, ca: sage. halbesleben, j. r. b., wheeler, a. r., & rossi, a. m. (2012). the costs and benefits of working with one’s spouse: a two-sample examination of spousal support, work-family conflict, and emotional exhaustion in work-linked relationships. journal of organizational behavior, 33, 597–615. henseler, j., ringle, c. m., & sarstedt, m. (2015). a new criterion for assessing discriminant validity in variancebased structural equation modeling. journal of the academy of marketing science, 43, 115-135. hewlett, s., & luce, c. (2005). off-ramps and on-ramps. harvard business review, 83,43-53. hobfoll, s. e. (1989). conservation of resources: a new attempt at conceptualizing stress. american psychologist, 44, 513–524. hobfoll, s. e. (2002). social and psychological resources and adaption. review of general psychology, 6, 307– 324. hobfoll, s. e. (2011). conservation of resources theory: its implication for stress, health, and resilience. in s. folkman (ed.), the oxford handbookof stress, health, and coping (pp.127–147). oxford, england: oxford university press. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 3; may-june 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 14 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe hobfoll, s. e., freedy, j., lane, c., & geller, p. (1990). conservation of social resources: social support resource theory. journal of social and personal relationships, 7, 465–478. hsieh, h. h., & huang, j. t. (2014). the effects of socioeconomic status and proactive personality on career decision self-efficacy. the career development quarterly, 62, 29-43. inglis, s., danylchuk, k. e., & pastore, d. (1996). understanding retention factors in coaching and athletic management positions. journal of sport management, 10, 237-249. jawahar, i. m., stone, t. h., & kisamore, j. l. (2007). role conflict and burnout: the direct and moderating effects of political skill and perceived organizational support on burnout dimensions. international journal of stress management, 12, 142–159. jowett, s., & poczwardowski, a. (2004). understanding the coach–athlete relationship. in jowett & d. lavallee (eds.), social psychology in sport (pp. 3–14). champaign, il: human kinetics. karabatsos, g., malousaris, g., & apostolidis, n. (2006). evaluation and comparison of burnout levels in basketball, volleyball and track and field coaches. studies in physical culture and tourism, 13, 79–83. karatepe, o. m., & azar, a. k. (2013). the effects of work–family conflict and facilitation on turnover intentions: the moderating role of core self-evaluations. international journal of hospitality and tourism administration, 14, 255– 281. kendrick, d. t., neuberg, s. l., & cialdini, r. b. (2010). social psychology: goals in interaction (5thed.). boston, ma: allyn & bacon. kenny, d. a. (2016). moderation. retrieved from http://davidakenny.net/cm/moderation.htm kim, j., & cunningham, g. (2005). moderating effects of organizational support on the relationship between work experiences and job satisfaction among university coaches. international journal of sport psychology, 36, 50-64. knight, c. j., rodgers, w. m., reade, i. l., mrak, j. m., & hall, c. r. (2015). coach transitions: influence of interpersonal and work environment factors. sport, exercise, and performance psychology, 4, 170-187. kossek, e. e., pichler, s., bodner, t., & hammer, l. b. (2011). workplace social support and work-family conflict: a meta-analysis clarifying the influence of general and work-family specific supervisor and organizationalsupport. personnel psychology, 64, 289–313. lee, y. h., & chelladurai, p. (2018). emotional intelligence, emotional labor, coach burnout, job satisfaction, and turnover intention in sport leadership. european sport management quarterly, 18, 393-412. mesmer-magnus, j. r., & viswesvaran, c. (2005). convergence between measures of work-to-family and family-towork conflict: a meta-analytic examination. journal of vocational behavior, 67, 215–232. mailto:topacademicjournals@gmail.com http://davidakenny.net/cm/moderation.htm http://davidakenny.net/cm/moderation.htm http://davidakenny.net/cm/moderation.htm american journal of medical and physical education vol.7, issue 3; may-june 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 15 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe meyer, j. p., allen, n. j., & smith, c. a. (1993). commitment to organizations and occupations: extension and test of a three-component conceptualization. journal of applied psychology, 78, 538 – 551. mitchell, t. r., holtom, b. c., & lee, t.w. (2001). how to keep your best employees: developing an effective retention policy. academy of management executive, 15, 96-108. netemeyer, r. g., boles, j. s., & mcmurrian, r. (1996). development and validation of work-family conflict and familywork conflict scales. journal of applied psychology, 81, 400-410. o'connor, d., & bennie, a. (2006). the retention of youth sport coaches. change: transformations in education, 9, 2738. olusoga, j. b., hays, k., & maynard, i. (2009). stress in elite sports coaching: identifying stressors. journal of applied sport psychology, 21, 442-459. parasuraman, s. (1982). predicting turnover intentions and turnover behavior: a multivariate analysis. journal of vocational behavior, 21, 111-121. parker, d. f., & decotiis, t. a. (1983). organizational determinants of job stress. organizational behavior and human performance, 32, 160-177. raedeke, t. d., warren, a. h., & granzyk, t. l. (2002). coaching commitment and turnover: a comparison of current and former coaches. research quarterly for exercise and sport, 73, 73–86. ren, s., & chadee, d. (2017). influence of work pressure on proactive skill development in china: the role of career networking behavior and guanxi hrm. journal of vocational behavior, 98, 152-162. rockstuhl, t., eisenberger, r., shore, l., kurtessis, j. n., ford, m. t., buffardi, l. c., & mesdaghinia, s. (2020). perceived organizational support (pos) across 54 nations: a cross-cultural meta-analysis of pos effects. journal of international business studies, 51, 933-962. ryan, t. d., & sagas, m. (2009). relationships between pay satisfaction, work-family conflict, and coaching turnover intentions. team performance management: an international journal, 15, 128-140. schenewark, j. d., & dixon, m. a. (2012). a dual model of work-family conflict and enrichment in collegiate coaches. journal of issues in intercollegiate athletics, 5, 15–39. shipherd, a. m., wakefield, j. c., stokowski, s., & filho, e. (2019). the influence of coach turnover on studentathletes' affective states and team dynamics: an exploratory study in collegiate sports. international journal of sports science & coaching, 14, 97-106. stebbings, j., taylor, i. m., spray, c. m., & ntoumanis, n. (2012). antecedents of perceived coach interpersonal behaviors: the coaching environment and coach psychological welland ill-being. journal of sport & exercise psychology, 34, 481-502. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 3; may-june 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 16 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe stone, m. (1974). cross-validatory choice and assessment of statistical predictions. journal of the royal statistical society, 36, 111-147. taylor, e. a., huml, m. r., & dixon, m. a. (2019). workaholism in sport: a mediated model of work-family conflict and burnout. journal of sport management, 33, 249-260. waters, l. (2004). protégé-mentor agreement about the provision of psychosocial support: the mentoring relationship, personality, and workload. journal of vocational behavior, 65, 519-532. weight, e. a., cooper, c., & popp, n. k. (2015). the coach-educator: ncaa division i coach perspectives about an integrated university organizational structure. journal of sport management, 29, 510–522. westman, j., firman, m., & olsson, l.e. (2017). what drives them to drive? -parents reasons for choosing the car to take their children to school. frontiers in psychology, 8, 1 – 8. zoroya, n. m. (2020). examining coach retention methods in college athletic departments (doctoral dissertation). retrieved from proquest digital dissertations (aat 28092023). concordia university, chicago, il. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 47 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe development of a motivation and confidence in sport and physical activity instrument for assessing affective physical literacy of adolescents thomas b. popp and jonathan v. deboncoeur department of sport management at the university of florida abstract: the assessment of physical literacy is challenging due to the lack of a clear and absolute conceptualization. this study developed a physical literacy assessment tool based on two definitions of physical literacy: the motivation, confidence, physical competence, knowledge and understanding to value and take responsibility for engagement in physical activities for life (ipla, 2017) and the ability to move with competence and confidence in a wide variety of physical activities in multiple environments that benefit the healthy development of the whole person (shape america, 2014). the tool was tested with a sample of adolescents and showed good psychometric properties. keywords: physical literacy, assessment, motivation, confidence, ipla, shape america introduction the assessment and evaluation of one‟s level of physical literacy has proven to be challenging, divisive and not without criticism. there are several reasons for this, with the most evident and problematic being the lack of a clear and absolute conceptualization with definitive standards and expectations (corbin, 2016;edwards, bryant, keegan, morgan,& jones, 2017; edwards et al., 2018; giblin, collins,& button, 2014; jurbala, 2015; lounsbery& mckenzie, 2015; robinson & randall, 2017; roetert & macdonald, 2015; shape america, 2014; tremblay & lloyd, 2010; whitehead, 2013a, 2013b; whitehead & maude, 2016). spengler and cohen (2015) found that most countries concerned with physical literacy have developed their own definition and conceptual standards that reflect their respective cultural values and logics, resulting in a multitude of assessments, a lack of comparable data, and subsequent discrepancies in the interpretation of said data (edwards et al., 2017; giblin et al., 2014). even within the same country, multiple physical literacy assessment tools have been developed with various goals (e.g., education, performance, participation) and constituents (e.g., educators, coaches, trainers) in mind (robinson & randall, 2017). a systematic review of physical literacy measurement studies led edwards et al. (2017) to conclude that diverse and nontraditional approaches to understanding and assessing physical literacy might allow researchers to better understand its theoretical and holistic underpinnings, however, the integration of more empirical work situated within the various philosophical and nuanced definitions of physical literacy must also be considered. given it is difficult to manage what one cannot measure, and likewise, hard to measure what one cannot define (aspen institute, 2015; farrey, 2017), any discussion on physical literacy must first begin with clearly identifying mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 48 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe how it will be operationalized, what is to be measured and which definition will guide the direction of the study (edwards et al., 2017; green, roberts, sheehan, & keegan, 2018). it is in this vein that wedevelopedour instrument in accordance with two particulardefinitions of physical literacy. the more internationally recognized definition describes it “as the motivation, confidence, physical competence, knowledge and understanding to value and take responsibility for engagement in physical activities for life” (ipla, 2017). this “whiteheadian” definition has been found to be the most utilized amongst both qualitative and quantitative studies (edwards et al., 2018) and has been adopted as canada‟s physical literacy consensus statement (participaction et al., 2015). the second definition of physical literacy from which we develop our tool comes from the society of health and physical educators (shape america). they reason physical literacy as a grade-level learning outcome in the national standards for physical educators and define it as “the ability to move with competence and confidence in a wide variety of physical activities in multiple environments that benefit the healthy development of the whole person” (shape america, 2014, p. 4).from these two conceptualizations of physical literacy,we are able to ascertain the importance of two particular affective constructs, motivation and confidence (see edwards et al., 2018; participaction et al., 2015; robinson & randall, 2017; whitehead, 2013b), toward becoming physically literate and positively engaging in a lifetime of physical activity. currently, there are but a few instruments that assess the constructs of motivation and confidencewhen positioned in the domain of physical literacy affect, and of those that are, even fewer are contextualized outside a physical education setting and cogitate physical literacy after the age of 12 (edwards et al., 2017). this can be problematic given the potential for pedagogical standards and educational settings to influence assessmentssuch that they become focused more on normative scores and evaluation, rather than acknowledging individual achievements and progress (green et al., 2018).further, if physical literacy is to “serve as a unifying term to describethe overall outcome of quality physical education, physical activity, sport, and recreation programs” (roetert & jeffries, 2014, p. 39), as well as provide the theoretical and practical underpinnings for the “development of evidencebased programs andassessments” (p. 24) for all levels of sport (e.g., youth, recreation, amateur, elite), public health, and physical education (corbin, 2016), then the operationalization of the term and subsequent instruments is paramount. to this end, we developed a tool intended to provide a better understanding of one‟s affective physical literacy, via the constructs of motivation and confidence, factoring both sport and physical activity. given the evolving and dynamic nature of said constructs, this tool will yield a snapshot of one‟s affective physical literacy, while also providing practical applications for individuals(e.g., coaches, administrators, parents, participants)in various sport and physical activity programs (e.g., educational, out-of-school, community, etc.). however, the intent is not to set standards and/or expectations regarding evaluative scores, as that may hinder advancing one‟s physical literacy towards positive outcomes (robinson & randall, 2017). rather, this instrument is being developed for individuals, programs, and policy makers to better understand affective components of physical literacy (i.e., motivation and confidence) so as to advance more diverse and inclusive access and opportunities for lifetime engagement with sport and physical activity. thus, the purpose of this study is threefold: mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 49 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 1) to develop an instrument that assesses physical literacy affect within and outside of educational settings, inclusive of sport and physical activity spaces; 2) to comprise said instrument with items established for the subpopulation of adolescents, ages 10-17; and 3) to provide a detailed description of how the tool was developed, both conceptually and methodologically. 2. physical literacy: centering adolescents and physical education a key component of the physically literate individual is the “healthy development of the whole person” (shape america, 2014, p. 4), such that they may come to both value and take responsibility for their engagement in physical activity across the life course (ipla, 2017). moreover, given the breadth of knowledge needed to become and maintain a physically literate life, as well as the “unique and intrinsic value of physical activity (whitehead, 2013b, p. 33), it comes as no surprise that whitehead (2005; 2007; 2013b) argued that physical literacy should exist not only as a primary learning outcome of physical education, but also as a lifelong learning opportunity. it is in a similar vein that physical literacy can be conceptualized within educational settings through an application of gardner and hatch‟s (1989) theory of multiple intelligences. as a literacy construct within the educational context, physical literacy operates as one of seven human intelligences that provide individuals with the ability to solve problems or create value through the skillful manipulation and control of their body among the surrounding elements; and much like logic, mathematical, and linguistic skills, require appropriate curriculum, assessment, and evaluation within pedagogy (gardner & hatch, 1989).for instance, motivation and confidence are two of seven key principles needing consideration when physical education teachers choose physical literacy as a learning objective (durden-myers, green, & whitehead, 2018). according to durden-myers et al. (2018), “engaging learners‟ interest through positive experiences will foster the motivation to take part in physical education and help establish a desire for life-long participation in physical activity,” to the extent that participants of varied physical activities will be provided opportunities to discover and solve problems as they continue to learn about and engage with movement (p. 267). as it specifically pertains to physical literacy within educational settings, the construct of motivation includes behaviors such as proactively “taking part in physical activity, applying [one‟s] self to physical activity tasks with interest and enthusiasm, and persevering through challenging situations in physical activity environments” (green et al., 2018, p. 277). likewise, confidence must be considered in relation to not only one‟s ability to progress in the learning of new activities and tasks, but also procuring an assurance that their respective experiences are worthwhile in nature (green et al., 2018). taken together, physical literacy has been and continues to serve as a valuable construct within educational settings, both in terms of a pedagogical framework and as an outcome. evidence-based data derived from proper assessment of physical literacy has been demonstrated to be a resource utilized to direct policy change for the betterment of physical education curricula and overall adolescent health outcomes (tremblay & lloyd, 2010). likewise, we agree that further efforts toward collecting and providing evidence-based data must be made to aid vested stakeholders in sport and physical education settings (i.e., pe teachers, program administrators, coaches) to better address physical literacy affect; such that the motivation and confidence of adolescents are developed mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 50 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe and henceforth fostered to keep them physically active and/or engaged in sport. thus, our measurement tool bears each of these points in mind, particularly the sub-population of early adolescence (ages 10 to 14), given the increased dropout rates of youth sport participation around these ages (see witt& dangi, 2018). it is here that we extend upon a growing literature base that demonstrates the transition to adolescence as being associated with a dramatic decline in both physical activity levels and sport participation (bradley,mcritchie, houts, nader, & o‟brien, 2011), the likes of which continue to manifest in middle to later adolescence (ages 14 to 18; terzian & moore, 2009) and even into adulthood (barnekow-bergkvist, hedberg, janlert, & jansson, 1998). for instance, sport &fitness industry association (sfia) data provided to the aspen institute revealed that “fewer than half of children ages 6 to 11 meet the u.s. surgeon general‟s recommendation for engaging in at least 60 minutes of moderate physical activity most days of the week,” a stark reality that is further exacerbated by participatory factors such as gender, race and ethnicity, household income, and parental marital status (aspen institute, 2016, p. 6). additional contributing factors to increased dropout rates at this age include a lack of enjoyment, perceptions of physical (in)competence, intrinsic pressures (e.g., stress, negative team dynamics), performance pressures (e.g., family, coach, peers), competing priorities, and physical factors, including physical maturation and injuries (crane & temple, 2015). due to these barriers to and reality concerning both the participation of youth in physical activity and sport, organizations such as the aspen institute‟s project play initiative have identified early adolescence as a particularly crucial time within which youth are either provided or precluded from the “ability, confidence, and desire to be physically active for life” (aspen institute, 2016, p. 8). thus, we are in alignment with the assertion that “both health and performance are served if the preteen years are treated as a developmental zone, with activities that build physical literacy” (aspen institute, 2016, p. 9), the crux of which, we argue, rests in the affective domain of physical literacy, particularly given that both confidence and motivation play an integral role in one‟s life course trajectory of healthy physical activity. 3. current physical literacy measurement tools as “cornerstones of the education and health fields” (p. 176), assessment and evaluation are imperative to providing measurements for advancement and achievement, practical updates on students/patients/clients, normalized and comparative data, and a baseline from which informed decisions can be made regarding education, interventions, treatment and policies (lloyd, colley, & tremblay, 2010). furthermore, vigilant and purposeful “measurement will improve the standards, expectations, profile, credibility and confidence of” (p. 26) physical education, subsequently leading to more physically literate children (tremblay & lloyd, 2010). lundvall (2015) expressed doubt regarding the feasibility and possibility of assessing physical literacy, particularly when placed in an educational setting that likely dictates measurement toward the learner‟s skill performance and mastery of the abstract concept, thereby making it very difficult to account for and assess the ideals and holistic aspects of physical literacy. given that physical literacy is a lifelong process and not an age-specific ideal, there is adearth of measurement tools that comprehensively account for the many and nuanced domains of physical literacy (affective, behavioral, mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 51 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe physical, and cognitive) that offer an all-inclusive and continual approach to understanding and evaluating one‟s level of physical literacy, further complicating efforts to attain normalized, comparative data (edwards et al., 2017). consequently, corbin (2016) posed several critical questions regarding the validity and reliability of instruments, specifically concerned with a) the multidimensional nature of physical literacy, b) physical literacy as an enduring or transient outcome/goal, c) whether or not assessment standards be criterion-related or normative, and d) the extent to which the ability of the individual or the features of the environment should be accounted.robinson and randall (2017) echoed those sentiments, suggesting the difficulties of assessing an ever-evolving, socially constructed concept, as well as advocating for researchers, educators and practitioners to consider whether or not it is necessary, or even possible, to assess one‟s physical literacy. regardless, because “general” tests of physical literacy might not adequately assess and account for its multidimensional nature, corbin (2016) stressed the importance of considering specific characteristics as the catalyst for the development of assessment procedures. thus, we focus our instrument on two core constructs of physical literacy affect: motivation and confidence (see edwards et al., 2018; participaction et al., 2015; robinson & randall, 2017; whitehead, 2013b). given the two sources from which we determined the necessity to study motivation and confidence, we felt it only prudent that we discuss how they assess the affective constructs in the context of physical literacy. shape america (2014) incorporated physical literacy into its most recent iteration of the national standards &grade-level outcomes for k-12 physical education, positioning it as a comprehensive term “conveying what we are trying to accomplish in physical education” (p. 4). more specifically, the physically literate individual can enjoy a lifetime of healthy physical activity through the five standards of: 1) demonstrating competency in a variety of motor skills and movement patterns, 2) applying of concepts, principles, strategies, and tactics related to movement and performance, 3) demonstrating the knowledge and skills to achieve and maintain a healthenhancing level of physical activity and fitness, 4) exhibiting responsible personal and social behavior that respects self and others, and 5) recognizes the value ofphysical activity for health, enjoyment, challenge,selfexpression and/or social interaction (shape america, 2014, p. 12). however, the assessment of physical literacy is largely based on skill and movement competence in accordance with grade-level criteria. very little is done towards the assessment of a student‟s motivation and confidence regarding physical activity. this embodies lundvall‟s (2015) concern that within an educational setting, one‟s level of physical literacy is likely to be considered with regards to their ability to perform and master movement competence and physical skills, rather than their holistic development towards a physically active lifecourse trajectory. whitehead (2013b) suggests that in and of itself, mastery of movement skills does not result in physical literacy, nor does it enhance motivation towards an activity. canada‟s physical literacy consensus statement (participaction et al., 2015) also highlights motivation and confidence as the key components of physical literacy affect. despite this agreed upon definition, there remain three primary assessment instruments: phe canada‟s passport for life,canadian sport for life‟sphysical literacy assessment for youth (play), and the healthy active living and obesity researchgroup‟s (halo) mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 52 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe canadian assessment of physical literacy (capl) (see robinson & randall, 2017 for critiques of and comparisons). the play tools were found to be the least conclusive in that confidence was determined by an evaluator‟s assessment of a participant‟s completion of a motor task, while motivation was simply assumed to be a subsequent outcome of one‟s competence and confidence (robinson & randall, 2017). the passport for life assesses motivation and confidence via the living skills questionnaire. we reviewed the two subpopulations that best aligned with our sample (i.e., grades 4-6 and grades 7-9) and found the instrument provides a holistic approach to motivation and confidence, integrating them with other aspects of physical literacy such as physical activity engagement, autonomy, enjoyment, and anxiety (passport for life, 2013). while this certainly embodies whitehead‟s (2013b) monistic conceptualization of physical literacy, it may be difficult to parcel out and specifically address the constructs of motivation and confidence (corbin, 2016). the capl (2017) addresses such concerns with dualistic interpretations of physical literacy, with a weighted scoring system that allows evaluators to reflect on a cumulative score across the four domains of physical literacy. concurrently, administrators can consider the constructs of motivation and confidence independently, so as to better assess one‟s “confidence in their ability to be physically active and their motivation to participate in physical activity” (capl, 2017, p.69). 4. assessing the affective constructs of physical literacy: an overview fox (2010) noted that the individualized “self” can be best understood as a dynamic, yet distinct system that is in a consistent state of reaction and adjustment to life experiences. comprised of cognitive, physical, and social domains, the self, when situated in the physical sense, is informed by both psychosocial correlates and selfperceptions, such as motivation and confidence (crocker, eklund, & kowalski, 2000). each of these affective domainsis integral to an individual‟s ability to procure and advance physical literacy across the life course, per the definitions on which this instrument is predicated (ipla, 2017; shape america, 2014). much in the same manner that researchers continue to engage in active debate surrounding the differentiation between constructs of selfperceptions (see horn, 2004), measurement tools have been constructed, tested, and re-evaluated to better understand and predict an individual‟s motivation and confidence within the physical activity and sporting contexts. thus, what follows is an overview of the materialization of measurement tools for each construct (i.e., motivation and confidence), as well as the detailed validation of the means by which items were adapted. 4.1 motivation predicated on the notion of self-determined motivation, the physical activity enjoyment scale (paces; kendzierski&decarlo, 1991) was constructed to assess the extent to which an individual experiences enjoyment during physical activity across the life course (e.g., children and adults) regardless of context (e.g., exercise or sport). consequently, an individual‟s motivation to be physically active was assessed primarily through exercise (exercise motivation scale [ems]; li, 1999) or general physical activity (behavioral regulation in exercise questionnaire [breq]; mullan, markland, &ingledew, 1997), thus failing to account for motivation as it relates more pointedly to sport and sport settings. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 53 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe however, in keeping with the tradition of self-determined motivation, pelletier et al. (1995) expanded upon the tenets of self-determination theory (sdt) and developed a new measure of motivation that took into consideration an individual‟s motivation toward sport. the sport motivation scale (sms) was designed to provide a multidimensional measurement tool, grounded in sdt, which accommodated both the assessment and henceforth validated measurement of sport activity motivation. as noted by pelletier, rocchi, vallerand, deci, and ryan (2013), researchers have utilized the sms to examine sport motivation through more autonomous forms to predict positive outcomes such as affect (ntoumanis &standage, 2009) and self-esteem (zamboni, crawford, &carrico, 2008), as well as non-autonomous antecedents such as determinants of athlete dropout (pelletier, fortier, vallerand, &briere,2001) and fear of failure in sport (conroy, 2004). nevertheless, while the sms has provided researchers with the means to propose meaningful implications for the physical and psychological well-being of sport participants, the scale is not without its limitations. mallett, kawabata, newcombe, otero-forero, and jackson (2007) suggested that the sms was not fully representative of each of the constructs that comprise sdt, whereby they proposed a revised scale (sms-6) that included a measure of extrinsic motivation (integrated regulation) and the contraction of intrinsic motivation subscales into a single measure. likewise, lonsdale, hodge, and rose (2008) introduced the behavioural regulation in sport questionnaire (brsq) as an alternative measure. unlike the sms-6, the brsq utilized a newly constructed set of items that were represented in two distinct forms: 1) the brsq-8 assessed extrinsic and intrinsic motivation, as well as motivation, and 2) the brsq-6 made no distinction between intrinsic motivation types, instead choosing to curate a more general measure of intrinsic motivation. as a result of questionable psychometric properties and theoretical inconsistencies among subscale items, pelletier et al. (2013) revisited the sms and constructed a revised measure (sms-ii) that streamlined intrinsic motivation to a single subscale and in turn, expanded the extrinsic motivation subscale to include integrated regulation. while both pelletier et al. (2013) and lonsdale, hodge, hargreaves, and ng (2014) may contend that their respective scales best capture the context of what it means to participate in sport, both are in agreement that further work is needed to better examine the applicability and longevity of sport motivation measurement tools. particularly, how they align with sdt, as well as consider motivation as a function of different cultural and sporting contexts. 4.2 confidence mcauley and gill (1983) indicated that confidence, as expressed through engagement in sport, may very well be context and skill dependent, the nature of which is accounted for in bandura‟s (1986) understanding of specific self-confidence as self-efficacy. similarly, vealey (1986) understood sport and self-efficacy theory to be inextricably linked, a resounding recognition that underscores manzo, silva, and mink‟s (2001) assertion that much of the research conducted on self-confidence in sport has been informed by self-efficacy theory. for instance, ryckman, robbins, thornton, and cantrell(1982) introduced the physical self-efficacy scale (pses) as an early measurement scale of physical self-efficacy, but it would later be rendered a poor instrument as it failed to account for situation-specificity (bandura, 1997) and conflated the construct with that of self-esteem mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 54 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe (feltz& chase, 1998). hu, mcauley, and elavsky (2005) furthered this argument by submitting that although the constructs of self-efficacy and self-esteem are related conceptualizations of “self,” they are not isomorphic and as a result, should not be conflated in terms of measurement. while the pses has been deemed to be a more accurate measure of selfesteem, it is also focused more broadly on physical ability, and by extension, activity. thus, vealey (1986) developed a pair of measures that assessed the self-confidence of participants in the sporting context. the state sport confidence inventory (ssci) and the trait sport confidence inventory (tsci) were constructed to account for “the goals that individuals strive for when they compete,” whereby confidence in sport should be “grounded in perceptions of ability, thus the competitive orientations should reflect an athlete‟s belief that attainment of a certain type of goal demonstrates competence and success” (p. 222). vealey, garner-holman, hayashi, andgiacobbi (1998), through their continued identification of sport confidence predictors,constructed the sources of sport confidence questionnaire (sscq), a multidimensional measure of sources of sport confidence that in its consideration of nine distinct sources, posits that “athletes gain self-confidence when they achieve their goals, engage in effective self-regulation of cognitions and behavior, and train and compete in a competitive climate that is supportive, challenging, comfortable, and motivating” (p. 76). taking a broader approach to scale development, fox and corbin (1989) introduced the physical selfperception profile (pspp), a three-tiered hierarchical measure that assesses self-esteem and maintains confidence as a common thread through each of its four sub-domains of physical self-worth. while initially developed as an instrument to assess the “physical self” in relation to self-worth within late adolescent populations (e.g., college students), the pspp has since been adapted to assess perceived self-confidence within early adolescent populations (e.g., barnett, ridgers, zask, & salmon, 2015; whitehead, 1995). however, mcgrane, belton, powell, woods and issatel (2015) argued that despite the efforts of barnett el al. (2015), “a gap still remains as there is no instrument for adolescents measuring physical self-confidence in relation to specific skills” (p. 564). as such, they constructed a skill specific self-confidence assessment tool that assesses physical self-confidence among adolescents, specifically that of the relationship between self-confidence and adolescent fundamental movement skills (fms). in a follow-up study (mcgrane, belton, powell, &issatel, 2017), mcgrane and colleagues tested and confirmed the assessment tool, drawing upon mcauley and gill (1983) and bandura (1997) to underscore the need for future research to assess fms proficiency, physical activity, and physical selfconfidence in such a way as to gain a better understanding of how participation in physical activity might be informed by self-confidence. 5. methodology and results 5.1 participants after irb approval was provided and county protocol followed, a questionnaire regarding the affective physical literacy constructs of motivation and confidence was distributed to students at two middle schools. the questionnaire was developed via consolidation of adapted items from various motivation and confidence scales. it was then transposed to qualtrics, an online survey platform, and the link shared. students were randomly mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 55 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe selected to participate and of 400 students chosen, 373 opted to participate. regarding the age of the participants, of the 343 who provided valid responses, 299 were aged either 11 (n = 98, 28.6%), 12 (n = 100, 29.2%), or 13 years (n = 101, 29.4%). the only other age group comprised of over 0.6% of the participants was the 14 year olds (n = 36, 10.5%). a similar number of participants (n = 340) provided their racial identity, of which 110 (29.5%) were african american and 108 (29%) were caucasian. of the remaining participants, 16.9% (n = 63) racially identified as other, with 9.7% (n = 36) identifying as hispanic/latino and 5.6% (n = 21)as asian american. two participants (0.5%) identified as pacific islander. regarding the number of days per week the participants (n = 340) took part in sport and/or physical activity, 116 (34.1%) were active 4-5 days per week, nearly a third (n = 113, 33.2%) participated 6-7 days per week, just under a quarter (n = 76, 22.4%) were active 2-3 days per week, and 35 (10.3%) participated only one day or not at all during the week. 5.2 motivation items for the motivation subscale were adapted from the sport motivation scale ii (sms-ii) (pelletier et al., 2013), motivation for physical activities measure-revised (mpam-r) (ryan, frederick, lepes, rubio, & sheldon, 1997), physical activity enjoyment scale (paes) (kendzierski&decarlo, 1991), and a leisure involvement scale (li) (chang & gibson, 2015). the initial compilation of items resulted in 85 questions. after removing duplicate and unrelated questions, per subdimension(s), and adapting questions for adolescents aged 10-14 years old, the resultant list comprised 3510-point likert scale questions specific to one‟s motivation to participate in sport and/or physical activity. spss 25 was utilizedfor data reduction via principal component analysis (pca). results confirmed the data were suitable for a factor analysis, with a kaiser-meyer-olkin measure of sampling adequacy of .97, well above the suggested value of 0.6 (pallant, 2016), and a significant bartlett‟s test of sphericity (χ2 (595) = 11556.40, p < .001).four dimensions accounting for 69.5% of the total variance were revealed. scale items for each of the dimensions considered different motivations for participating in sport and/or physical activity: enjoyment (dimension one), identity (dimension two), socialization (dimension three), and self-improvement (dimension four). enjoyment accounted for the most variance at 51.8%, followed by one‟s identity with a particular sport or physical activity explaining 9.9%. one‟s penchant for capitalizing on sport and/ or physical activity as a chance to socialize or improve one‟s self resulted in explaining 4.1% and 3.7% of the variance, respectively. of the 35 items, those that cross loaded at higher than .32 (costello & osborne, 2005)were deleted. per hair, black, babin, and anderson (2014), “loadings ±.50 or greater are considered practically significant” (p. 115); thus, using this as a minimum threshold when interpreting results of the oblimin rotation we deleted items loading at .6 or below, resulting in 26 items. reliability analyses were then run on the remaining items across the four dimensions. dimension one (enjoyment) accounted for 12 of the 26 items and was reduced to four items with excellent internal consistency (.96). dimension two (identity) was found to be in the range of good internal consistency (.88), having gone from nine to two items; as did dimension three (socialization), which had two items and an internal consistency of .82. lastly, dimension four (self-improvement) decreased from three items mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 56 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe to two, with an acceptable internal consistency of .77.thus, the final motivation subscalewas completed with 10 items and a cronbach alpha of .93(see table 1). table 1 items included in the instrument measuring motivation, inter-item correlation matrix, factor alphas, and variance explained factor variance questions m1 m2 m3 m4 m5 m6 m7 alpha explained m8 m9 m1 0 m1 it is fun. 0.96 51.8% 1.000 m2 it is interesting. 0.797 1.000 m3 it is exciting. 0.864 0.877 1.000 m10 i like to learn new ways to play and be active. 0.531 0.568 0.578 0.57 4 0.542 0.514 0.4 81 0.4 55 0.6 20 1.0 00 all items are measured on a 10-point likert scale (1 = do not agree at all; 10 = completely agree) and prefaced with the following instructions: please think about all the sports you play and your levels of physical activity, then rate to what extent you agree with the below statements. m7 it helps me meet new people. 0.82 4.1% 0.554 0.634 0.630 6 0.424 0.430 1.0 00 m8 it allows me the chance to socialize with my friends & family. 0.542 0.613 0.599 0.59 9 0.435 0.415 0.6 88 1.0 00 m9 i like to learn how i can improve. 0.77 3.7% 0.404 0.449 0.435 0.43 2 0.454 0.438 0.3 99 0.3 71 1.0 00 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 57 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe i participate in sport and/or physical activity because:note. areas are shaded to distinguish between subdimensions. 5.3 confidence items for the confidence subscale were adapted from the trait sport confidence inventory instrument (vealy, 1986). the scale consists of 13 items which ask participants to think about their self-confidence as it relates to their sport and compare it to the most self-confident athlete they know. after adaptation, the instrument asked participants to consider how confident they feel when playing their sport or participating in physical activityacross 1410-point likert scale questions. a pca was run, confirming the data were suitable for factor analysis. the kaisermeyer-olkin measure of sampling adequacy was .95 and bartlett‟s test of sphericity was significant (χ2 (91) = 4229.58, p < .001). the pca revealed two dimensions, accounting for 71.8% of the variance, with the first (belief in physical skills leading towards positive outcomes) and second (beliefin cognitive abilities) dimension explaining 64.3% and 7.5%, respectively. results from the oblimin rotation revealed four items that loaded below the ideal cutoff of .7(hair et al., 2014), which were deleted. reliability analyses were run on the remaining 10 items, resulting in a final confidence scalewith eight items, across two dimensions, and a cronbach alpha of .92. internal consistency was excellent for dimension one (belief in physical skills leading towards positive outcomes) at .94 and acceptable for the second dimension (belief in cognitive abilities) at .72 (see table 2). table 2 items included in the instrument measuring confidence, inter-item correlation matrix, factor alphas and variance explained variance questions factor alpha c1 c2 c3 c4 c5 c6 explained c7 c8 all items are measured on a 10-point likert scale (1 = not confident; 10 = very confident) and prefaced with the following instructions: answer the questions below based on how confident you feel when you are playing your sport or participating in physical activity. please answer how you really feel, not how you would like to feel. how confident are you in your ability to... note. areas are shaded to distinguish between subdimensions. 6. discussion c7 c8 make decisions perform pressure critical 0.72 under 7.5% 0.476 0.415 0.435 0.530 0.542 0.502 1.000 0.430 0.356 0.342 0.442 0.437 0.383 0.558 1.000 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 58 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe the purpose of this study was to develop an assessment tool to provide sport and physical activity participants and administrators an efficient and effective tool to assess one‟s affective domain of physical literacy as situated in the constructs of motivation and confidence. the instrument was developed with an adolescentsample because it is at this age when dropout rates from sport and physical activity significantly increase (crane & temple, 2015; witt & dangi, 2018) and potentially direct youth towards a lifecourse trajectory void of or lacking in healthy physical activity (barnekow-bergkvist et al., 1998; terzian & moore, 2009).we feel that framing the questions in the context of sport and/or physical activity better aligns with the conceptualization(s), practical applications, and implications of affective physical literacy within the context of applied sport management and/or physical activity and education spaces.we accomplished this purpose with the development of an18-item questionnaire, spanning two constructs (motivation and confidence) across six dimensions (enjoyment, identity, socialization, self-improvement, belief in physical skills, and belief in cognitive abilities).by doing so, we are not making a value judgment on current physical literacy assessments; rather, we anticipate and aspire for this instrumentto serve as a supplement to sport and physical activity programs, coaches, managers, and participants outside of an educational setting. by doing this, we are avoiding the potential deterministic approach of performance and skill mastery (lundvall, 2015), and instead recognize the affective domain of physical literacy as a contributing factor in one‟s lifelong journey towards healthy physical activity (robinson & randall, 2017). as an antecedent to physical activity and sport participation, motivation encompasses factors ranging from physical competence to social acceptance to enjoyment (stuntz& weiss, 2010; weiss & williams, 2004). the final tally of motivation items comprising the scale was 10, across four dimensions, with high internal consistency. the four dimensions, being enjoyment, identity, socialization, and self-improvement, are straightforwardand make it easy to understand and interpret the results, allowing for sport and physical activity managers and administrators, as well as participants and policy makers, tomake appropriate adjustments or corrections accordingly. for instance, if a recreational league administers the assessment to its members and finds that they joined the league because they enjoy the sport, then the focus of games and practices can be planned more towards having fun. conversely, if they find players to be more interested in self-improvement, they may consider modifying training regimens or practices to foster sport-specific skilldevelopment. if a sport-based youth development (sbyd) program wants to reach and retain more participants, they might benefit from knowing their local youth want to spend their time socializing and provide more opportunities to share stories, personally connect, and be inclusive through their sport and physical activity program offerings. regardless, a suggested, if c1 achieve your goals 0.94 64.3% 1.000 c2 be successful 0.799 1.000 c3 think and act positively during participation 0.700 0.736 1.000 c4 accept the challenges of competition 0.700 0.691 0.724 1.000 c5 be successful even when the odds are against you 0.657 0.664 0.668 0.778 1.000 c6 bounce back from playing bad and be successful 0.681 0.682 0.728 0.741 0.760 1.000 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 59 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe not expected, outcome of all physical activity, recreation, sport and sbyd programs can and should be to provide for and enhance youth and athlete development opportunities (fraserthomas, côté, & deakin, 2005). motivation is key to physical literacy, as it allows individuals to capitalize on their embodied abilities so as to enhance their quality of life (whitehead, 2005, 2013a, 2013b), and thus, is a critical element of one‟s journey on an active lifecourse (ipla, 2017). confidence isalso a critical element of physical literacy affect (edwards et al., 2017). confidencecan be largely impactful on one‟s participation in sport and physical activity and has been purported to be “the most critical psychological characteristic influencing sport performance” (vealey et al., 1998, p. 54).as noted earlier in this paper, when considering confidence within sport and physical activityprograms and spaces, it must be done relative to a participant‟s ability to make progressions as they learn new activities and tasks, as well as assure their experiences will be rewarding (green et al., 2018).for example, if a physical education instructor utilizes this assessment with their students and finds that they embrace the challenges that new activities might present, then the instructor may be compelled to modify their curriculum in a way that emphasizes the refinement of activity-based skill development or even the introduction of new, innovative activities. moreover, given that confidence is a strong informant of one‟s choice to engage in sport and physical activity, a lack of confidence may actually supplant one‟s ability to develop movementcompetence (stodden et al., 2008). therefore, it becomes important for sbyd, physical activity, recreation, and sport programs to understand confidence as both context and skill dependent, such that confidence can be “associated with the setting of challenging goals and the expenditure of maximal effort and persistence to achieve those goals” (p. 1186);in turn, allowing confident youth to succeed based on their achievement-based behaviors (hays, thomas, maynard, &bawden, 2009). in addition to its implications within the aforementioned affective elements of physical literacy, physical activity is linked to health-related outcomes such as healthy weight levels, physiological and psychological well-being, as well as cardiorespiratory and muscular fitness (see barnett et al., 2016; cdc, 2011; dhhs, 2018).regular physical activity has also been found to have positive effects on brain development (esteban-cornejo et al., 2017), academic competency (esteban-cornejo, tejero-gonzalez, sallis, &veiga, 2015), and behavior in school (cdc, 2018); in contrast to the detrimental impacts of low levels of physical activity, which can lead to missed school days and poor academic performance (aspen institute, 2015). as such,results from this instrument can guide educational policy makers towards curricula and school-based programming that educates and empowers youth to become more physically literate and experience not only the inherent benefits of physical activity, but also the supplemental and intangible outcomes associated with increased academic engagement and educational behaviors. likewise, results can be utilized by programs to evaluate their current offering of sport or physical activities and determine if they are appropriately promoting and facilitating a lifetime commitment to being active. given the decreasing rates of sport participation and physical activity, as well as increased health issues and sedentary lifestyles in the united states (aspen institute, 2016), it is critical to understand why adolescents may not be demonstrating more concern for the development and enhancement of their physical and mental wellmailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 60 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe being. therefore, thistoolcan be helpful in evaluating long-term developmental outcomes associated with physical activity and sport programs. this assessment is designed to be a snapshot of one‟s affective physical literacy in early adolescence (ages 10 to 14), the utility of which may allow for not only access to, but also opportunities for engagement with sport and physical activity across the lifecourse. as such, the ease of use and longitudinal application of the tool validates its practical importance to any sport, fitness, physical activity, recreation, or sbyd program. affording users with the capability to consider motivation, across four subdimensions, and confidence, between two subdimensions, of both sport and physical activity is a unique contribution of this manuscript. as this instrument becomes more widely utilized to assess affective physical literacy among sport and physical activity participants, we expect it will be adapted and validated for participants and administrators of all skill-levels, abilities, knowledge and ages in a multitude of environments. this should afford participants, coaches, administrators, and policy makers the opportunity to better understand the affective domain of physical literacy (i.e., motivation and confidence) and enhance programming and daily interaction with sport and physical activity so as to facilitate and promote physical literacy. 7. limitations as with most studies, this one was not without limitations. though the participant sample was diverse regarding both race and gender, being recruited from only two middle schools in the same county may limit generalizability to a greater population. the scoring of this new instrument could also prove a bit restrictive, as it does not align with any other sport and physical activity scales to which it can be compared. however, physical literacy is conceptualized as pertinent to an individual‟s journey, arguably not to be considered in regards to peers or other groups (whitehead, 2013b). regardless, the opportunity to parcel out scores pertaining to the core affective domains of physical literacy (i.e., motivation and confidence) is beneficial to better understanding one‟s particular psychosocial/emotional engagement with sport and physical activity. lastly, a unique contribution is that the assessment considers motivation and confidence in both sport and physical activity. however, this can also serve as a limitation given the instrument‟s current inability to determine whether a participant‟s self-reported scores were in the context of sport, physical activity, or both. we recommend future iterations consider this potential hindrance. references aspen institute. (2015). physical literacy in the united states: a model, strategic plan, and call to action. retrieved september 30 from http://aspenprojectplay.org/sites/default/files/physicalliteracy_aspeninstitute.pdfbandura aspen institute. (2016). sport for all, play for life: a playbook to get every kid in the game. retrieved september 29 fromhttps://assets.aspeninstitute.org/content/uploads/2015/01/aspen-institute-projectplayreport.pdf?_ga=2.43945125.1828781204.1569807104-994970563.1569807104. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 61 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe bandura, a. (1986). social foundations of thought and action: a social cognitive theory. englewood cliffs, nj: prentice-hall. bandura, a. (1997). self-efficacy: the exercise of control. new york, ny: freeman. barnekow-bergkvist, m., hedberg, g., janlert, u., & jansson, e. (1998). prediction of physical fitness and physical activity level in adulthood by physical performance and physical activity in adolescence – an 18year follow-up study. scandinavian journal of medicine and science in sports, 8(5), 299-308. barnett, l. m., ridgers, n. d., zask, a., & salmon, j. (2015). face validity and reliability of a pictorial instrument for assessing fundamental movement skill perceived competence in young children. journal of science and medicine in sport, 18(1), 98-102. barnett, l. m., stodden, d., cohen, k. e., smith, j. j., lubans, d. r., lenoir, m., livonen, s., miller, a.d., laukkanen, a., dudley, d., lander, n.j., brown, h., & morgan, p.j. (2016). fundamental movement skills: an important focus. journal of teaching in physical education, 35(3), 219-225. bradley, r.h., mcritchie, s., houts, r.m., nader, p., & o‟brien, m. (2011). parenting and the decline of physical activity from age 9 to 15. international journal of behavioral nutrition and physical activity, 8(33), 1-10. canadian assessment of physical literacy (2017). manual for test administration (2nded.). retrieved from https://www.capl-eclp.ca/capl-manual/. canadian sport for life (2014). physical literacy assessment in canada. retrieved from http://canadiansportforlife.ca/sites/default/files/resources/physical%20literacy%20assessment%20in% 20 canada%20final%20may%206%20-%202014.pdf. centers for disease control and prevention (2011). the cdc guide to strategies to increase physical activity in the community. retrieved from https://www.cdc.gov/obesity/downloads/pa_2011_web.pdf. centers for disease control and prevention (2018). healthy schools: physical activity facts. retrieved from https://www.cdc.gov/healthyschools/physicalactivity/facts.htm. chang, s., & gibson, h. (2015). the relationships between four concepts (involvement, commitment, loyalty, and habit) and consistency in behavior across leisure and tourism. tourism management perspectives, 13, 41-50. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 62 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe conroy, d. (2004). the unique psychological meanings of multidimensional fears of failing. journal of sport & exercise psychology, 26, 484-491. corbin, c. b. (2016). implications of physical literacy for research and practice: a commentary. research quarterly for exercise and aport, 87(1), 14-27. costello, a.b., & osborne, j.w. (2005). best practices in exploratory factor analysis: four recommendations for getting the most from your analysis. practical assessment, research & evaluation, 10(7), 1-9. crane, j., & temple, v. (2015). a systematic review of dropout from organized sport among children and youth. european physical education review, 21(1), 114-131. crocker, p. r. e., eklund, r. c., & kowalski, k. c. (2000). children‟s physical activity and physical selfperceptions. journal of sports sciences, 18, 383-394. department of health and human services (dhhs, 2018). physical activity guidelines for americans (2nd ed). washington, dc: u.s. department of health and human services. durden-myers, e.j., green, n.r., & whitehead, m.e. (2018). implications for promoting physical literacy. journal of teaching in physical education, 37, 262-271. edwards, l. c., bryant, a. s., keegan, r. j., morgan, k., & jones, a. m. (2017). definitions, foundations and associations of physical literacy: a systematic review. sports medicine, 47(1), 113-126. edwards, l.c., bryant, a.s., keegan, r.j., morgan, k., cooper, s., & jones, a.m. (2018). „measuring‟ physical literacy and related constructs: a systematic review of empirical findings. sports medicine, 48(3), 659682. esteban-cornejo, i., tejero-gonzalez, c. m., sallis, j. f., &veiga, o. l. (2015). physical activity and cognition in adolescents: a systematic review. journal of science and medicine in sport, 18(5), 534-539. esteban-cornejo, i., cadenas-sanchez, c., contreras-rodriguez, o., verdejo-roman, j., mora-gonzalez, j., migueles, j. h., henriksson, p., davis, c.l., verdejo-garcia, a., catena, a., & ortega, f. b. (2017). a whole brain volumetric approach in overweight/obese children: examining the association with different physical fitness components and academic performance. the activebrains project. neuroimage, 159, 346-354. farrey, t. (2017). sport for all: play for life. a vision worth pursuing. keynote address given at 2017 north american society for sport management in denver, co on friday, june 2, 2017. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 63 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe feltz, d.l., & chase, m.a. (1998). the measurement of self-efficacy and confidence in sport. in j. duda (ed.), advancements in sport and exercise psychology measurement (pp. 65-80). morgantown, wv: fitness information technology. fox, k. (2010). the physical self and physical literacy. in m. whitehead (ed.), physical literacy: throughout the lifecourse (pp. 71-82). new york, ny: routledge. fox, k. r., & corbin, c. b. (1989). the physical self-perception profile: development and preliminary validation. journal of sport & exercise psychology, 11, 408–430. fraser-thomas, j.l., côté, j., &deakin, j. (2005). youth sport programs: an avenue to foster positive youth development, physical education and sport pedagogy, 10(1), 19-40. gardner, h. & hatch, t. (1989). multiple intelligences go to school: educational implications of the theory of multiple intelligences. educational researcher, 18(8), 4-10. giblin, s., collins, d., & button, c. (2014). physical literacy: importance, assessment and future directions. sports medicine, 44, 1177-1184. green, n.r., roberts, w.m., sheehan, d., & keegan, r.j. (2018). charting physical literacy journeys within physical education settings. journal of teaching in physical education, 37, 272-279. hair jr., j.f., black, w.c., babin, b.j., & anderson, r.e. (2014). multivariate data analysis (7thed.). essex, england: pearson education limited. hays, k., thomas, o., maynard, i., &bawden, m. (2009). the role of confidence in world-class sport performance. journal of sports sciences, 27(11), 1185-1199. horn, t. s. (2004). developmental perspectives on self-perceptions in children and adolescents. in m. r. weiss (ed.), developmental sport and exercise psychology: a lifespan perspective (pp. 101-143). morgantown, wv: fitness information technology. hu, l., mcauley, e., &elvasky, s. (2005). does the physical self-efficacy scale assess self-efficacy or selfesteem? journal of sport & exercise psychology, 27, 152-170. international physical literacy association (ipla, 2017). about. retrieved from https://www.physicalliteracy.org.uk/about/ mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 64 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe kendzierski, d., &decarlo, k. j. (1991). physical activity enjoyment scale: two validation studies. journal of sport & exercise psychology, 13, 50-64. li, f. (1999). the exercise motivation scale: its multifaceted structure and construct validity. journal of applied sport psychology, 11, 97-115. lloyd, m., colley, r. c., & tremblay, m. s. (2010). advancing the debate on 'fitness testing' for children: perhaps we're riding the wrong animal. pediatric exercise science, 22(2), 176-182. lonsdale, c., hodge, k., & rose, e. a. (2008). the behavioral regulation in sport questionnaire (brsq): instrument development and initial validity evidence. journal of sport and exercise psychology, 30, 323355. lonsdale, c., hodge, k., hargreaves, e. a., & ng, j. y. (2014). comparing sport motivation scales: a response to pelletier et al. psychology of sport and exercise, 15, 446-452. lundvall, s. (2015). physical literacy in the field of physical education a challenge and a possibility. journal of sport and health science, 4, 113-118. mcauley, b. e., & gill, d. (1983). reliability and validity of the physical self-efficacy scale in a competitive sport setting. journal of sport & exercise psychology, 5, 410–418. mcgrane, b., belton, s., powell, d., woods, c. b., &issartel, j. (2015). physical self-confidence levels of adolescents: scale reliability and validity. journal of science and medicine in sport, 19, 563-567. mcgrane, b., belton, s., powell, d., &issartel, j. (2017). the relationship between fundamental movement skill proficiency and physical self-confidence among adolescents. journal of sports sciences, 35(17), 17091714. mallett, c., kawabata, m., newcombe, p., otero-forero, a., & jackson, s. (2007). sport motivation scale-6 (sms-6): a revised six-factor sport motivation scale. psychology of sport and exercise, 8, 600-614. manzo, l. g., silva, j. m., & mink, r. (2001). the carolina sport confidence inventory. journal of applied sport psychology, 13, 260-274. mullan, e., markland, d., &ingledew, d. k. (1997). a graded conceptualization of self-determination in the regulation of exercise behavior: development of a measure using confirmatory factor analytic procedures. personality and individual differences, 23(5), 745-752. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 65 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe ntoumanis, n., &standage, m. (2009). motivation in physical education classes: a self-determination theory perspective. theory and research in education, 7, 194-202. pallant, j. (2016). spss survival manual: a step by step guide to data analysis using spss (6thed.). berkshire, england: open university press/mcgraw-hill. participaction, sport for life society, the healthy active living and obesityresearch group at the children‟s hospital of eastern ontario research institute, physicaland health education canada, canadian parks and recreation association, &the ontario society of physical activity promoters in public health (june, 2015).canada‟s physical literacy consensus statement. retrieved from http://physicalliteracy.ca/wp-content/uploads/2016/08/consensus-handoutenweb_1.pdf passport for life (2013). living skills. retrieved from https://passportforlife.ca/home/teachers-guide/passportlifeassessments/student-online-surveys/living-skills pelletier, l. g., fortier, m. s., vallerand, r. j., &briere, n. m. (2001). associations among perceived autonomy support, forms of self-regulation, and persistence: a prospective study. motivation and emotion, 25, 279306. pelletier, l. g., fortier, m. s., vallerand, r. j., tuson, k. m., briere, n. m., & blais, m. r. (1995). toward a new measure of intrinsic motivation, extrinsic motivation, and amotivation in sports: the sport motivation scale (sms). journal of sport & exercise psychology, 17, 35-53. pelletier, l. g., rocchi, m. a., vallerand, r. j., deci, e. l., & ryan, r. m. (2013). validation of the revised sport motivation scale (sms-ii). psychology of sport and exercise, 14, 329-341. robinson, d.r., & randall, l. (2017). marking physical literacy or missing the mark on physical literacy? a conceptual critique of canada‟s physical literacy assessment instruments. measurement in physical education and exercise science, 21(1), 40-55. roetert, e.p., & jefferies, s.c. (2014). embracing physical literacy. journal of physical education, recreation and dance, 85(8), 38-40. ryan, r.m., frederick, c.m., lepes, d., rubio, n. & sheldon, k.m. (1997). intrinsic motivation and exercise adherence. international journal of sport psychology, 28, 335-354. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 66 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe ryckman, r. m., robbins, m. a., thornton, b., & cantrell, p. (1982). development and validation of a physical selfefficacy scale. journal of personality and social psychology, 42(5), 891. society of health and physical educators (shape america). (2014). national standards & grade-level outcomes for k-12 physical education. champaign, il: human kinetics. spengler, j.o., & cohen, j. (2015). physical literacy: a global environmental scan. washington, dc: the aspen institute. stodden, d. f., goodway, j. d., langendorfer, s. j., roberton, m. a., rudisill, m. e., garcia, c., & garcia, l. e. (2008). a developmental perspective on the role of motor skill competence in physical activity: an emergent relationship. quest, 60(2), 290-306. stuntz, c. p., & weiss, m. r. (2010). motivating children and adolescents to sustain a physically active lifestyle. american journal of lifestyle medicine, 4(5), 433-444. terzian, m., & moore, k. a. (2009). physical inactivity in us adolescents: family, neighborhood, and individual factors. child trends research brief. publication# 2009-28. tremblay, m., &llyod, m. (2010). physical literacy measurement the missing piece. physical & health education journal, 76(1), 26. vealey, r. s. (1986). conceptualization of sport-confidence and competitive orientation: preliminary investigation and instrument development. journal of sport psychology, 8, 221–246. vealey, r. s., garner-holman, m., hayashi, s. w., &giacobbi, p. (1998). sources of sport-confidence: conceptualization and instrument development. journal of sport and exercise psychology, 20(1), 54-80. weiss m. r., & williams l. (2004). the why of youth sport involvement: a developmental perspective on motivational processes. in m. r. weiss (ed.), developmental sport and exercise psychology: a lifespan perspective (pp. 223-268). morgantown, wv: fitness information technology. whitehead, j. r. (1995). a study of children‟s physical self-perceptions using an adapted physical self-perception profile questionnaire. pediatric exercise science, 7(2), 132-151. whitehead, m. (2005). developing physical literacy. unpublished paper presented at pe for today‟s children: primary physical education conference. roehampton, england. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 67 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe whitehead, m. (2007). physical literacy: philosophical considerations in relation to developing a sense of self, universality and propositional knowledge. sports ethics and philosophy, 1(3), 281-298. whitehead, m. (2013a). the history and development of physical literacy. journal of sport science and physical education (bulletin 65), 22-28. whitehead, m. (2013b). definition of physical literacy and clarification of related issues. journal of sport science and physical education (bulletin 65), 29-34. whitehead, m., & maude, p. (2016). from the creation of a concept to the globalisation of physical literacy. in dolltepper, g., koenen, k., & bailey, r. (eds.), sport, education and social policy: the state of the social sciences of sport. routledge: new york. witt, p.a., & dangi, t.b. (2018). why children/youth drop out of sports. journal of park and recreation administration, 36(3), 191-199. zamboni, d., crawford, i., &carrico, a. (2008). predictors of sports motivation among gay and bisexual men. journal of homosexuality, 54, 449-468. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 1; january-febuary 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 7 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe legal mastery for golf directors: vital competencies john michael anderson department of health, physical education, & recreation, missouri western state university, 4525 downs, dr.st. joseph abstract: golf, a popular leisure sport in the united states, has evolved into a thriving industry. in 2011, the u.s. golf industry boasted a staggering $43.5 billion in revenue, encompassing various sectors, including facility operations, course investment, supplies, endorsements, tournaments, and charitable contributions. as per the national sporting goods association, golf expenditures ranked third among recreational activities in 2012. golf management involves a diverse range of responsibilities, as outlined in the professional golfers’ association (pga) curriculum. prospective golf professionals must undergo comprehensive training in areas such as turf management, tournament operations, merchandising, food and beverage control, customer relations, and golf teaching skills. keywords: golf industry, leisure sport, golf management, pga curriculum, revenue sources introduction golf is one of the most popular leisure sport and has grown into an enormous business in the united states. the size of the u.s. golf industry in 2011 was $ 43.5 billion consisting of $29.85 billion for golf facility operations, $2.07 billion for golf course capital investment, $5.64 billion for golf supplies, $2.05 billion for endorsement/tournaments/associations, and $3.9 billion for charities (statista, 2014). according to the national sporting goods association (nsga, 2012), golf-related expenditures ranked third in recreational pursuitsin 2012. no matter what types of facilities golf directors manage, golf operations comprise different aspects of golf management. according to the golf management curriculum created by the professional golfers’ association (pga, 2009), golf apprentices are required to complete a variety of courses in golf management such as turf grass management, golf car fleet management, tournament operations, merchandising and inventory management, food and beverage control, golf operations, human resources, customer relations, business planning, golf club fitting, and golf teaching skills. while golf operations include various complex tasks, golf directors must be aware of the importance of legal aspects because issues of law have been inextricably woven into their managerial responsibilities. in today’s litigious society, one minor mistake may lead to the risk of lawsuits against any golf facilities because of the many mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 1; january-febuary 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 8 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe participants and such a large financial assets involved. yet, the current golf management program by the pga neglects legal aspects as part of golf management competencies. over the past three decades, litigation and award expenses related to recreational sport have steadily increased (rapp, 2012) and are expected to continue to increase in the future (cotton & wolohan, 2013). the trends in civil and criminal cases revealed the massive problems of legal actions in the united states. in 2013, approximately 328,403 civil cases were filed in the federal district and appellate courts and this was a 4.3% increase compared to the year of 2000 (u.s. courts, n.d.). in terms of sport-related injury, approximately 1.9 million people visited emergency room in 2012 (u.s. consumer product safety commission, n.d.). as a result of this trend, golf directors need to gain and maintain essential legal literacy in these areas of the law that could possibly influence the golf operation and its delivery. it is vital for golf directors to demonstrate that they have identified and classified potential risks and implemented adequate measures to control them. although many studies were completed on the subject of legal aspects relating to recreational sport contexts (fields & young, 2010; jamieson, 1980; lee, farley, & kwon, 2010; skipper, 1990; toh, 1997; yong, fields, & powell, 2007), a review of literature indicated limited benchmarking information regarding legal competencies in the field of golf management. thus, the purpose of this study was: (1) to identify the requisite foundation of knowledge in relation to legal liability, the law, and risk management that assists golf directors; (2) to examine a profile of legal competencies that golf directors actually need to possess; and (3) to provide information that could be used to structure a curriculum focusing on legal aspects. the findings of this study can benefit the golf management field by providing a foundation of legal literacy that assists golf directors. this information provides academicians a conceptual paradigm for making necessary adjustments to recreational sport law courses in golf management curricula. further, this study may assist the pga in developing a legal aspects curriculum in its apprentice education program by identifying the importance of legal competencies for golf directors. related literature due to an increasing number of lawsuits and prevalence of sports injuries, a fundamental sense of legal aspects and risk management has become an important part of the golf management competencies and professional preparation for current golf directors (choi, 2010). in order to gain a better understanding of suitability for this study, it is necessary to review the previous literature on this topic. the following sections discuss the legal competencies as part of management skills studies in recreational sport and areas of legal concerns for golf operations. legal competencies studies early studies related to management competencies for recreational sports managers confirmed the importance of legal competencies. jamieson (1980) initiated the first empirical analysis of competency among recreational sport administrators. while developing the competency instrument, jamieson investigated the validity and reliability of the instrument and tested its adequacy of the instrument. of 12 areas in the management competency model, mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 1; january-febuary 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 9 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe the most needed legal competencies included safety/accident prevention, program techniques, personnel/customer relations, organizational policies/procedures, facility/maintenance, and business procedures. a few years later jennings (1984) claimed that chairpersons of physical education and recreation departments in four-year colleges ranked legal competency items higher than other management competencies for entry level recreational sports personnel. both chairperson groups regarded safety/accident prevention, personnel/customer relations, officiating, legality, facilities maintenance, and program techniques as important competencies among entry-level recreational sports professionals. with the modification of jamieson’s instrument, skipper (1990) found six managerial tasks deemed important to collegiate sports facility managers. those six areas were resource management/facility planning, computer utilization, facility operations, philosophy/foundations, marketing, and event/schedule management. based on jamieson’s (1980) competency analysis instrument, toh(1997) constructed another research instrument to determine sport management competencies. a total of 96 competency statements divided into 10 categories were developed. toh tested the validity and reliability of the sport management competency model by surveying managers from private athletic clubs, young men’s christian associations (ymcas), and parks and recreation agencies. the results indicated six areas of sport management competency: governance, sport foundations, budgeting, risk management, computer skills, and communications. since four of his categories associated with legal competencies were not included, toh suggested that further study should be conducted to verify appropriateness for the determination of sport management competencies among different populations. those excluded legal competency items were business procedures, facility/equipment management, management techniques, and research/evaluation. in terms of the legal competency study, young (2001) specified the fundamental legal knowledge needed among recreational sport professionals with experience in both municipal and educational settings. essential legal topics for recreation sport professionals included (in order of importance): risk management, administrative law, tort law, contract law, products liability, constitutional law, judicial system, and legal research. respondents indicated risk management as the most important area because they perceived that appropriate risk management techniques might help to reduce their liability. descriptions of legal topics are as follows: administrative law is the study of governmental regulation by administrative agencies and the nature and scope of judicial review exercised by the courts over such agencies. constitutional law is the study of the judicial legal function as it relates to the powers of the federal government and the powers delegated to the states by the federal government. contract law is the study of contract formation, termination, avoidance, performance, breach of performance, remedies for breach and dispute resolution. judicial system is the study of the structure and relationships of the federal, state, and local court systems, how laws are made, and the trial system. legal research is the study of how to located and look up case law while using a variety of resources (i.e., annotated law reports, law reviews, legal dictionaries and encyclopedias, etc.) in researching legal topics. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 1; january-febuary 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 10 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe product liability is the study of negligence, breach of warranty, and strict liability in tort as it relates to recreational sport equipment. risk management is the study of risk identification, evaluation, treatment and implementation with the goal of learning to efficiently manage the organization by reducing the potential for loss to property, clients, employees, and the public. tort law is the study of a wrongful act resulting in an injury, loss or damage for which the injured party can bring civil action. this area includes a study of negligence and defenses to negligence. (“methods,” para. 3) pedagogical research in the recreational sport field also revealed the importance of legal competencies. stier and schneider (2000) and petersen and pierce (2009) claimed that a legal aspects course was one of the most important courses within the undergraduate sport management curricula. further, the legal aspects content is recommended in core content areas by accreditation bodies in the fields of recreation (national recreation and park association, nrpa: council on accreditation of parks, recreation, tourism and related professions, coaprt, 2014), sport management (commission on sport management accreditation, cosma, n.d.), hospitality management (accreditation commission for programs in hospitality administration, acpha, 2013), and business administration (association to advance college schools of business, aacsb, 2013). accreditation procedures have been established to legitimize programs and ensure a standard of excellence to the given field. the national intramural-recreational sports association (2014) included legal liability and risk management as part of its eight professional core competencies. the legal competencies consist of risk management/crisis management, injury liability, sports waivers/consent, the legal process, and insurance coverage and plans. noticeably, some legal competencies are also imbedded in the curricula such as human resource management, business management, and facility management. risk management plans numerous studies in the scholarly literature have addressed the need for risk management in recreational sport programs. since the 1990s, recreational sport professionals have realized importance of effective risk management practices, and risk management practices among recreational sport professionals have been improved (mulrooney& styles, 2005). risk management studies agree that the use of risk management plans and manuals has been an excellent managerial practice to provide quality services and to continue financial wellbeing (lee, farley, & kwon, 2010; mulrooney & green, 1997; stier, schneider, kampf, haines, & gaskins, 2008; young, et al., 2007). yong et al. (2007) claimed that recreational sport directors were aware of and concerned about the risk issues most oftenlitigated and took the proper steps to reduce the incidence of risk issues becoming litigations and to successfully defend the litigations that were filed. young and her associates analyzed published legal cases relating to campus recreation within the last 30 years and examined campus recreation directors’ risk management perceptions with the published cases. of the 54 campus recreation related cases, the most frequent type of case was tort law followed by discrimination, criminal, employment and labor, and tax status/property rights/zoning cases. the risk issues that recreational sport directors worried about the most dealt with facility maintenance, mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 1; january-febuary 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 11 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe travel of student groups, negligent supervision, training of staff, inappropriate use of equipment, and providing a safe environment. young and her colleagues asserted that directors as well as staff members need to effectively handle risk factors facing the recreational sport organization and they must educate themselves in legal issues and effective risk management practices. in recreational sport programs at division i-a colleges and universities, the most needed part of the risk management plan was the supervision of activity followed by staff training, written policies/procedures, emergency plan, facility check list, release/consent form, warning signs, and inspection procedure(lee et al., 2010). in order to ensure participants’ safety in the activity, most programs with a risk management plan provided supervision of activities and safety training to both full-time and part-time staff members. regarding the relationship between a risk management plan and the reported participant injury rates, universities without a riskmanagement plan had higher injury rates than universities with a risk management plan. the majority of recreational sport program directors perceived that a well written risk management plan can improve the quality of services for participants, reduce injury rates, reduce money paid for loss claims, and save on insurance premiums. to investigate how risk management practices have advanced in recreational sport contexts, stier and his colleagues (2008) surveyed the current risk management practices, procedures, and policies associated with intramural and sport activities. many administrators attempted to protect themselves from liability by using waiver forms, using automated external defibrillators (aed), having cardiopulmonary resuscitation (cpr) and first aid certifications for staff members, providing supervision of activities, having restrictive policies, and using communication devices. the use of a waiver was common practicefor recreational sports programs, and most programs required a signed waiver prior to participation in intramural sport. all recreational sport programs provided some sort of supervision for home events and did not require a coach to have first aid/cpr certifications. similarly, kampf, haines, schneider, stier, and gaskins (2011) described current legal practices in club sport programs. the legal practice areas included the use of waivers, travel, coaching, first aid/cpr, and supervision. the results revealed that most programskept participants to self-administer and self-regulate their programs. while traveling to away games, participants used an outside vendors the most followed by the use of private transportation, driving personal vehicles, and renting organization owned vans. however, few programs provided professional employees to accompany teams during away travel. noticeably, while the majority of recreation administrators had a written risk management plan, some administrators did not. regarding risk management efforts, some professional staff had been given responsibility for overall risk management of the total intramural program. therefore, all club sport programs need to prepare a written plan for emergencies and designate the professional staff who is in charge of emergency procedures in case of an incident or accident at a home event and during away travel. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 1; january-febuary 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 12 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe golf directors have various responsibilities such as organizing golf tournaments, supervising golf clinics, managing golf carts, merchandise, foods and beverages, as well as monitoring and maintaining facility and equipment. as a number of publications indicated (lee et al., 2010; stier, et al., 2008; young, 2001, 2007), essential legal topics within the scope of work for golf directors may include tort law, contract law, premises liability, participatory and contractual forms, negligence, human resources laws, product liability, fiduciary responsibilities, constitutional law, and administrative law. since a comprehensive risk management manual not only helps to reduce the frequency of legal claims, but also generates an environment where the inherent risks are minimized (cooper, 1997; lee et al., 2010), golf directors should create asound risk management plan that serves the customer, the employee, and the organization. a strong risk management plan evaluatespolicies, areas, facilities, staff, participants, and programs on a continuous basis. it can classify if any organizational policies are contradictory to local, state, or federal laws, regulations, and ordinances (e.g., american with disabilities act, fair labor standards act, occupational safety and health administration, etc.). golf directors should include the comprehensive risk management in the training of each golf professionals in the golf environment. further, it would be beneficial to future golf professionals if golf management programs and pga education programs implement these legal competency areas in their curricula. methods subjects regarding the sampling method, judgment sampling was used to measure different golf environments including different populations served and year-round and seasonal golf facility. among the association’s 14 districts, four districts (district 2, 11, 12, and 13) were chosen from the pga membership and golf directory. district 2 includes new york, new jersey, and philadelphia; district 11 includes california and hawaii; district 12 includes new mexico and texas; and district 13 includes florida and georgia. a total of 390 pga certified golf course directors who were in a golf operations position participated in this study. usually, individuals who manage golf courses in the united states are licensed professionals who hold a membership from the pga (pga, 2014). therefore, they were deemed to be the most suitable population from which to collect feedback on fundamental legal knowledge needed. instrument the instrument used for the data collection was toh’s (1997) competencies of sport managers (cosm) instrument because the cosm was the most appropriate instrument that assessed the suggested competencies required to manage recreational sports that were related to the purpose of this study. further, the cosm was one of the few instruments in the recreational sport field of study to convey evidence of validity and reliability (cronbach’s α = .97). toh’s study provided information of value for the selection of competencies and the general framework for the questionnaire. of the 96 competency statements categorized within 10 areas from the cosm, a total of six legal competency factors were selected. it was determined that modifying the original statement of the cosm was appropriate mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 1; january-febuary 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 13 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe because the legal needs of directors in the golf industry might differ from those of managers in the recreational sport field. in the content validity process of legal competencies instrument modified for this study, the delphi technique was executed using information provided by a panel of experts. five pga professionals who held the general manager position with more than 10 years of expertise in golf management were selected to form the expert jury. of the modified 39 legal competency statements, the jurors were asked to evaluate and validate the statements. throughout three steps of the content validation process for legal competencies instrument by expert jurors, all 39 statements were retained. the result of cronbach’s alpha internal consistency reliability of the legal competencies instrument was found to be .95.hereafter, the instrument measuring legal competencies essential for the golf directors is identified as the legal competencies of golf directors (lcgd). the six-factor golf legal competencies include (1) business procedures; (2) facilities/equipment management; (3) personnel/customer relations; (4) emergency planning; (5) risk management; and (6) legal compliance. a four-point scale likert-type was chosen because by omitting a neutral answer respondents are required to indicate some level of importance. according to statpac (2005), a physical placement of a “neutral” category (at the midpoint of the scale) makes a difference in conclusions that can be drawn from the data. thus, respondents rated the importance of legal competency statements using a four-point likert scale: 1. unimportant, 2. of little important, 3. important, and 4. critically important. procedures respondents voluntarily self-selected by responding to the electronic survey. the tailored design method (dillman, smyth, & christian, 2009) for internet survey was implemented for purposes of data collection. it is modified from dillman’s total design method which includes four mailings in eight weeks. thus, the initial email invitation to participate was sent, and followed by three email reminders. during the electronic mailing processes, 423 out of 1,223 questionnaires were returned for a response rate of 35%. after data screening, cleaning, and omitting outliers, 390 were deemed suitable for data analysis. factor analyses in order to identify integral constructs underlying the items on the lcgd, this study chose to employee exploratory factor analysis (efa) rather than confirmatory factor analysis (cfa). as empirical research presented evidence, cfa may be a less desirable technique for determining the number of factors measured by a data set because specification searches in correlation matrices often do not uncover the correct population model (maccallum, roznowski, &nowrwitz, 1992). therefore, this study employed efa to determine the correct number of factors to retain and rotate (fabrigar, wegener, maccallum, &strahan, 1999). results sample characteristics the vast majority of respondents were male (94%), with only 23 female respondents. more than half of respondents (58%) were between 35 and 49 years old. one-fifth of the population was 35-39 years old (19.7%), almost one-third (31.6%) were over age 50; fewer than 2% of respondents were younger than 30 years old. of the mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 1; january-febuary 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 14 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe respondents, 57.8% had earned a bachelor’s degree, followed by those who completed some college (18%), and high school graduates (10.3%). golf directors in private golf courses comprised the largest sub-group within the sample at 47.8% with 187 responses, followed by those at semi-private golf courses at 29.9% and 127 responses. public golf facilities formed the smallest portion of the sample, representing 19.4% with 76 responses. the majority of the respondents (75.6%) indicated that they had been employed in the golf industry for over 13 years. one hundred seventy-nine (45%) respondents indicated that they had been working as directors in the golf industry for over 20 years. descriptive statistics for the legal competencies variables the legal competencies perceived as important for the effective performance of a golf director were (in order of importance): organizational policies and procedures, followed by risk management, personnel/customer relations, facility/equipment management, emergency planning, and legal compliance (table 1). approximately 30% of the golf directors indicated that knowledge in organizational policies and procedures was extremely important for the golf course operation. though the legal compliance scale received the lowest mean score (m=2.58) with a range of 2.47 to 2.73 on the 4point scale, legal complianceitems are important legal competencies for golf operation. table 1 presents means, standard deviations, and coefficient alphas for total scales in testing the dimensions of legal competencies. table 1: descriptive statistics for the legal competencies variables legal competencies number of items m sd coefficient alpha organizational policies and procedures 9 3.16 .67 .90 facility/equipment management 7 2.89 .74 .89 personnel/customer relations 7 3.02 .76 .88 risk management 6 3.10 .76 .87 emergency plan 4 2.83 .73 .82 legal compliance 4 2.58 .83 .79 exploration of dimensions of legal competencies for golf course directors a principal component analysis with a direct oblimin rotation scheme was performed to discover the pattern of the factor structure in the relationship to legal competency variables measured by the lcgd. to determine whether factor analysis was an appropriate measure and to estimate the number of factors for the data, the kaisermeyer-olkin measure of sampling and bartlett’s test of sphericity were examined using spss factor. the resulting values of both tests indicated that factor analysis was an appropriate measurement [kaiser-meyer-olkin measure of sampling adequacy, .94 and bartlett’s test of sphericity, c2=8353.93, p<.000]. based on these observations, it was expected that the factorability of the correlation matrices produced by each dataset would be adequate. the solution with six factors met the goals of interpretability. the six factors extracted explained 59.6% of the overall variance in the solution. table 2 shows the factors and their contributions to explaining variance. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 1; january-febuary 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 15 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe table 2: factor analysis of legal competencies for golf directors legal competency items factor loading ft 1 ft 2 ft 3 ft 4 ft 5 ft 6 implement planning strategies for programs (e.g., group lessons, tournaments, special events, etc.) .74 .11 .19 .18 .08 .09 utilize effective problem-solving skills related to accidents or emergencies .72 .11 .12 .13 .25 .07 prepare organizational guidelines for staffing and programming .72 .22 .20 .18 .20 .24 establish standard of performance for program operation .68 .09 .09 .16 .25 .21 prepare and review incident/accident reports .67 .17 .23 .14 -.03 .26 evaluate staff for career development .65 .16 .30 .10 .07 .09 conduct meetings with legal professionals for updating legal issues .65 .18 .15 .06 .15 .07 train, recruit, interview, and hire fulltime/parttime staff .62 .13 .24 .11 .06 .10 utilize effective procedures to handle reports, registrations, notices, etc. .52 .24 .19 .30 .06 .16 develop planning schedules for facility maintenance .09 .74 .12 .06 .16 .21 implement system for inventory of equipment and supplies .12 .74 .16 .12 .21 .01 design strategies/policies to prevent misuse of facilities and equipment .14 .72 .21 .11 .25 .16 conduct routine inspections of facilities and equipment .23 .71 .07 .18 .07 .08 provide legal input for facility maintenance and development .22 .69 .15 .08 .23 .13 develop appropriate means of storing equipment and supplies .15 .68 .16 .15 .16 .04 administer an equipment lease and purchase system and a facility reservation system .11 .59 .13 .17 .03 .29 handle disciplinary action, accidents, protests, and eligibility status reports .21 .09 .72 .19 .05 .13 use sound procedures for settling protests .26 .12 .72 .14 .27 .09 prepare written documentation of protests .22 .17 .70 .18 .31 .03 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 1; january-febuary 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 16 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe establish eligibility guidelines for customers, members, and/or golfers .32 .13 .65 .19 -.02 .21 develop personnel/customer related policy .13 .32 .62 .03 .02 .17 establish procedures reflecting fair treatment of both staff and customers, members, and/or golfers .26 .14 .61 .08 .24 .14 utilize procedures to regulate the conduct of customers, members, and/or golfers implement sound procedures for scheduling, .35 .19 .53 .21 .10 .16 postponements, rescheduling, and forfeiture of golf games, special events, and tournaments .26 .20 .17 .74 .15 .13 demonstrate a legal knowledge of the organizational and operational aspects of different types of golf programming (e.g. special events, tournaments, group lessons, etc.) .27 .16 .04 .74 .15 -.05 organize legal clinics for staff and/or marshals .07 .14 .17 .65 .04 .25 implement appropriate system of procurement and evaluation of staff and/or marshals .14 .16 .17 .61 .16 .32 adapt programs to the special needs of persons with disabilities .14 .09 .18 .60 .20 .29 supervise customers, members, employees, and/or organizations .28 .20 .14 .44 -.06 .29 exercise effective decision making in dealing with accidents coordinate training for staff on legal and safety .23 .27 .18 .13 .76 .11 issues (e.g., first aid training, cpr training, ada, osha, etc.) .19 .32 .13 .16 .65 .27 establish a safety program to prevent injuries and accidents .23 .38 .22 .11 .64 .21 demonstrate an understanding of inherent risks of golf .24 .24 .22 .18 .63 .21 implement legal framework for fiscal management .11 .26 .05 .19 .09 .66 write and process contractual agreements for both staff and customers, members, and/or .05 .25 .21 .17 .23 .64 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 1; january-febuary 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 17 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe golfers demonstrate an understanding of both basic business and sport laws and other important legal matters .20 .19 .37 .08 .20 .58 understand and implement appropriate legislation that applies to golf .15 .08 .21 .18 .39 .57 rotation sums of squared loadings 5.2 4.7 4.4 3.3 2.9 2.8 total % of variance 13.4 12.1 11.2 8.4 7.3 7.1 cumulative % 13.4 25.5 36.7 45.2 52.5 59.6 in factor 1, a total of nine items had loadings of greater than .40 and accounted for 13.38% of the total variance. the item with the largest loading at .74 was “implement planning strategies for programs (e.g., tournaments, special events, group lessons, etc.).” the lowest loading at .52 was “utilize effective office procedures to handle reports, registrations, notices, etc.” all items loading on this factor were concerned with “organizational policies and procedures.” the seven variables that loaded on factor 2 had a loading ranging from .74 to .59. variables “develop planning schedules for facility maintenance” and “administer an equipment lease and purchase system and a facility reservation system” had the highest and lowest loading respectively. factor 2 was named “facilities and equipment management” and explained 12.11% of the total variance. for factor 3, seven variables had loadings ranging from .72 to .53. the highest factor loading was “handling disciplinary action, accidents, protests, and eligibility status reports” and the lowest factor loading was “utilize procedures to regulate the conduct of customers, members, and employees.” most items loading on this factor were concerned with tasks related to “personnel/customer relations.” this factor explained 11.23% of the variance in the total variance. factor 4 was named “risk management” and consisted of six items ranging from .74 to .44. the variable with the highest loading was “implement sound procedures for scheduling, postponements, rescheduling, and forfeiture of golf games, special events, and tournaments” and the one with the lowest loading was “supervise golfers, customers, and/or members.” these six variables together accounted for 8.44% of the total variance. four items with a factor loading ranging from .76 to .63, loaded on factor 5. items “exercise effective decision making in dealing with accidents” and “demonstrate an understanding of specific inherent risks of golf” had the highest and lowest loading respectively. all items appeared to be concerned with emergency procedures; thus, this factor was named “emergency planning.” together, these four variables explained 7.31% of the total variance. finally, factor 6 consisted of four variables that had a factor loading ranging from .66 to .57. the highest loading was “implement legal framework for fiscal management,” and the lowest loading was “understand and implement mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 1; january-febuary 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 18 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe appropriate legislation that applies to golf.” most items loading on this factor were concerned with legal compliance. it was thus named “legal compliance.” this factor accounted for 7.12% of the total variance. overall, 37 of 39 items on the legal competencies loaded on six factors at a factor loading of .40 or higher. it appears that golf directors who are employed at different environments shared perceptions of important legal competenciesfor effective golf operation. two items were not interpreted because of the weak relationship between item and factor (e.g., factor loading lower than .40 and double-loading). these two items were “utilize effective office procedures to handle registrations, reports, and notices, etc.” and “supervise governing or appeal board.” even though these items were not included in classifying factors in the present study, these items may be important legal competencies for golf directors because both documentation of any incidents/accidents and supervisory issues is prevalent disputes in recreational sport. discussion the findings of this study represented the necessary knowledge in legal competencies and a profile of essential legal competencies for golf directors in the united states. these findings underlined an understanding of the foundational areas important to the legal aspects in golf. the result of factor analysis on legal competencies of golf directors indicated the presence of a 6-factor model, which consisted of 37 observed competencies. the six factors were labeled: (1) organizational policies and procedures, (2) facilities/equipment management, (3) personnel/customer relations, (4) risk management, (5) emergency planning, and (6) legal compliance. the results of this study suggest that the lcgd is an internally consistent, reliable, and valid measure of major areas of legal competencies in golf. further, all items in the legal competencies instrument were content validated and considered to be necessary and important by expert juries. therefore, the legal competencies instrument seems appropriate for the verification of the golf legal competencies. because no previous researchers, to this investigator’s knowledge, have reported legal competencies in the golf context, the legal competencies instrument in this study could be useful for researchers interested in exploring legal competencies in different golf environments. the findings of this study also provide golf directors with important information regarding adequate knowledge of legal competencies. for instance, organizational policies and procedures in legal competencies are of very high importance for golf directors. this clearly indicates that golf directors must develop organizational policies and procedures for communicating with their staff to maintain a standard of care mandated by the courts and expected by their customers. when negligence litigation occurs, a standard of care is applied to determine the competence of a professional. one way to measure the standard of care is derived from standards of practice developed by professional organizations. liability associated with negligence can be minimized when staff members at golf facilities adhere to standards of practice. therefore, golf directors need to develop sound organizational policies and procedures in accordance with the standards of the pga and the united states golf association (usga). further, golf directors may comply with standards from recreational sport associations such as the ethical creed mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 1; january-febuary 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 19 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe from the north american society for sport management (nassm), and the code of ethics and interpretive guidelines from the national recreation and park association (nrpa). in terms of facilities/equipment management, golf directors indicated the following as important competencies in effective golf operations: developing policies for periodically inspecting equipment and golf areas (e.g., driving range, practice green, golf course); providing facility development; administering equipment lease; and providing personnel to supervise golf areas to assist in accident or injury situations. because most legal litigations regarding personal injuries and negligence are involved with equipment and facilities, it is essential for golf course directors to have sufficient knowledge in facilities/equipment management. consistent with the findings from many publications (jamieson, 1980; jennings, 1984; lee, et al., 2010; skipper, 1990; toh, 1997; young et al., 2007), golf directors in the present study considered managing facilities and equipment as an important competency because they are in charge of golf tournaments, facilities, lessons, and course operations. a possible explanation for the importance assigned by golf directors to personnel/customer relations may be caused by their more frequent interactions with members, customers, and the public than directors in different settings (e.g., campus recreation, private athletic clubs, ymca, parks and recreation agencies, etc.) have. golf directors require more of an emphasis on a fundamental knowledge of personnel/customer relations as an important legal aspect of their job. golf directors in contrast may deal with, but are not limited to, members, staff, and the public in situations such as handling disciplinary action, settling protests, developing policy, and regulating the conduct of members, customers, and employees. because golf directors deal primarily with regulations by club or association members, respondents ranked personnel/customer relations an important legal competency. the personnel/customer relations role was considered to be an important management competency identified byjamieson (1980) and jennings (1984). for golf directors, the personnel/customer relations role could include initiating interaction with other agencies, clubs, and golf courses. in terms of emergency planning, golf directors regarded this as important legal competencies related to members, golfers, and the public in emergency situations such as implementing sound procedures for scheduling, postponements, rescheduling, and forfeiture of golf games, special events, and tournaments. because golf directors considered emergency procedures as governed by state statutes, governmental agencies, and professional associations (schoepferbochicchio, 2013), this is an important legal competency in golf operation. professionals in recreational sport programs supported this finding in lee and his colleagues’ study (2010). they perceived that emergency planning was an important part in a sound risk management plan. the risk management literature in the recreational sport context supported the findings of this study that risk management is an important legal competency for golf course directors. young and her associates (2007) claimed that risk management was the most important legal knowledge needed for recreational sport professionals. sound risk management policies and procedures must be developed in order to reduce participant injuries, negligence, and legal lawsuits (cooper, 1997; lee, et al., 2010; fields &young, 2010). as part of the best practice management system within golf and recreational sport contexts, the risk management process should be mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 1; january-febuary 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 20 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe implemented. it is important for golf directors to have an ability to develop, implement, and manage risk management plans for their effective golf operation. in this study, the importance of legal compliance was consistent with the findings of jamieson (1980). recreational sport administrators in municipal, military, and institutional settings considered legal compliance in order to prevent accident and lawsuits as important golf management competencies. similar results were found in studies from jennings(1984), fields and young (2010), and young (2001). golf directors as well as recreational sports managers need a fundamental understanding of legal concepts related to the individual manager’s segment of the golf, recreation, or leisure industry. they should learn types of risks and risk prevention strategies as much as possible and constantly care for the safety of those in and around their facilities/golf courses. as many researchers stressed, a comprehensive risk management plan is of utmost importance and best practice for golf course directors. further, a sound risk management plan is vital to not only reduce participant injuries, negligence, and legal lawsuits, but to achieve organizational synergy and success. conclusion the findings of this study revealed the essential legal competencies for golf directors. according to this study, the development of legal competencies helps to improve a golf course director’s management competencies. these findings underline the six-factor legal competencies that comprise the fundamental legal knowledge for the golf management field. the six-factor golf legal competencies can be used as a guideline when a director operates a golf facility. the current directors can implement the legal competencies model to discover the potential areas in which they need to improve and/or manage their golf sites effectively. the model can also be used as a guideline for directors when recruiting junior golf professionals to ensure the assistant golf professional possesses the minimum standards of legal competencies in golf. although it is unknown for the purpose of this study how the professional golf management curriculum from the pga is developed, the importance of the theoretical and foundational contexts for legal competencies cannot be undervalued. even though statistical results indicated that the perceived importance of legal competencies for golf directors is a six-factor model, it does not mean that it is the only model. when developing the model, two issues are raised: (1) whether the model is consistent with the data, or (2) whether the model is consistent with the real world (toh, 1997). it is unknown whether the six-factor model is replicable in time or with directors in different golf environments such as different golf courses and/or different regions. hence, it is necessary to test the model again using different samples to further examine whether it has a reasonable correspondence to reality. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 1; january-febuary 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 21 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe references choi, h. s. (2010, june). legal risks of golf course directors. paper presented at the proceedings of the north american society of sport management (nassm) 2010 conference, tampa, fl. cooper, n. (1997). will the defendant please rise: how effective is your risk management plan? nirsa journal, 21(2), 34-41. cotton, d. j., &wolohan, j. t. (2013). law for recreation and sport managers (6thed). dubuque, ia: kendall hunt. council on hotel, restaurant, and institutional education (2013). accreditation commissions. http://www.chrie.org/about/accreditation/accreditation-commissions/index.aspx dillman, d., smyth, j., & christian, l. (2009). internet, mail, and mixed-mode surveys: the tailored design method. new york, ny: wiley. fabrigar, l. r., wegener, d. t., maccallum, r. c., &strahan, e. j. (1999). evaluating the use of exploratory factor analysis in psychological research. psychological methods, 4, 272299. fields, s. k.,& young, s. j. (2010). learning from the past: an analysis of case law impacting campus recreational sport programs. journal of legal aspects of sport, 20(1), 73-94. jamieson, l. m. (1980). a competency analysis of recreational sports personnel in selected institutional settings (unpublished doctoral dissertation). indiana university, bloomington, in. jennings, m. w. (1984). entry level competencies for recreational sports personnel as identified by chairs of preparatory institutions (unpublished doctoral dissertation). indiana university, bloomington, in. kampf, s., haines, s., schneider, r., stier, w., & gaskins, b. (2011). current legal practice in collegiate club sport programs. sport risk: solutions in recreation risk management. retrieved from http://sportrisk.com/2011/05/current-legal-practices-in-collegiateclub-sport-programs/ lee, s., farley, l. a., & kwon, o. (2010). the effectiveness of risk management plans in recreational sport programs of division i-a universities. recreational sports journal, 34(1), 58-68. maccallum, r. c., roznowski, m., &nowrwitz, l. b. (1992). model modifications in covariance structure analysis. the problem of capitalizations on chance. psychological bulletin, 111, 490-504. mulrooney, a. l., & green, e. (1997). risk management has its price. nirsa journal, 21(2), 42-45. mailto:topacademicjournals@gmail.com http://www.chrie.org/about/accreditation/accreditation-commissions/index.aspx http://sportrisk.com/2011/05/current-legal-practices-in-collegiate-club-sport-programs/ http://sportrisk.com/2011/05/current-legal-practices-in-collegiate-club-sport-programs/ american journal of medical and physical education vol.8, issue 1; january-febuary 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 22 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe mulrooney, a. l., & styles, a. e. (2005). directors of public and private state-of-the-art multimillion dollar recreational facilities lead the way in risk management practices. recreational sports journal, 29(2), 92107. national intramural-recreational sports association (2014). core competencies underpin nirsa’s professional development opportunities. retrieved from http://www.nirsa.org/wcm/grow/registry/core_competencies/wcm/_grow/re gistry/core_competencies.aspx?hkey=400eb9eb-0e09-4171-9615-841aabf2983a national recreation and park association (2014). overview of the coaprt accreditation process. retrieved from http://www.nrpa.org/professional-development/accreditation/coaprt/overviewof-thecoaprt-accreditation-process/ national sporting goods association (2012). purchases of golf equipment in the us since 2007. retrieved from http://www.statista.com/statistics/201038 petersen, j., & pierce, d. (2009). professional sport league assessment of sport management curriculum. sport management education journal, 3(1), 110-124 professional golfers’ association (2009). pgm program at a glance. retrieved from http://pdf.pgalinks.com/regmemos/pgm_ataglance.pdf professional golfers’ association (2014). pga of america member classification. retrieved from http://www.pga.com/pga-america/member-classifications rapp, g. c. (2012). field of broken dreams: the quest for rule-of-law in sports litigation. texas review of entertainment & sports law, 13, 102. schoepferbochicchio, k. (2013). emergency care. in d. j. cotton & j. t. wolohan (6thed), law for recreation and sport managers (pp. 151-165). dubuque, ia: kendall hunt. skipper, w. t. (1990). competencies for collegiate sports facility managers: implication for a facility management curricular model (unpublished doctoral dissertation). university of arkansas, fayetteville, ar. statista (2014). size of the core u.s. golf economy by industry segment in 2000, 2005, and 2011. retrieved from http://www.statista.com/statistics/273849/size-of-the-core-us-golfindustry/ statpac (2005). the “don’t know,” “undecided,” and “neutral” response options. retrieved from http://www.statpac.com/surveys/undecidedcategory.htm mailto:topacademicjournals@gmail.com http://www.nirsa.org/wcm/grow/registry/core_competencies/wcm/_grow/registry/core_competencies.aspx?hkey=400eb9eb-0e09-4171-9615-841aabf2983a http://www.nirsa.org/wcm/grow/registry/core_competencies/wcm/_grow/registry/core_competencies.aspx?hkey=400eb9eb-0e09-4171-9615-841aabf2983a http://www.nirsa.org/wcm/grow/registry/core_competencies/wcm/_grow/registry/core_competencies.aspx?hkey=400eb9eb-0e09-4171-9615-841aabf2983a http://www.nrpa.org/professional-development/accreditation/coaprt/overview-of-the-coaprt-accreditation-process/ http://www.nrpa.org/professional-development/accreditation/coaprt/overview-of-the-coaprt-accreditation-process/ http://www.nrpa.org/professional-development/accreditation/coaprt/overview-of-the-coaprt-accreditation-process/ http://www.statista.com/statistics/201038 http://pdf.pgalinks.com/regmemos/pgm_ataglance.pdf http://www.pga.com/pga-america/member-classifications http://www.statista.com/statistics/273849/size-of-the-core-us-golf-industry/ http://www.statista.com/statistics/273849/size-of-the-core-us-golf-industry/ http://www.statpac.com/surveys/undecidedcategory.htm american journal of medical and physical education vol.8, issue 1; january-febuary 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 23 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe stier, w. f., & schneider, r. c. (2000). sport management curricular standards 2000 studyundergraduate level. international journal of sport management, 1(1), 56-69. stier, w., schneider, r., kampf, s., haines, s., & gaskins, b. (2008). selected risk management policies, practices, and procedures for intramural activities at nirsa institutions. recreation sports journal, 32(1), 28-44. the association to advance college schools of business (2013). 2013 business accreditation standards. retrieved from http://www.aacsb.edu/accreditation/business/standards/2013/learningandteaching/standard9.asp the commission on sport management accreditation (n.d.). guidelines for accreditation site visits: for site team evaluators and institutions. retrieved from http://www.cosmaweb.org/accreditation-manuals.html toh, k. l. (1997). constructing and validating competencies of sport managers (cosm) instrument: a model development (unpublished doctoral dissertation). indiana university, bloomington, in. u.s. courts (n.d.). caseload statistics 2013. retrieved from http://www.uscourts.gov/statistics/federaljudicialcaseloadstatistics/caseloadstatistics-2013.aspx u.s. consumer product safety commission (n.d.). national electronic injury surveillance system (neiss) data highlights—2012. retrieved from http://www.cpsc.gov//global/neiss_prod/2012neissdatahighlights.pdf young, s. j. (2001). the importance of legal aspects for new professionals in recreational sports: a perspective of practicing professionals. larnet, the cyber journal of applied leisure and recreation research, retrieved from http://larnet.org/2001-2.htm young, s. j., fields, s. k., & powell, g. m. (2007). risk perceptions versus legal realities incampus recreational sport programs. recreational sports journal, 31(2), 131-145. mailto:topacademicjournals@gmail.com http://www.aacsb.edu/accreditation/business/standards/2013/learning-and-teaching/standard9.asp http://www.aacsb.edu/accreditation/business/standards/2013/learning-and-teaching/standard9.asp http://www.aacsb.edu/accreditation/business/standards/2013/learning-and-teaching/standard9.asp http://www.cosmaweb.org/accreditation-manuals.html http://www.uscourts.gov/statistics/federaljudicialcaseloadstatistics/caseload-statistics-2013.aspx http://www.uscourts.gov/statistics/federaljudicialcaseloadstatistics/caseload-statistics-2013.aspx http://www.cpsc.gov/global/neiss_prod/2012neissdatahighlights.pdf http://larnet.org/2001-2.htm american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 1 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe the impact of injuries on student-athletes' health and performance 1ezzeldin mohamed aly, gari latoya tookes, 3sherin ahmed elmahdy 1king faisal specialist hospital and research centre 3dublin, ohio, united states abstract sports injuries are a common occurrence in collegiate athletics, and can have a significant impact on athletes' health and performance. this paper reviews the common causes of sports injuries in college athletes, and discusses strategies for prevention. the paper also highlights the importance of comprehensive sports safety promotion programs that involve all stakeholders, including athletes, coaches, trainers, and facility managers. keywords: sports injuries, college athletes, prevention, safety promotion, rehabilitation, structural measures, educational measures introduction in collegiate sports today, many athletes every year acquire an injury during participation in athletics. injuries can occur and reoccur in athletes for multiple reasons such as the use of improper equipment, not putting in full effort in performance drills, improper stretching before engaging in athletic competition or practice, and not participating in necessary treatment to prevent the injury from reoccurring. sports injuries are the result of severe trauma or repetitive stress when participating in athletic activities and can have an impact on bones or soft tissue such as ligaments, tendons, or muscles. the majority of sports injuries are minor involving soft tissue trauma such as a bruise or sprain. although most injuries are minor, some that occur can be very severe such as broken bones or torn ligaments or muscles. these injuries may require analysis from an orthopedic surgeon and can result in a need for surgery or extensive rehabilitation. according to timpka, ekstrand, andsvanström (2006), every fifth unintentional injury that was treated at a healthcare facility were associated with sports and physical exercise. to have a successful knowledge of injury prevention, one must understand the interventions in terms of structural or educational measures, and sports safety promotion must be enforced. comprehensive sports safety promotion programs require that the perspective on the sports injury problem is made broader than the consideration of the individual athlete. those responsible for the upkeep of sports facilities also should be included and aware of the promotion of sports safety due to them having control over the sporting environment (timpka et al., 2006). mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 2 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 1.1 purpose of the study the purpose of this study was to investigate and determine the common reasons softball, volleyball, basketball, baseball,and football athletes at florida a&m university have injuries, why they may reoccur, and what recovery methods (conditioning, warm-up, and flexibility)persist used while injured. the study investigated three injury sites: ankle, knee, and shoulder. before conducting this current study, a hypothesizedwas made that the most common injury site for these athletes occurs in the ankle. the study also sought to investigate the cause of the injuries in the shoulder, knee,and ankle. if we know the cause, we can find alternative ways to perform exercises and practices or tasks within a game. 1.2 need for the study the need for this study was to find ways to prevent the injuries from reoccurring and to discover methods inadequately treating these injuries. the most common injuries focused on during the research were shoulder, ankle, and knee injuries. the research explored the description of the injury, how flexible the injury site was, how much conditioning was done at the time of the injury, how well the participant recovered, what safety equipment was utilized in the sport, and the cause of the injury will be analyzed. 1.3 basic assumptions in softball, volleyball, basketball, baseball, and football sports the ankle is an important ligament that undergoes much physical activity daily for these athletes. based on the survey that florida a&m university studentathletes completed, this study identified the most common injury occurred in the ankle, in comparison to the shoulder and knee. it is assumed all participants answered each question honestly. 1.4 limitations of the study the limitations in this research were finding previous research literature that relates to specific injuries in softball, volleyball, baseball, basketball, and football athletes. also, the athletes surveyedhad many responsibilities outside of their sport activities such as academics, and it might have been difficult for them to remember all reasons related to injuries. also, the research was basedon the subject’s point of view. if they had anything that factored into the injury that was not a part of the survey, it could bea limitation to the results. 2. review of literature an injury is identified as a bodily harm an athlete has sustained in a sports-related activity that has caused absence from a practice session or competition (timpka et al., 2006). sports injuries are continually happening in collegiate sports today and are an obstacle that most athletes have to face, which can have an occupational, economic, physical, psychological, and educational impact on athletes (almeida, olmedilla, rubio & palou, 2014). according to the national institute of health in the u.s., the most common sport injuries are due to accidents, inadequate training practices, or using the wrong gear or equipment (paddock, 2012). the number of sport injuries is increasing today due to the increase in professionalization, competitiveness, and extension in practice (almeida et al., 2014). a sports injury involves the dysfunction of an organism which produces pain and limitations or interruption of participation in sport activity (almeida et al., 2014). the most common sports injuries contain knee injuries, sprains and strains, swollen muscles, achilles tendon injuries, and fractures (paddock, 2012). mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 3 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe according to meeuwisse (1994), there are two different categories of athletic injuries: acute injuries and overuse injuries. these two types of injuries differ in their etiology. acute injuries are those associated with a macro traumatic event such as fractures and ligament sprains. these provokingoccurrenceswerecharacteristically identified by the application of an exterior force with a subsequent tissue disruption. in overuse injuries, the results are due to repetitive microtraumas such as stress fractures and tendinitis. the provoking event in overuse injuries is less apparent,and the resultant tissue damage is due to overstress rather than acute disruption. overuse injuries have a more significant contribution from intrinsic risk factors. in running-related injuries, the age and biomechanical alignment of individuals may predispose them to injuries. extrinsic risk factors may include the use of worn shoes in the running on rough terrain, making the athlete susceptible to an injury (meeuwisse, 1994). furthermore, meeuwisse (1994) asserts having an understanding of the cause of an injury is essential to advancing knowledge, particularly regarding prediction and prevention in sports injuries. many research avenues have attempted to clarify the cause of athletic injuries, but little attention has been provided to which cause may asses casual relationships. the majority of the studies that have examined risk factors in athletic injury have yet to approach the issue of etiology. when data on multiple factors have been available, a univariate which is a single risk factor, an approach to assessing causation has typically been employed. due to athletic injuries being similar to most diseases in the sense of being multifactorial in etiology, examining each risk factor separately without controlling other risk factors would not yield an accurate picture on how it contributes to the injury. although using a univariate has given an inside look at some of the risk factors, it has also limited the progress of determining which factors are casual (meeuwisse, 1994). starting in 1982, the national collegiate athletic association (ncaa) began conducting standardized injury, and exposure data for collegiate sports completed its injury surveillance system (iss) (hootman, dick, &agel, 2007). in this review, 182,000 injuries, and more than 1 million exposure records captured over 16 years were used. game and practice injuries were also included that required medical attention and resulted in at least one day of time loss. the iss consisted of injury and exposure data from 16 sports activities such s men’s fall and spring football, women’s softball, women’s volleyball, men’s soccer, men’s wrestling (hootman et al., 2007). in the report, an overview of the 16 individual sports teams included a general injury trend in college athletics (hootman et al., 2007). injury rates that were highlighted included three specific conditions for all sports: ankle ligament sprains, anterior cruciate ligament (acl) injuries, and concussions. a reportable sports’ injury in the iss had to meet all of the following criteria: the injury happened as a consequence of participation in an organized intercollegiate practice or contest, the injury required medical attention by a certified athletic trainer or physician, and the injury resulted in restriction of the student athlete’s participation or performance in 1 practice or game (hootman et al., 2007). injury trends over the 16 years have been influenced by many factors such as increased athletic participation, changes in ncaa rule, and the continued evolution of sports medicine. the participation in ncaa collegiate sports has increased among both sexes, with an 80% increase in females and a 20 percent increase in males (hootman et al., 2007). according to hootman, dick, and agel, (2007), medical coverage for collegiate athletics has improved particularly with the creation of the national athletic training association in 2000. the number of certified trainers working in the collegiate setting has increased 86 percent over the last ten years. an increase in mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 4 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe the number of certified trainers allows better medical support for collegiate teams and for athletes to receive the best treatment after an injury has occurred. the field of sports medicine has innovative over the years with regard toevidence-based interventions. these interventions have included bracing, physical conditioning programs, and medical awareness and diagnosis (hootman et al., 2007). furthermore, hootman, dick, andagel, (2007) assert the higher intensity of game activity is vitalto the more significant injury rates in games compared to practices. many reasons are evident in why injury rates are higher during the preseason than during other parts of the sports season. for example, some athletes may arrive to preseason poorly conditioned and as a result, the stress of the high-intensity preseason training may resultmore thaninjuries. on the other hand, preseason practice typically lasts longer than an in-season or postseason practice. due to the iss exposure not having a time component, an individual is at a higher risk of injury in a longer practice because of the extended exposure to athletic activity (hootman et al., 2007). in preseason practice, student-athletes usually have more than one practice a day. this may limit the recovery of muscles for subsequent activities and pose a higher risk for injury on players. preseason practice may also have more less-skilled or walk-on athletes trying out for a sport in which these athletes may be more susceptible to injury. preseason is also a time in which players are competing for a starting position, thus creating a highly competitive atmosphere mightescalation injury rates. these seasonal factors may be modifiable; therefore, the potential for developing injury prevention to address the high rates of preseason injuries is great. the preseason competition injury rates were lower than in-season or postseason competition rates (hootman et al., 2007). many injury prevention strategies should be implemented to reduce preseason injury rates. these strategies may include phased-in, multipleday practices, modifying practice times to accommodate environmental conditions, mandating appropriate recovery times, and preparation of medical examinations (hootman et al., 2007). the traditional model for injury prevention involves four stages including establishing the extent of the sports injury problem, establishing the etiology and mechanisms of injuries, introducing the preventive measures, and assessing the effectiveness of the preventive interventions by repeating the first step (timpka et al., 2006). furthermore, according to hootman, dick, and agel (2007), player contact is an essential factor in many sports. for practices and games, player contact accounted for the majority of injuries, with 58 percent in games and 41.6 percent in practices. in practice, non-contact injury mechanisms account for 36.8 percent of all injuries, compared to only 17.7 percent in games. although player contact is a normal part of some sports, the percentages of player contact injuries might be slightlycomparableamong practices and games. the overall practice injury rate in these contact-sports might be significantly lower than the game. in football, the no-spearing and no-clipping rules were instituted to reduce contact-related injury rates, specifically head and neck injuries and knee injuries. protective equipment has been put in to help reduce injury rates such as face guards in men’s hockey and protective devices for injured body parts. athletic trainers play a critical leading role in creating innovative protection for sensitive body parts that allow players to participate with a reduced risk of injury from a direct blow (hootman et al., 2007). sports medicine specialist has begun to use the slogan “prehab to avoid rehab.” prehab which is short for prehabilitation is a new idea in the field of sports medicine and therapy that is a personalized exercise program mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 5 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe that is individually designed for athletes to help them prevent injury in their given sport (paddock, 2012). also, paddock (2012) asserts that prehab is also used to refer to improving an athlete’s fitness before undergoing surgery to have a faster recovery and the ability to withstand the inactivity after the procedure. the purpose of rehab is to avoid injury by compensating for the repetitive movements and stresses of regular training every day. naturally, during a physical activity session, the repetitive use of muscles makes them tight with the body developing imbalances in strength and muscle coordination (paddock, 2012). with the incorporation of a prehab routine in a daily workout, it allows the body to adjust to the repetitive motions of muscles that will later have a positive effect and result in fewer injuries in athletes. a successful prehab program forms a regular part of an athlete's training routine (paddock, 2012). football is a common sport played by many people at different levels, starting as early as age 5 (levine & owens, 2016). injuries in football are beginning to start at an early age now due to the high competitiveness and deep physical contact in the sport. in 2007, over 920,000 athletes under the age of 18 were treated in emergency rooms, doctors’ offices, and clinics due to football-related injuries (levine & owens, 2016). injuries are occurring during practices and games in football due to the high speeds and full contact involved in the sport (levine & owens, 2016). overuse injuries occur in football, but most injuries sustained are traumatic injuries (levine & owens, 2016). traumatic injuries can include concussions, fractures, sprains,and strains and usually happen after the physical contact has taken place in a sporting event. knee injuries in football are the most mutual,particularly when directed toward the anterior and posterior cruciate ligament (acl and pcl) and the menisci. knee injuries can have an adverse affect an athlete's long term career in the sport of football (levine & owens, 2016). football players also have a great chance of acquiring ankle injuries due to the various surfaces played on and the quick cutting motions used in techniques (levine & owens, 2016). shoulder injuries are prevalent for football athletes with the labrum being most susceptible to injury (levine & owens, 2016). the labrum is the cartilage bumper surrounding the socket part of the shoulder. these injuries are typically occurring in athletes who are offensive or defensive linemen (levine & owens, 2016). football injuries can be prevented in many ways. having a pre-season health and wellness evaluation is a great way to reduce injuries. this educates athletes on injuries and parts of their body that needs rehabilitation to prevent injuries from occurring in the season. performing warm-up and cool-down routines are essential in programming the body in preparing for a workout and for a cool down after the workout to begin the recovery mode of the muscles. hydration is a crucial factor when participating in athletic competitions or practices. hydrating the body adequately maintains a healthy workout and helps to minimize cramping in the body (levine & owens, 2016). wearing properly fitted protective equipment such as a helmet, pads, mouth guards, and braces will help in the reduction of injuries sustained in physical activity. over 16 years, data collection using the ncaa injury surveillance system was collected to take a closer look at softball injuries at the collegiate level. in the data analysis, the rate of injury was 1.6 times higher in games than in practices (shaginaw, 2014). the preseason injury rates were more than double the regular season injury rates, and the postseason injury rates were much lower than both the preseason and in-season injury rates (shaginaw, 2014). most of the injuries acquired were to the lower extremity of the body at 43% compared to the 33% of mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 6 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe injuries to the upper extremity of the body, and most of the injuries sustained were to the ankle and knee (shaginaw, 2014). upper extremity injuries are more common in baseball rather than softball due to the underhand pitching motion used in softball, and this pitching technique places less stress on the shoulder and elbow (shaginaw, 2014). most upper extremity injuries that may occur in softball include traumatic injuries to the wrist and hand, such as fractures or dislocations (shaginaw, 2014). when examining shoulder injuries, it is not clear how to prevent them completely,but proper stretching and conditioning are vital to improving throwing and pitching biomechanics (reinberg, 2010). shaginaw (2014) asserts the most common softball injuries are ankle sprains and knee internal derangements which are classified under lower extremity. ankle and knee injuries combined account for 22% of all injuries acquired while participating in softball and typically took ten days or more of not participating in softball activities. devries (2015) asserts ankle injuries are tending to occur due to quick stops and starts of base running and sliding into a base. ways to prevent these injuries from occurring include educating and training softball athletes on the proper sliding techniques and how to judge when it is appropriate (devries, 2015). with the majority of ankle sprains being minor injuries, treatment can involve a short time off from playing on the injured site (shaginaw, 2014). rehabilitation consisting of regaining range of motion or flexibility, strength, and balance may be used if needed (shaginaw, 2014). knee injuries are the second most common injuries in softball. these injuries usually consist of meniscal tears and acl tears (shaginaw, 2014). when acquiring an acl injury, the athlete is required to consult with a surgical professional in which the result is usually the end of the season for the athlete (shaginaw, 2014). athletes are sometimes able to finish their season with mildly symptomatic meniscal tears,but consultation with an orthopedic surgeon is needed to determine (shaginaw, 2014). when playing a sport, precautions must be made to prevent injuries. in volleyball, players usually wear ankle braces to prevent ankle sprains. there are also pads on each pole in case a player collides with a pole. kneepads are worn to protect the skin on knees from breaking open. if there has been a previous injury, the player will wear an ace wrap or get the injury taped with athletic tape. the volleyball court is kept clean of hazards and free balls that could cause trips or falls (seaton, 1948).there are many ways an injury can occur. if two players collide with a large force, they can injure each other. if a player has incorrect form, such as hitting the ball or setting the ball, they can injure themselves. players could also be injured during conditioning, where they are pushing their bodies to do strenuous activities. no matter how the injury occurs, it should always be taken seriously and treated correctly.according to the national athletic trainers association (nata) (2010), the most volleyball injuries occur in the ankles. the nata performed a three-year study with 87 high school players. the study took place in 1995 by certified athletic trainers throughout the country and found that 50 percent of injuries were sprains. the setting position was found to be the position with the most injuries. nata also found that 80 percent of injuries occurred during practices. only less than two percent required surgery (national athletic trainers association, 2010). mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 7 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 3. methodology 3.1 research design this study focused on florida a&m university women’s softball, volleyball, and basketball teams; and men’s football, baseball, and basketball teams, ages 18-24. the study used a 16-item researcher-designed survey to investigate the causes of student-athletes injuries to their knee, ankle, and shoulder. each participant completed one survey per injury type experienced in their lifetime (ankle, knee, and shoulder). the survey required participants to identify demographic information: gender, sport, classification, major, and state of residence. then, the survey required responses to questions specific to their injury in the following categories: description of the injury, flexibility during injury, warm-up process while injured, conditioning process while injured, recovery period, safety equipment used to prevent injury, and the cause of the injury. each category required a likert scale response to either identify a rate on a scale of one to five; yes, or no; easy, moderate, or intense; or to select from a list of options. 3.2 selection of participants research participants were florida a&m university women’s softball, volleyball, and basketball team members; and men’s football, baseball,and basketball team members. they were 49student-athletes ranging between the ages of 18 to 24 years old, who were actively enrolled and eligible according to ncaa regulations and acted on their corresponding teams. 3.3 data collection procedures approval to conduct research was acquired through ph.d. review board (irb), a committee recognized to review andapprove research involving human subjects. participants were identified using the university’s athletic student roster. permission was sought from coaches to provide the questionnaire to team members. potential participants received the general recruitment letter, an informed consent, the questionnaire, debriefing statement, and a lettersized envelope. if the student-athlete decided to participate, the participant's hand-delivered their responses within 48 hours to the researcher after their lunch break in the sealed envelope provided, in efforts to maintain confidentiality. each participant was notified that information would be kept confidential according to the irb policies and procedures and that no self-identifying information would be needed or recorded. each student was informed of available services provided by the university in the debriefing statement in case assistance was needed due to an injury. 3.4 data analysis a quantitative analysis was used in this study. descriptive statistics were used to exam demographic data. the study used a one-way analysis of variance (anova), and basic computations. the one-way anova was used to determine a correlation between student athlete’s injuries, sport types, and recovery methods in college sports. the dependent variables were the student-athletes responses on the researcher-designed survey (conditioning time, warmup time, and flexibility), and the independent variables were the types of injuries experienced (ankle, knee, and shoulder).after the surveys were conducted, data wereexamined using the statistical package for the social sciences (spss) program to approach the research results. the study used an alpha level of .05 for the analysis. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 8 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 4. results the purposes of this study were to explore the relationship between student athlete’s injuries, sport types, and recovery methods in college sports. the data below in tables one through three suggests there is a significant difference between the type of sport and the extent of conditioning at the time of an ankle injury, but there is no evidence to support a correlation between the type of sport and the extent of conditioning for the knee or shoulder injuries. the data suggests on average athletes who experienced ankle injuries believed conditioning to be between easy and moderate (1.63). table 1.ankle conditioning for student-athletes after injury sum of squares df mean square f sig between groups 17.499 3 5.833 4.241 .010 within groups 61.889 45 1.375 total 79.388 48 table 2. knee condi tioning for st udent-athletes after injury sum of squares df mean square f sig between groups 2.821 3 .940 .671 .575 within groups 63.097 45 1.402 total 65.918 48 table 3. shoulder con ditioning for student-athletes after injury sum of squares df mean square f sig between groups .180 3 .060 .048 .986 within groups 56.514 45 1.256 total 56.694 48 the data below in tables four through six suggests there is no evidence to support a correlation between the type of sport and the length of time of warm-up time for shoulder, knee or ankle injuries. although there was no evidence of significance, the data suggests, on average, athletes who experienced any of the three injuries performed at least five to 10 minutes of warm-ups at the time of their injury. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 9 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe table 4. ankle warm-up time for student-athletes after injury sum of squares df mean square f sig between groups 6.750 3 2.250 1.506 .226 within groups 67.250 45 1.494 total 74.000 48 table 5. knee warmup time for student-athletes after injury sum of squares df mean square f sig between groups 9.082 3 3.027 1.884 .146 within groups 72.306 45 1.607 total 81.388 48 table 6. shoulder warmup time for student-athletes after injury sum of squares df mean square f sig between groups 1.392 3 .464 .219 .882 within groups 95.139 45 2.114 total 96.531 48 the data below in table seven through nine suggest there is a significant difference between the type of sport and the level of flexibility after a knee injury, but there is no evidence to suggest a correlation between the type of sport and the level of flexibility after shoulder or ankle injuries. the data suggests, on average, athletes who experienced knee injuries believed their flexibility to below (1.65) at the time of injury. on average, football participants who experienced knee injuries believed their flexibility to be midrange (2.9) at the time of injury, and volleyball participants who experienced knee injuries believed their flexibility to be low (.89) at the time of injury. table 7.ankle flexibility for student-athletes after injury sum of squares df mean square f sig between groups 15.947 3 5.316 2.378 .082 within groups 100.583 45 2.235 total 116.531 48 table 8.knee warm-up time for student-athletes after injury sum of squares df mean square f sig between groups 26.921 3 8.974 3.360 .027 within groups 120.181 45 2.671 total 147.102 48 table 9. shoulder warm-up time for student-athletes after injury sum of squares df mean square f sig between groups 5.273 3 1.758 .577 .633 within groups 136.972 45 3.044 total 142.245 48 5. conclusion although sports injuries can not be eliminated, many prevention methods can be implemented to help reduce and prevent injuries in athletes at the collegiate level (paddock, 2012). this research was conducted to learn the mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 10 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe common injuries for the student-athletes at florida a&m university and why these injuries may be occurring. through the literature reviewed, in both sports, the ankle is a cite in which injury occurs the most. ankle ligament sprains are a common injury area in all levels of college athletics (hootman et al., 2007). injuries in the lower extremity area accounted for more than half of all injuries in the sample report conducted justifying the particular emphasis on this region in athletic training education, clinical practice, and prevention efforts (hootman et al., 2007). many prevention measures have been researched to help this epidemic of injuries in these athletes. having basic knowledge of the specific injury and why it may be occurring can help determine what preventative methods should be taken to prevent injuries from re-occurring. when participating in softball, ankle injuries are tending to occur due to quick stops and starts of base running and sliding into a base (devries, 2015). ankle injuries account for about 10% of injuries in practices and games for female softball players (devries, 2015). as in most collegiate institutions, athletic trainers typically use the rest, ice, compression, and elevation (r.i.c.e) method in treating ankle sprains. during the resting stage, the athlete is recommended to rest the injured site by applying minimum to no activity on it in the first 24 to 48 hours after the injury to avoid any extra pain. in the first 48-hours post-injury, apply ice to the injured site for no more than 20 minutes at a time every four hours. the ice does not have to be an ice bag necessarily; it can be a frozen bag of vegetables that can be re-used. ice cups can also be used and rubbed on the injury in a circular motion until it melts. it is essentialnot to ice the injured site for more than 20 minutes at a time. extending the amount of time icing will not speed up the healing process; instead, it may cause tissue damage. compressing the injury involves using an ace bandage or wrap to snug the injury without cutting off the circulation and elevatingyour injured sites as high as possible by placing a pillow under the injury. after analyzing the data collected, the hypothesis of the ankle being the most common injury in softball and football athletes at florida a&m university was accurate. most of the injuries were mild or reasonable in relation to severity and only left athletes out from participation for a couple of weeks or less. only a few of the ankle injuries surveyed from athletes were severe in which the athletes were out from participation in their sport for two to four months. the leading cause of the injuries in the ankle, knee, and shoulder for the football team was due to a collision in the sport. the leading cause of injury in the ankle, shoulder, and knee for the softball team was due to overuse of the ligaments over a while. the study supported the hypothesized that there was a relationship between student athlete’s injuries, sport types, and recovery methods in ankle injuries. it showed that 50 percent of the softball athletes surveyed were given on ankle injuries, 30 percent of shoulder injuries, and 20 percent of knee injuries. the football athletes reported 50 percent having ankle injuries also, 40 percent shoulder injuries, and 10 percent knee injuries. the results also showed that the most common cause of injury was from the incorrect form when performing drills and in athletic competitions. the results were significant and showed that injuries in the ankle are common in softball and football. it also showed that the correct form is crucial to maintaining a healthy body. results from this study showed that having the correct form is crucial to maintaining an injury-free body. the form should be monitored at all times, including practices, games, or conditioning. the study from the national athletic training association (2010) found that 80 percent of all volleyball injuries occur at practice, which is mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 11 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe where players spend most of their time. this is also the time that is supervised the least. an article in the sports medicine journal stated that it is easy to land incorrectly on the feet after jumping and twisting during certain movements in volleyball (ferreti, 1990). teaching volleyball players the correct form of each movement is essential when training a team. overuse of the body is likely when the sport is competitive and demanding. it is essential to give the body rest in between conditioning sessions and practices. “jumper’s knee” is a common injury in volleyball, caused by overuse of the knee ligaments (ferreti, 1990). strengthening ligaments are also significant. overuse and weak ligaments were both the second-highest causes of injuries from this study. the conditioning sessions should contain exercises to strengthen the ligaments specifically. the third-highest causes of injury were from the collision and lack of strength. running into another player can be simple because the movements are very quick and in a small area. the athletes need to be aware of their surroundings at all times because of this. they also need to condition regularly, so their bodies are strong enough to support themselves. the study showed details of the athlete at the time of the injury. it showed how flexible, reliable, and advanced they were at the time of the injury. there was no apparent relationship found between the flexibility of the subject and the severity of the injury. there had also been no connection between the amount of conditioning done at the time and the severity of the injury. only 50 percent of the surveys showed that the athlete had a proper warm-up at the time. having a proper warm-up and cool-down helps the body prevent injuries by using a gradual transition. this study supported the hypothesis. it showed that the most common injury found in collegiate female volleyball players was the ankle. the national athletic training association (2010) also completed a study that showed the same results. shoulder and knee injuries were also common, but not as common as ankle injuries. this shows that ankle braces should be highly suggested to players to prevent ankle injuries. there are various types of braces and equipment offered to help prevent injuries (seaton, 1948). teams should take many precautions, as well as monitor the players to attempt keeping the team injury-free. references almeida, p. l., olmedilla, a., rubio, v. j., & palou, p. (2014, december). psychology in the realm of sport injury: what it is all about. retrieved november 10, 2016. devries, c. (2015, april 22). top 5 injuries for softball players. retrieved november 30, 2016, from http://www.sports-health.com/blog/top-5-injuries-softball-players ferreti, a., papandrea, p., &conteduca, f. (1990, august). knee injuries in volleyball. sports medicine. retrieved from <http://www.ncbi.nlm.nih.gov/pubmed/2396052>. hootman, j., dick, r., &agel, j. (2007, june). epidemiology of collegiate injuries for 15 sports: summary and recommendations for injury prevention initiatives. retrieved november 10, 2016, from http://search.proquest.com/docview/206652447?pq-origsite=gscholar mailto:topacademicjournals@gmail.com http://www.sports-health.com/blog/top-5-injuries-softball-players http://search.proquest.com/docview/206652447?pq-origsite=gscholar american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 12 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe levine, w. l., & owens, b. d. (2016). preventing football injuries. retrieved november 28, 2016, from http://www.stopsportsinjuries.org/stop/prevent_injuries/football_skating_injury_prevention.aspx meeuwisse, w. h. (1994). assessing causation in sport injury: a multifactorial model.clinical journal ofsport medicine. retrieved november 10, 2016, from http://journals.lww.com/cjsportsmed/abstract/1994/07000/ assessing_causation_in_sport_injury__a.4.aspx national athletic trainer’s association. (2010). volleyball injury: nata injury information. retrieved from <http://www.nata.org/consumer/injuryinfo/index.htm#volleyball> paddock, c. (2012, august 9). young athletes: injuries and prevention. retrieved november 10, 2016, from http://www.medicalnewstoday.com/articles/248796.php reinberg, s. (2010). girl softball players suffering more shoulder injuries. retrieved november 30, 2016, from https://consumer.healthday.com/fitness-information-14/baseball-or-softball-health-news-240/girlsoftballplayers-suffering-more-shoulder-injuries-635759.html seaton, don. (1948). safety in sports. new york, ny: prentice-hall, inc. national athletic trainers' association. (2010). volleyball injury: nata injury information. retrieved from <http://www.nata.org/consumer/injuryinfo/ index.htm#volleyball>. shaginaw, j. (2014). common softball injuries and recommended treatments. retrieved november 30, 2016, from http://www.philly.com/philly/blogs/sportsdoc/common-softball-injuriesandrecommended-treatments.html timpka, t., ekstrand, j., &svanström, l. (2006, september). from sports injury prevention to safety promotion in sports. retrieved november 10, 2016, from http://link.springer.com/article/10.2165/0000725620063609000002 van mechelen, w., hlobil, h., & kemper, h. c. (1992). incidence, severity, aetiology and prevention of sports injuries: a review of concepts. sports medicine, 14, 82-99. doi: 10.2165/00007256-199214020-00002 mailto:topacademicjournals@gmail.com http://www.stopsportsinjuries.org/stop/prevent_injuries/football_skating_injury_prevention.aspx http://www.medicalnewstoday.com/articles/248796.php https://consumer.healthday.com/fitness-information-14/baseball-or-softball-health-news-240/girl-softball-players-suffering-more-shoulder-injuries-635759.html https://consumer.healthday.com/fitness-information-14/baseball-or-softball-health-news-240/girl-softball-players-suffering-more-shoulder-injuries-635759.html https://consumer.healthday.com/fitness-information-14/baseball-or-softball-health-news-240/girl-softball-players-suffering-more-shoulder-injuries-635759.html http://www.philly.com/philly/blogs/sportsdoc/common-softball-injuries-and-recommended-treatments.html http://www.philly.com/philly/blogs/sportsdoc/common-softball-injuries-and-recommended-treatments.html http://www.philly.com/philly/blogs/sportsdoc/common-softball-injuries-and-recommended-treatments.html http://link.springer.com/article/10.2165/00007256-200636090-00002 http://link.springer.com/article/10.2165/00007256-200636090-00002 http://link.springer.com/article/10.2165/00007256-200636090-00002 american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 36 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe factors influencing sport spectators' qr code scanning behavior: an application of the technology acceptance model matthew n. smith, kristin m. miller and jonathan t. baker university of michigan abstract: mobile marketing is a powerful tool for attracting and engaging sport consumers. personalized mobile messages and interactivity can make sport consumers more committed to their teams and athletes. however, few studies have systematically examined sport consumers' behaviors regarding mobile marketing. this study aims to fill this gap by exploring the factors that influence sport consumers' mobile marketing acceptance and usage. keywords: mobile marketing, sport consumers, acceptance, usage, factors introduction as a new technology, mobile marketing has proven itself a powerful tool for attracting consumers (stavros, meng, westberg, & farrelly, 2014; watson, mccarthy, & rowley, 2013). nowhere is this trend so evident at it is in the sport industry. sport consumers can electronically receive many personalized messages based on their preferences and experience more interactivity online with their favorite teams or athletes. this customized mobile marketing makes sport consumers become more committed to their teams and athletes (filo & funk, 2013). according to the nielsen (2015), out of 151 million mobile application users, in 2014 the us population of sports-related mobile application users was 35,783 million. in spite of this growing market, few systematic approaches have been made to understand sport consumers’ behaviors regarding mobile marketing (cf. cooper, 2010; dees, 2011). in delivering customized message to a specific segment, one of the most effective technologies is quick response (qr) code. qr code is a two-dimensional barcode that can be placed on any physical object (e.g., posters, flyers, pamphlets). using a mobile device, sport consumers scan those barcodes converting them into either text and/or graphic information visible on the mobile device or a means for identification or authorization. qr code has recently received attention as a useful way to bring electronic content to consumers by connecting physical objects to online information (e.g., website information or text messages). a typical example of this technology in the sport industry is the virtual credential. by scanning the qr code at the moment of purchase, sporting event attendees are able to keep their tickets in their smartphones, freeing them from having to keep track of print-out tickets. a sport consumer’s behavior of scanning a qr code is theoretically explained by the technology acceptance model (davis, 1989). the model suggests that technology users’ behaviors are determined by perceived usefulness and perceived ease of use (davis, bagozzi, & warshaw, 1989). by theorizing the effects of these components on users’ intentions, the model predicts the effect of external factors on a consumer’s decision to use technology as well as identifies which technology systems are deemed acceptable. the model thus provides theoretical implications that lead researchers to examine which attributes make sport consumers scan qr codes available at a sporting event. we still have much to learn about sport consumers’ behavioral patterns of scanning qr codes and what makes them scan qr codes in their sport consumption. one characteristic of sport fans is that they seek new information regarding their teams or athletes (chung & hwang, 2015; ioakimidis, 2010). to satisfy their needs, sport organizations should engage in mobile marketing mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 37 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe that lead sport fans to the latest information on the team and its team members or exclusive content. in fact, such marketing strengthens the commitment of fans to sport organizations and athletes. fans more likely to react to those promotional activities are of course expected to be the more committed fans (bernthal & graham, 2003; mcdonald & rascher, 2000). a sport fan can be an early adopter of new technology. wanting to know more about teams or athletes would make them adopt new technology if using such technology gives them more opportunities to be able to do so. that is, a sport consumer’s fanship should be an indicator of the degree to which they adopt new technology provided by sport organizations. a number of studies in sport consumer behavior have suggested that the role of team identification factors into sport fans’ behaviors on social media (e.g., kassing & sanderson, 2010; kwak, kim, & zimmerman, 2010; pegoraro, 2010; phua, 2010; sanderson, 2009). having a grasp of sport fans and their technology usage is important because these sport fans can voluntarily spread the adoption of such technology. qr code enables sport organizations to develop diverse marketing activities online. in addition, the technology makes sport organizations save their expenses in operating those marketing activities. if sport organizations understand their consumers’ behaviors concerning qr codes, they will be better equipped to find specific ways of implementing new technology that strengthens relations with sport fans and attracts new ones. this study then aims to reveal the behavioral patterns of sport consumers in scanning qr codes. this study also aims at finding which consumer attributes make, in the context of a spectating sport, sport consumers scan qr codes. the study poses three research questions. 1) where do sport consumers mostly scan qr codes? 2) what types of qr codes do sport consumers mostly scan? 3) which consumer attributes that pertain to accepting new technology affect sport consumers’ intentions to scan qr codes? answering these questions would hold theoretical implications for sport consumer behavior by adding to our knowledge of how such behavior is influenced by new technology. 2. literature review 2.1. technology acceptance model the technology acceptance model (tam), which explains how people’s behavior using new technology is affected by external factors, was developed by davis (1989). tam posits that important factors that influence online consumers’ behavioral intentions to use technology are “perceived usefulness” and “perceived ease of use” (davis, 1989; davis et al., 1989). in the model, the perceived usefulness means the prospective user’s subjective probability in using a specific application system to increase their job performance within an organizational context. the perceived ease of use is the degree to which the prospective user expects the target system to be free of effort. these factors affect consumers’ attitude toward using the technology; their attitudes then influence their behavioral intention to use the technology. a number of studies have demonstrated that the perceived usefulness and perceived ease of use are significant in affecting a consumer’s behavioral intentions to use technology (lee, kozar, & larsen, 2003; legris, ingham, & collerette, 2003; pavlou, 2003). in particular, pavlou (2003) examined a consumer’s acceptance of electronic commerce, finding that an online consumer’s intention to transact using an electronic commerce system was significantly affected by perceived usefulness and perceived ease of use. koufaris (2002) found that a consumer’s perceived usefulness and perceived ease of use significantly affected his or her willingness to make an online purchase. as mobile applications have been becoming popular, such components of applications’ content as design, color, and logo have become another key in shaping technology users’ attitudes. a number of studies have found a role being played content attractiveness in making consumers respond to mobile marketing (chang, kaasinen, & mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 38 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe kaipainen, 2013; sparks, perkins, & buckley, 2013; zhang, yao, & zhou, 2012). chang et al. (2012) suggested mobile application’s content attractiveness affected users’ attitudes and their decisions to use the applications. 2.2. qr code in sport qr code refers to a two-dimensional barcode that can be read by readable devices such as mobile scanners or smartphones (lai, chang, li, fan, & wu, 2013; okazaki, li, & hirose, 2012). qr code may contain not only basic information such as location, phone numbers, or email addresses but also the capacity to transfer such information to physical objects and to include hyperlinks to mobile coupons or tickets (canadi, höpken, & fuchs, 2010). qr code has played an important role in mobile marketing in that it allows consumers, through offline media such as magazines or posters, to access online media information by scanning the qr code (dou, & li, 2008; okazaki et al., 2012). in the sport industry, by linking to webpages, qr codes are usually used as a means of providing additional information about a team, an athlete, or a sporting event. sport organizations also implement qr codes either to promote merchandise by offering coupons and discount tickets or to enhance a company’s brand image by advertising a product or symbol. although a number of studies regarding sport consumer behavior have found how sport consumers use social media and the internet-driven technology for their consumption (kassing & sanderson, 2010; wallace, wilson, & miloch, 2011; witkemper, lim, & waldburger, 2012), only a few studies have looked at sport consumers’ qr code-scanning behavior (c.f. filo & funk, 2013; smith, 2009; tollivernigro, 2011). such a lack of studies is somewhat surprising when compared to the number of systematic attempts made to know qr code scanners’ motivations and behavioral patterns outside of sport settings (cf. ertekin & pelton, 2014; lai et al., 2013; shin, jung, & chang, 2012). 3. method 3.1. sample and procedures the surveys were conducted in the parking lots of a major league baseball (mlb) stadium in the midwest. participants were spectators who had come to the stadium. researchers asked about their willingness to participate in the survey and whether or not they had scanned qr codes that day. upon their approval, they were given the self-administered questionnaires. researchers were on hand to answer any possible questions. most of the data were collected when spectators exited the stadium after the game. the final sample consisted of 93 females and 82 males (n = 175). 3.2. measurement the survey consisted of two parts. the first part asked participants about behavioral patterns of qr code scanning. participants answered questions regarding the frequency of qr code scanning, where scanning took place, and the types of qr codes scanned. the second part asked participants about their attributes in scanning qr codes. based on tam (davis, 1989; davis et al., 1989), participants specifically answered questions about the degree to which they perceived content usefulness, content attractiveness, ease of use, and attitude toward qr codes. also, they were asked about their degree of sport fanship and intentions to continue scanning qr codes. every item of each construct was asked using a 7-point, likert-type scale ranging from 1 (not at all) to 7 (very much). content usefulness refers to the extent to which qr code messages were found to be useful and important to participants. three items were modified based on the work of hur, ko, and valacich (2011). the content attractiveness is the extent to which the design and content of qr codes were attractive to participants. three items were created based on huang and lo’s (2012). the ease of use was operated to the extent to which participants could easily scan qr codes. two items were modified based on the work of hur et al. (2011). the attitude toward qr codes means a participant’s predisposition to using that technology. three items were employed from davis et al. (1989). regarding sport fanship, three items were modified based on the sport team mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 39 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe identification and commitment scale (wann & pierce, 2003). finally, one question asked participants their willingness to continue scanning qr codes. table 1 displays the details of all the items. scanning qr codes is useful for coupons and discounts. 4.88 (1.80) usefulness scanning qr codes is useful for seeing videos and photos. 3.72 (1.94) (.78) scanning qr codes is useful for receiving information. 4.32 (2.00 4.32 (1.62 4.59 (1.60 5.40 (1.42 5.12 (1.15 3.91 (1.47 4.01 (1.40) 3.87 (1.48 5.74 (1.41 5.54 (1.35) 5.77 (1.47 intention* i intend to continue scanning qr codes in the future. 3.88 (1.42 note. * no internal reliability is provided for the questions asking spectators’ discrete event. [table 1: items descriptions and descriptive statistics] 3.3 data analysis descriptive statistics were first secured to find behavioral patterns of scanning qr codes. then a hierarchical regression analysis was employed to find which attribute had the most effect on sport spectators’ intentions to use qr codes. to control the effects of constructs that were not directly related to scanning qr codes, the spectators’ attitudes toward qr codes and their sport fanship were first entered on the intention to scan the code. three other constructs (content usefulness, content attractiveness, and ease of use) were then entered, via a stepwise method, into the intention to scan the code. the final model suggested the significance and magnitude of each construct’s effect on sport spectators’ intention to scan qr codes. attractiveness (.87) the design of qr codes is attractive to make me scan it. the content of qr codes is attractive to make me scan it. ease of use (.77) qr codes are accessible in scanning it. qr codes are visible in scanning it. attitude (.94) i have fun in using qr codes. i enjoy using qr codes. using qr codes does not bother me. fanship (.92) i am dedicated to my sport team. it is hard to quit watching the game of my team. i will continue attending games of my team. construct ( cronbach’s α ) items mean/ sd mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 40 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 4. results 4.1. descriptive statistics a majority of participants (70.9%) used a sport-related qr code one to five times per month; 24.0% used it between 6 and 10 times a month. few (4.0%) used it 11 to 15 times a month and even fewer (1.1%) used it 16 to 20 times a month. regarding where qr codes were scanned, the most common location was on a wall poster (49.7%), followed by magazines (36.6%), game tickets (20.6%), websites (16.0%), and jumbotrons (13.1%). most qr codes were related to merchandise coupons (43.4%) followed by codes related to game ticket discounts (37.1%) and sport event lottery (24.6%). more details are shown at table 2. places frequency % types frequency % posters 87 49.7 merchandise coupons 76 43.4 magazines 64 36.6 discounted tickets 65 37.1 tickets 28 16.0 event lottery 43 24.6 websites 23 13.1 bonus points 32 18.3 stadium screen board 14 8.0 videos / photos 27 15.4 newspapers 13 7.4 cash rebate 23 13.1 restaurants 7 4.0 event advertising 21 12.0 stadium seats 7 4.0 event news 15 8.6 building signs 5 2.9 team’s public relations 8 4.6 clothing 4 2.3 transportation 3 1.7 note. multiple answers were allowed to pick the places and types of scanned qr codes. [table 2: places and types of scanned qr codes] 4.2. hierarchical regression analysis in the first model, spectators’ attitudes toward qr codes (β = .61, p < .001) and sport fanship (β = .22, p < .001) influenced their intentions to scan qr codes. both components explained 53% of the variance in their intentions (p < .001). after entering three other qr code-related constructs in the model, the second model showed that spectators’ intentions to scan qr codes were affected by attitudes toward qr codes (β = .66, p < .001), sport fanship (β = .21, p < .001), and content attractiveness (β = −.12, p < .05). although the variance only increased by 1.2%, such a change was still significant at .05 levels. the final model suggested that spectators’ intentions to scan qr code were affected by attitudes toward qr codes (β = .65, p < .001), sport fanship (β = .20, p < .01), content attractiveness (β = −.17, p < .01), ease of use (β = .14, p < .05). qr code usefulness was found to be not significant (p = .66). these significant factors explained a total of 56% of the variance in their behavioral intentions to scan qr codes (p < .05). more details of these results are laid out in table 3. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 41 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe model constructs standardized β standard error t p r2 p 1 attitude .61 .06 10.58 < .001 .536 < .001 fanship .22 .06 3.90 < .001 2 attitude .66 .06 10.65 < .001 .548 < .05 fanship .21 .06 3.62 < .001 attractiveness -.12 .05 -2.09 < .05 3 attitude .65 .06 10.63 < .001 .564 < .05 fanship .20 .06 3.47 < .01 attractiveness -.17 .06 -2.87 < .01 ease of use .14 .07 2.48 < .05 [table 3: results of hierarchical regression] 5. discussion mobile marketing through qr codes has been growing in the sport industry (filo & funk, 2013; kunz, santomeir, & woratschek, 2010). this study revealed the behavioral patterns of sport spectators’ qr code scanning. in addition, this study found which attributes of sport consumers’ technology adoption made them engage in qr codes scanning. tam suggests that what is important in shaping consumers’ attitudes to new technology is its perceived usefulness and perceived ease of use (davis, 1989; davis et al., 1989). applying this to sport consumer behaviors, this study found attitudes had a great effect on sport consumers’ intention to scan qr codes. such results are compatible with previous studies (lee & chang, 2011; narang, jain, & roy, 2012; suki & suki, 2011). watson et al. (2013) studied how consumers shaped their attitudes toward qr codes and found that scanning behavior was prevented by a lack of prior experience and the attendant lack of knowledge about how to scan qr codes. that is, major determinants for the behaviors of qr codes scanning were what experience they had and how confident they were about using such technology. understanding the impact of sport consumers’ attitudes toward qr codes would encourage sport organizations to include social aspects in promoting the benefits of qr codes to their specific market. such a function has already become an attracting point for sport consumers (stavros et al., 2014). for example, running mobile applications provide not only fitness management information but also an opportunity where runners can find other runners geographically and form a community based on their interests. the social aspect of technology has also been proven by the rapid growth of social media online (whiting & williams, 2013). given the chance to enjoy social aspects in sporting events more, it is more likely that sport consumers would shape positive attitudes toward technology and continue using it. regarding content attractiveness, it is surprising to find its negative effect on sport consumers’ intentions to scan qr codes. this result might be explained by instrumental purposes of qr code scanning. this study found that sport spectators mostly scanned qr codes to receive financial benefits (i.e., coupons and price discounts). also, mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 42 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe the frequently scanned places were not their final destinations. participants scanned qr codes on their way to a game or while they sought valuable information about the game (i.e., posters, magazines, and game tickets). these behavioral patterns explain well what they really wanted to obtain from scanning qr codes. spectators’ qr code scanning was not an ad-hoc behavior but purposedriven and preplanned so as to bring more benefits to their consumption. they rarely scanned them to satisfy mere curiosity or for fun. this claim becomes stronger when the tam is theoretically rooted in the model of preplanned behavior (ajzen, 2002). nonetheless, the visual look of technology plays a powerful role in determining its popularity (sparks et al., 2013; zhang et al., 2012). it should be noted that qr codes are two-dimensional bar codes that consist of unidentifiable and abstract patterns of shapes and objects. this might distract spectators’ attention from the intention to scan them. they would be more likely to scan qr codes if the design of the qr code was attractive and easily identifiable and its appearance included an informative sign that was directly matched with the consumer’s interests. having the second largest effect on intention to scan qr codes was sport spectators’ fanship. seeing the role that sport fanship plays provides a new dimension of understanding sport consumers’ behavior online by revealing how sport consumers’ psychological commitment affects their adoption of technology. this study’s findings suggest that sport consumers’ adopting of technology is predicted not only by technology-related attributes but by their tendency to affiliate with a sport organization. for sport consumers, employing new technology is a contextual outcome in which their sport fanship interacts with the possible benefits of using the technology. this suggests how qr codes should be leveraged to provide sport spectators a quality experience. to maximize its utilization, sport organizations should understand that such mobile marketing as qr codes ought to be directed toward providing fundamental benefits to sport fans as well as satisfying sport fans’ loyalty to team or athletes. 6. practical implications although a diversity of places were found related to the location that qr codes were scanned, it should be noted that most were not directly related to a sport venue (i.e., posters, magazines, game tickets, and websites). relatively less popular locations for scanning were stadium scoreboards and seats. given this, it may be surmised that sport spectators’ qr codes scanning occur ubiquitously and simultaneously. thus, sport organizations should place qr codes near the spectators’ traffic flow (e.g., parking lots, public transportation stations) and time to time across diverse locations. frequently scanned qr codes pertained to tangible benefits such as coupons or discounts. this also suggests where qr codes ought to be placed. sport organizations should place qr codes where a volume of consumers gather for shopping (e.g., concession, merchandise store). in addition, sport organizations would be better off creating mobile content that incorporates spectators’ tangible benefits into qr codes by synchronizing such benefits with their marketing promotions. finally, it is highly suggested that sport organizations implement qr codes toward developing spectators’ fanship. one example would be providing exclusive content via qr codes. further, more diverse content needs to be made, via scanning qr codes, to generate revenue from highly committed sport fans. 7. limitations and future research it should be noted that this study has several limitations. first, the samples were only collected from one particular mlb stadium in the midwest. in other words, the results of this study might be limited in being able to predict sport consumers’ technology usage in other sports and in other parts of the country. second, the survey was performed at a time when smartphones had become popular. since mobile devices are essential to scanning qr codes, the results should be interpreted in light of that social trend which continues even today. future research should focus on how sport consumers use new technology differently according to the demographics of sport consumers. age, gender, and education have significant influences on the attitudes of mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 43 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe having new technology and consequent behaviors (morris, venkatesh, & ackerman, 2005). these studies would help sport organizations identify a specific segment and create a customized mobile marketing agenda, particularly when they try to integrate new technology into their sporting events. it would be worthwhile knowing when scanning qr codes frequently occurs. it has been reported that posting on social media is done mostly right before and after a game (rice, 2015). considering qr codes are informative and functional, knowing these things would be useful in finding a way to incorporate mobile marketing activities into sport organization’s sales such as tickets or merchandise. finally, a number of sport venues have just begun using technology by which spectators can order food and have them delivered to their seats. further studies should be more context-oriented, including such elements as facility support or social components. 8. conclusion qr code marketing has been extensively examined in a variety of fields. in the field of sport management, however, there has been minimal research regarding how to utilize qr codes to attract more fans. results of study suggested that spectators of mlb tended to mostly scan sportrelated qr codes that appeared on posters, and that the most frequently scanned type of qr code was the merchandise coupon. the results of hierarchical regression analysis showed that sport fanship, content attractiveness, ease of use, and attitude toward new technology affected sport spectators’ intentions to scan sport-related qr codes. results of this study provide sport marketers with practical implications. to attract more fans using qr codes, marketers should offer sport fans simple and instant benefits such as merchandise coupons, discount tickets, or lotteries. in addition, sport marketers should consider designing qr codes with appropriate names, of proper size, and in a good location to encourage fans to scan sportrelated qr codes. future study should focus more on sport consumers’ technology acceptance based on diverse demographic variables such as age, gender, and level of education. references ajzen, i. (2002). perceived behavioral control, self-efficacy, locus of control, and the theory of planned behavior. journal of applied social psychology, 32, 665-683. bernthal, m. j., & graham, p. j. (2003). the effect of sport setting on fan attendance motivation: the case of minor league vs. collegiate baseball. journal of sport behavior, 26, 223. canadi, m., höpken, w., & fuchs, m. (2010). application of qr codes in online travel distribution. information and communication technologies in tourism 2010, 137-148. chang, t. r., kaasinen, e., & kaipainen, k. (2013). persuasive design in mobile applications for mental wellbeing: multidisciplinary expert review. wireless mobile communication and healthcare, 61, 154-162. chung, k.-s., & hwang, g. (2015). antecedents and consequences of formula one spectators’ fanship: the case of inaugural grand prix. journal of physical education and sport management, 6(6), 38-46. cooper, t. g. (2010). new media marketing: the innovative use of technology in ncaa athletic department ebranding initiatives. journal of marketing development and competitiveness, 5, 23-32. davis, f. d. (1989). perceived usefulness, perceived ease of use, and user information technology. mis quarterly, 13, 319-339. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 44 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe davis, f. d., bagozzi, r. p., & warshaw, p. r. (1989). user acceptance of computer technology: a comparison of two theoretical models. management science, 35, 9821003. dees, w. (2011). new media and technology use in corporate sport sponsorship: performing activational leverage from an exchange perspective. international journal of sport management and marketing, 10, 272-285. dou, x., & li, h. (2008). creative use of qr codes in consumer communication. international journal of mobile marketing, 3, 61-67. ertekin, s., & pelton, l. e. (2014). an empirical study of consumer motivations to use qr codes on magazine ads. american international journal of contemporary research, 4, 4755. filo, k., & funk, d. c. (2013). leveraging estrategies and the online environment. in m. p. pritchard & j. l. stinson (eds.), leveraging brands in sport business (pp. 204-220). new york, ny: routledge. huang, y., & lo, y. (2012). blogging content attractiveness. journal of computer assisted learning, 28, 208221. hur, y., ko, y. j., & valacich, j. (2011). a structural model of the relationships between sport website quality, e-satisfaction, and e-loyalty. journal of sport management, 25, 458-473. ioakimidis, m. (2010). online marketing of professional sports clubs: engaging fans on a new playing field. international journal of sports marketing & sponsorship, 11, 271. kassing, j., & sanderson, j. (2010). fan-athlete interaction and twitter tweeting through the giro: a case study. international journal of sport communication, 3, 113-128. koufaris, m. (2002). applying the technology acceptance model and flow theory to online consumer behavior. information systems research, 13, 205-223. kunz, r., santomeir, j., & woratschek, h. (2010). mobile tv and sport: consumer motivational factors. easm 2010 conference. prague, czech republic. kwak, d., kim, y., & zimmerman, m. (2010). user-versus mainstream-media-generated content: media source, message valence, and team identification and sport consumers’ response. international journal of sport communication. 3, 402-421. lai, h. c., chang, c. y., li, w. s., fan, y. l., & wu, y. t. (2013). the implementation of mobile learning in outdoor education: application of qr codes. british journal of educational technology, 44, 57-62. lee, h. h., & chang, e. (2011). consumer attitudes toward online mass customization: an application of extended technology acceptance model. journal of computer-mediated communication, 16, 171-200. lee, y., kozar, k., & larsen, k. r. t. (2003). the technology acceptance model: past, present, and future. communications of the association for information system, 12, 752-780. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 45 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe legris, p., ingham, j., & collerette, p. (2003). why do people use information technology? a critical review of the technology acceptance model. information and management, 40, 191-204. mcdonald, m., & rascher, d. a. (2000). does bat day make cents? the effect of promotions on the demand for baseball. journal of sport management, 14, 8-27. morris, m. g., venkatesh, v., & ackerman, p. l. (2005). gender and age differences in employee decisions about new technology: an extension to the theory of planned behavior. engineering management, 52, 6984. narang, s., jain, v., & roy, s. (2012). effect of qr codes on consumer attitudes. international journal of mobile marketing, 7, 52-64. nielsen (2015, june 11). so many apps, so much more time for entertainment. nielsen. retrieved from http://www.nielsen.com/us/en/insights/news/2015/so-many-appsso-much-more-time-forentertainment.html okazaki, s., li, h., & hirose, m. (2012). benchmarking the use of qr code in mobile promotion: three studies in japan. journal of advertising research, 52, 102-117. pavlou, p. a. (2003). consumer acceptance of electronic commerce: integrating trust and risk with the technology acceptance model. international journal of electronic commerce, 7, 101-134. pegoraro, a. (2010). look who’s talking-athletes on twitter: a case study. international journal of sport communication, 3, 501-514. phua, j. (2010). sports fans and media use: influence on sports fan identification and collective self-esteem. international journal of sport communication. 3, 190-206. rice, n. (2015, october 22). 4 ways data analytics can improve the game day experience. sporttechie. retrieved from http://www.sporttechie.com/2015/10/22/4-ways-dataanalytics-can-improve-game-day-experience/ sanderson, j. (2009). professional athletes’ shrinking privacy boundaries: fans, information and communication technologies, and athlete monitoring. international journal of sport communication, 2, 240-256. shin, d., jung, j., & chang, b. (2012). the psychology behind qr codes: user experience perspective. computers in human behavior, 28, 1417-1426. smith, j. (2009). leveraging mobile technologies to increase revenue for the nba and its properties. international journal of mobile marketing, 4, 68-74. sparks, b. a., perkins, h. e., & buckley, r. (2013). online travel reviews as persuasive communication: the effects of content type, source, and certification logos on consumer behavior. tourism management, 39, 1-9. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 5; september-october 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 46 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe stavros, c., meng, m. d., westberg, k., & farrelly, f. (2014). understanding fan motivation for interacting on social media. sport management review, 17, 455-469. suki, n. m., & suki, n. m. (2011). exploring the relationship between perceived usefulness, perceived ease of use, perceived enjoyment, attitude and subscribers’ intention towards using 3g mobile services. journal of information technology management, 22, 1-7. tolliver-nigro, h. (2011). make money with qr codes. printing impressions, 53, 26-27. wallace, l., wilson, j., & miloch, k. (2011). sporting facebook: a content analysis of ncaa organizational sport pages and big 12 conference athletic department pages. international journal of sport communication, 4, 422-444. wann, d. l., & pierce, s. (2003). measuring sport team identification and commitment: an empirical comparison of the sport spectator identification scale and the psychological commitment to team scale. north american journal of psychology, 5, 365-372. watson, c., mccarthy, j., & rowley, j. (2013). consumer attitudes towards mobile marketing in the smart phone era. international journal of information management, 33, 840-849. whiting, a., & williams, d. (2013). why people use social media: a uses and gratifications approach. qualitative market research: an international journal, 16, 362-369. witkemper, c., lim, c. h., & waldburger, a. (2012). social media and sports marketing: examining the motivations and constraints of twitter users. sport marketing quarterly, 21, 170-183. zhang, m., yao, d., & zhou q. (2012). the application and design of qr code in scenic spot’s e-ticketing system a case study of shenzhen happy valley. international journal of science and technology, 2, 817-822. mailto:topacademicjournals@gmail.com 050817-cr100.docx american journal of medical and physical education vol.8, issue 4; july-august 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 11 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe exploring gut health in heart failure: tcm and western medicine perspectives 1dr. wei zhang, and 2prof. ming liu, 1department of cardiology, shaanxi university of chinese medicine, xianyang, shaanxi, china 2hospital of shaanxi university of chinese medicine, xianyang, shaanxi, china abstract: heart failure (hf) is a prevalent and life-threatening condition characterized by cardiac insufficiency, leading to physical limitations and edema. aging populations have seen a surge in hf cases, with alarming mortality rates. recent research has unveiled the significance of intestinal flora in hf pathogenesis, introducing the "intestinal hypothesis of heart failure." traditional chinese medicine (tcm), rooted in holistic principles and organ interactions, aligns with this perspective, emphasizing the interplay between the heart and small intestine. various tcm conditions, such as heart impediment, heart cough, and heart water, relate to hf. this review synthesizes recent clinical and basic research endeavors in utilizing tcm to modulate intestinal flora for hf treatment. it sheds light on the potential of tcm as a complementary therapeutic approach to address the complexity of hf, aiming to provide innovative insights and a theoretical framework for hf prevention and management. keywords: heart failure, intestinal flora, traditional chinese medicine, holistic approach, cardiovascular disease. introduction heart failure (hf), is a group of syndromes caused by ventricular filling and/or impaired ejection capacity due to various heart structural or functional diseases, with cardiac output unable to meet the needs of body metabolism, insufficient blood perfusion of organs and tissues, and blood stasis of lung and/or systemic circulation. the clinical manifestations are mainly physical activity limitation and edema caused by dyspnea and weakness [1]. with the growth of age, the prevalence of heart failure increases rapidly. the prevalence of people over 70 years old rises to more than 10%. the four-year mortality rate of heart failure reaches 50%, and the one-year mortality rate of patients with severe heart failure reaches 50%. it is the end-stage manifestation of cardiovascular disease and the main cause of death. modern research indicates that intestinal flora plays an important role in the occurrence, development and treatment of heart failure, and "intestinal hypothesis of heart failure" has been proposed [2]. traditional chinese medicine (tcm) is a unique theoretical system of the chinese nation. in its traditional theory, the viewpoints of "holism" of zang-fu organs and "the exterior-interior relationship between heart and small intestine" have something in common with the role of intestinal microorganisms. in the literature of traditional chinese medicine, heart impediment, heart cough, heart water, heart distension, heart failure, heart mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 4; july-august 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 12 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe failure and other diseases are related to heart failure [3]. this study summarizes the clinical and basic research progress in the treatment of heart failure by regulating the intestinal flora in traditional chinese medicine in recent years, in order to provide new ideas and theoretical basis for the prevention and treatment of the disease. 1. overview of intestinal flora the intestinal tract is the largest digestive, excretory and immune organ of the human body, as well as the largest bacterial reservoir and endotoxin pool, with about 100 trillion microorganisms stored therein, which constitute the intestinal flora [4]. during the evolution of intestinal flora, a symbiotic relationship was formed with the host cells. the intestine provides a good living environment for the growth and reproduction of microorganisms, and the intestinal flora plays an important role in maintaining the homeostasis, nutritional metabolism and health of the intestinal environment [5]. studies have shown that the intestinal flora before birth is sterile. at birth, infants obtain the initial microflora from the mother's vagina and feces, which is mainly composed of lactobacillus and bifidobacterium, and the intestinal flora is basically formed by the age of 2 years old. since then, the number and type of intestinal flora are increasing, and it reaches a steady state in adulthood [6]. the intestinal flora is affected by age, gender, diet, lifestyle, antibiotic use and other factors, and the intestinal flora of the normal population is in dynamic balance with the human environment. at present, the main effects of intestinal flora recognized in clinical practice include: (1) natural biological protection barrier: the intestinal anaerobes mainly composed of bifidobacterium can form a natural biological barrier on the intestinal surface to resist the invasion of pathogenic bacteria and bacteria [7]. (2) regulate the nutrition metabolism of the body. the intestinal flora is an important physiological function for regulating the intestinal tract, and the carbohydrate in the body is the main energy source for host cells and the intestinal flora. when the host cells cannot normally digest the polysaccharide and cellulose in food, they need to be degraded under the assistance of the intestinal flora to effectively regulate the blood glucose and lipid levels of the body, and provide the basic energy for the body [8]. (3) immunoregulatory effect, intestinal anaerobes can enhance the immune ability and non-specific immune ability of the body by activating the activity of phagocytes of the body [9]. 2. the correlation between intestinal flora imbalance and heart failure in the current research, people's understanding of the pathological and physiological mechanism of heart failure has changed significantly. it is believed that heart failure is not only a hemodynamic disease, but also involves multiple system disease states in metabolism, neuroendocrine and inflammation. some basic studies have shown that changes in the composition of the intestinal flora and its metabolites are related to the occurrence and development of heart failure [10]. 3.1. intestinal flora imbalance the latest evidence indicates that the intestinal flora of patients with heart failure is different from that of healthy people. pasini [11] et al. confirmed that the number of intestinal pathogenic bacteria in patients with hf, such as salmonella, campylobacter, shiga, yersinia, candida and other foreign bacteria was increased, while the number of native bacteria, such as bifidobacterium and lactic acid bacteria was decreased. moreover, the age, gender and body mass index were not statistically significant compared with those of the healthy control group, suggesting mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 4; july-august 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 13 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe that patients with hf had dysbacteriosis [12]. 16s rrna gene sequencing showed that the number of actinomyces and bifidobacterium was increased, while the number of macromonas was decreased in patients with heart failure. metagenomics and metabolomics analyses have revealed that the basic characteristics of the flora changes in patients with chronic heart failure are the decrease of c. pratense and the increase of active rumen cocci [13]. bifidobacterium, lactobacillus and bacteroides are beneficial bacteria in intestinal flora and play an important role in body health. when hf occurs, its balance is damaged and the number of flora is significantly reduced, which is closely related to the severity of the disease. at the same time, the number of intestinal pathogenic bacteria such as escherichia coli and yeast-like fungi in the patient was significantly increased, which was positively correlated with the levels of hs-crp and bnp, and negatively correlated with lvef, further promoting the deterioration of the disease. therefore, the imbalance of intestinal flora in patients with hf is closely related to the level and condition of inflammatory response [14]. 3.2. increased permeability of the intestinal barrier and endotoxin translocation patients with heart failure not only have an imbalance of the intestinal flora, but also have increased permeability of the intestinal barrier and endotoxin translocation. under physiological conditions, there is a layer of mucosal barrier between the intestinal contents and intestinal tract of human body, which is mainly composed of mucus secreted by intestinal epithelial cells and connexins tightly connected at the top of epithelial cells, to prevent intestinal epithelial cells and immune cells from directly contacting bacteria in the intestinal tract and inhibit inflammation and infection [1]. in the case of heart failure, the body will adjust the blood distribution throughout the body to ensure the supply of vital organs, of which intestinal ischemia and hypoxia occur earliest, and intestinal mucosal structure will suffer from ischemia-reperfusion injury. patients with heart failure will have increased carbon dioxide pressure in gastric mucosa. even in the condition of low-level activity, the weakened intestinal wall circulation and microcirculation disorder of patients will lead to intestinal mucosal edema and malabsorption, further resulting in weakened immune defense function and weakened resistance to bacterial adhesion, which is conducive to the migration of bacteria and toxins to extra-intestinal tissues and organs [15]. endotoxin is a lipopolysaccharide (lps) present in the cell wall of gram-negative bacteria, which contains a hydrophilic polysaccharide moiety and a hydrophobic lipid a. the decline of intestinal barrier function results in the migration of large amount of endotoxin in the intestinal lumen to the extra-intestinal tissue, which is called endotoxin translocation. endotoxin can cause submucosal edema, necrosis of the cells at the top of the intestinal villi, and increased intestinal permeability, thereby destroying the function of the intestinal barrier. bacterial translocation may be controlled in some cases, but endotoxin can still pass through the "leaky" intestinal mucosa, causing the activation of inflammation and the release of cellular mediators [16]. microbial and lipopolysaccharide levels in the blood have been considered markers of impaired intestinal barrier. 3.3. metabolites of intestinal microflora the known intestinal metabolites related to heart failure include trimethylamine oxide (tmao), short-chain fatty acids (scfas), and bile acids. the intestinal flora has been shown to participate in tmao formation by producing trimethylamine (tma), which, once in the blood, is transported to the liver and then converted to tmao under mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 4; july-august 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 14 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe the catalysis of flavin monooxygenase (fmo) [17]. plasma tmao levels were elevated in patients with heart failure and the e. coli to shiga ratio was positively correlated with blood trimethylamine oxide levels in patients with compensated heart failure, indicating a correlation between intestinal flora imbalance and blood trimethylamine oxide levels [13]. in a 5-year follow-up of 720 patients with stable heart failure, the mean tmao of enrolled patients was 5.0μmol/l, which was higher than that of patients without heart failure (3.5μmol/l; p<0.001). patients with higher plasma tmao levels had a 3.4-fold increased risk of death. after adjusting for traditional cardiovascular risk factors and bnp, an increase in tmao levels still predicts an increase in the 5year mortality rate [18]. another key metabolite of intestinal flora, short-chain fatty acids (scfs), is the main energy source of the intestine. scfs not only maintain the stability of the intestinal barrier, but also regulate the immune system, improve the microenvironment of the intestinal mucosa, and maintain the normal function of the intestinal mucosa, playing a defense function against the invasion of pathogenic bacteria and harmful substances [19]. in addition, scfas can be recognized by specific host receptors and improve the prognosis of heart failure by regulating host blood pressure and inhibiting ventricular remodeling [20]. short-chain fatty acid-producing bacteria in the intestines of patients with heart failure are significantly reduced. 16s rna analysis of intestinal microorganisms showed a significant reduction in scfa-producing bacteria in intestinal microorganisms of patients with heart failure, e.g., eubacterium rectal, dorea longicatena [21,22]. short-chain fatty acids play an important role in the regulation of inflammation and the maintenance of the integrity of the intestinal barrier. scfa can exhibit multiple effects [23], which can exert anti-inflammatory and pro-inflammatory effects on macrophages, and induce the release of inflammatory mediators such as nitric oxide (no), il-6, and il-12 by activating intestinal macrophages, thereby preventing myocardial hypertrophy and fibrosis [24]. the metabolism of bile acids depends on the action of intestinal flora. the composition and content level of bile acids in patients with hf are significantly changed compared with those in the normal control group, especially the change of secondary bile acid spectrum. specific secondary bile acids (such as ursodeoxycholic acid) can inhibit the inflammatory response caused by nf-kb by regulating fxr bile acid receptors. studies have also shown that targeted treatment of fxr can reduce myocardial cell apoptosis and fibrosis, thereby improving the prognosis of heart failure [25]. 3. exploration of tcm theory of heart failure based on intestinal flora 4.1. heart-spleen correlation the concept of holism and the theory of the integration of five zang-organs are the important theory and essence of tcm, and the correlation between heart and spleen is an important part of the theory of the integration of five zang-organs. it is mentioned in lingshu meridian that "the pulse of the taiyin of the spleen foot, the branches of which are connected from the stomach to the septum and into the heart……the great collateral of the spleen, is called big bag, which comes out three inches into the axilla and spreads over the chest and hypochondrium". it is recorded in su wen ping ren qi lun that "the great collateral of the stomach is named xuli, which runs through the septum and collaterals lung. it comes from under the left breast, so its movement should be based on the hand, and the pulse should be based on qi". the spleen is located in the middle energizer and serves as the hub of qi mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 4; july-august 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 15 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe movement of the whole body. it is recorded in su wen bielun of meridians that "the food qi enters the stomach and disperses the essence into the liver, while the yin qi flows into the tendons. when the food qi enters the stomach, the turbid qi will return to the heart and the pathogen will be transferred to the pulse. the meridian qi flows through the meridians and is transferred to the lung, which faces hundreds of meridians and is used for seminal emission. mao pulse combines with essence and moves qi to the fu. the spirit of the government is clear, so it will remain in the four zang-forces, and the qi will be weighed ". according to zang-fu theory, the heart stores spirit, which is the sovereign of five-zang and six-fu, and has the function of commanding the physical and psychological activities of the whole body. the spleen, however, controls the transportation and transformation of qi and blood, serving as the source of biochemical transformation of qi and blood, as well as providing the material basis for the sovereign function of the heart. it indicated that the normal operation of spleen could promote the smooth flow of other organs, facilitate the coordination of qi and blood, and prevent the invasion of pathogenic factors [3]. the heart and spleen are separated in anatomical position by only one layer of diaphragm, which is in similar position. they are closely related through the meridian system. it is recorded in lingshu meridian that the branches of spleen meridian of foot taiyin were connected with heart meridian of lesser yin of hand "from stomach, from diaphragm to heart". "miraculous pivot, the don't" "foot taiyin is, up to the thigh, in yangming. and don't all line, knot in the pharynx, penetration of the tongue ... hand less yin is, don't into the yu yuan axillary between two tendons, belong to the heart, walk on the throat, out of the surface, eye inner canthus ". it could be seen that the difference between the two meridians met at the throat, further connecting the heart and spleen. combined with the running of meridians and collaterals, it was characterized by the intersection of yin and yang, which resembled an endless loop, thus laying a more adequate foundation for the related theories of heart and spleen" [26]. therefore, it indicates that the relevant theories of heart and spleen can guide the research on the relationship between intestinal flora and heart failure from the perspective of meridians and collaterals in traditional chinese medicine. studies have found that in the human intestinal micro-ecological system, the normal flora can produce a variety of enzymes and participate in the digestion and absorption of nutrients [27]. if the normal community structure of the intestinal flora is changed, symptoms such as gastrointestinal discomfort will occur, and related intestinal diseases will continue to occur over time, which are consistent with the clinical manifestations of spleen deficiency syndrome in traditional chinese medicine [28]. spleen deficiency syndrome is a common syndrome in tcm clinical practice, and its main manifestation is digestion and absorption dysfunction, accompanied by systemic qi deficiency. studies have found that spleen deficiency syndrome is closely related to the changes of intestinal flora [29]. studies have found that bifidobacterium in feces of patients with diarrhea due to spleen deficiency is significantly reduced, and the number of bifidobacterium in feces is significantly increased after treatment with invigorating spleen. animal experiments showed that the spleen deficiency mouse model prepared with radix et rhizoma rhei decoction also had significant microecological imbalance, and the intestinal lactobacilli and bifidobacterium were decreased to different degrees [30]. animal experiments showed that the mouse model of spleen deficiency constipation could be established by decocting folium sennae in water. the mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 4; july-august 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 16 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe total number of intestinal microorganisms after gavage was significantly lower than that in the normal group, and the e. coli and lactic acid bacteria were significantly increased, proving that the balance of intestinal microecology in the mouse model of spleen deficiency constipation was damaged to a certain extent [31]. 4.2. heart and small intestine exterior-interior the heart and small intestine communicate with each other and collateral with each other on the meridians and collaterals to form the exterior-interior relationship. it is recorded in lingshu meridian that "the pulse of heart and hand with less yin originates from the heart and goes out to belong to the heart system and the lower diaphragm collaterals and small intestine …", "the pulse of small intestine and hand with greater yang originates from the end of little finger and enters the deficiency basin to collateral the heart and travels down the pharynx to reach the stomach, which belongs to the small intestine." "su wen gu kong lun" said: "those who supervise the pulse, … enter the collateral brain, … penetrate the heart." lingshu meridian said: "the pulse of the sun is sufficient, and the straight pulse enters the collaterals from the top", "the pulse of the yin and kidney is insufficient, and the ridge (the ridge leads to the brain) belongs to the kidney, and its branches exit from the lung and enter the collaterals and are injected into the chest". it is stated in su wen zang qi shi lun that "for patients with heart disease, pain in the chest, fullness of the hypochondrium, pain in the hypochondrium, above the back and shoulders and between the nails, and pain in the two arms". from the perspective of clinical symptoms, the painful parts of patients with heartache tend to radiate to the scapular region, which is very consistent with the running paths of small intestinal meridians. small intestinal diseases are often accompanied by physical and mental diseases such as depression and anxiety. studies have confirmed that small intestinal diseases can be transmitted along the meridians and collaterals, leading to the dysfunction of the heart in governing spirit. many studies have shown that the trends of meridians and collaterals in multiple meridians, such as the governor vessel, manual taiyang (gv 16), and foot yangming (gv 20), are interconnected, and together they construct the meridian network system associated with the connection of the heart with the small intestine in the human body [28-29]. the exterior-interior relationship between the heart meridian and the small intestine meridian determines their physiological and pathological connections. the heart and small intestine physiologically function with each other. "classic of difficulties" reads: "heart camp, lung guard, yangqi traffic, the former residence on the; large intestine, small intestine, yin qi, former residence in the next, so a far cry from also ". on the one hand, the function of "heart governing blood vessel" is based on the sufficiency of "heart yin" and "heart yang", and the combination of the two plays a role in promoting the small intestinal mass transfer through the meridian connection. on the other hand, the small intestine mainly receives the exuberant nutrients and secretes away the pure and turbid to realize the digestion and absorption of the human body as well as the downward transmission of the dross to the large intestine and bladder. the normal function of the small intestine is an important condition for harmonizing blood vessels, nourishing the five internal organs, and draining the dross. the heart and small intestine interact pathologically. "on the causes and symptoms of diseases": "those who suffer from excessive salivation after heartache and stop drinking take advantage of the collaterals of the heart; those who stop drinking will behave like water and liquid ... the small intestine and the internal organs of the heart will also absorb the mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 4; july-august 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 17 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe moisture descending into the small intestine to urinate, so there is no need to stop drinking in the heart collaterals ... if the multiplication of cold and heat causes the internal organs to be irregular, and the drinking of body fluid and water stops accumulating, the upper part is forced by the heart to make the heart qi unable to communicate, so the pain will be excessive salivation". according to the provisions, if the normal function of the small intestine "saturated with urine" is affected, it will lead to dysfunction of transmission. the production of nutrient substances is reduced, so that they cannot provide the sustenance and supply for the normal blood vessels. on the one hand, it causes the normal blood vessels to promote the decline of blood function, and on the other hand, it causes the state of qi and blood deficiency in the body, leading to the slowdown of blood movement, and eventually blood stasis. if the function of "clearing away turbidity" in the small intestine is out of control, the ascending and descending of "turbid" substances will be out of control, and those who are clear will not ascend, which will lead to diarrhea, while those who are turbid will not descend, which will produce pathological products such as phlegm and water-dampness, and phlegm and blood stasis will lead to dishonor of heart blood and depression of heart yang [20]. 4. research on the treatment of heart failure with traditional chinese medicine based on the regulation of intestinal flora the important relationship between heart and spleen has been expounded as early as in internal classic and classic of difficulties. for example, it is mentioned in the plain questions on yin and yang correspondence theory that "heart begets blood, and blood begets spleen". "su wen yu ji zhen zang lun pian" also mentioned: "the five zang-organs are nourished by qi from their organs ... the heart is nourished by qi from the spleen and transmitted to the lung. qi is given up to the liver and ends up in the kidney. ...... grant gas in the spleen, grant gas in my son also ... ". spleen, stomach and five elements belong to soil, while heart and five elements belong to fire. heart and spleen are related. in addition, yin and yang of heart and spleen are interlinked, and qi and blood are mutually complementary. the related theories of heart and spleen came into existence in qin and han dynasties, flourished in song dynasty, matured in ming and qing dynasties, and gradually improved in modern times. on the treatment of chest stuffiness and heartache, professor deng tietao, a master professor of chinese medicine, proposed that "the key of tonifying heart and qi is to invigorate spleen" and "phlegm and blood stasis are related", and emphasized the related theory of heart and spleen, pointing out that the dysfunction of spleen and stomach transportation and transformation caused by improper diet, internal injuries caused by seven emotions, and aging and tonifying deficiency existed in dampness and turbidity, which gathered to produce phlegm, which grew into blood stasis over time, leading to chest stuffiness and stroke. deng lao used modified wendan decoction to treat coronary heart disease and obtained the effect of replenishing qi and removing dampness. the practice proved that the effect was quite good. the common pathological mechanism for the occurrence and development of cardiovascular and cerebrovascular diseases is "phlegm and blood stasis correlation". the dysfunction of spleen and stomach is the key, and it is closely related to the function of intestinal flora. specifically, it refers to the production of tma when eating fatty, sweet, and greasy products rich in choline under the related action of intestinal flora. tma is considered as the biological marker of "phlegm and blood mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 4; july-august 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 18 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe stasis". tma enters blood and is converted into tmao in liver, which promotes the progression of atherosclerotic plaques, activates platelet aggregation, promotes the formation of arterial thrombosis, and eventually leads to the occurrence of atherosclerotic diseases. these are the pathological bases of blood vessel occlusion caused by "phlegm and blood stasis mutual junction". professor lu zhizheng is good at using the methods of regulating spleen and stomach to treat chest impediment and heartache in clinical application, including invigorating spleen and nourishing blood, warming yang in principle, enlivening spleen and resolving dampness, invigorating spleen and eliminating phlegm, and the curative effect is significant. modern research has also shown that drugs related to the regulation of spleen and stomach can prevent atherosclerosis by promoting gastrointestinal digestion and absorption function, improving energy and material metabolism, reducing vascular pressure by regulating lipid metabolism, and reducing intimal damage and lipid deposition by improving lipid peroxidation damage. it can be seen that based on the "intestinal flora", it is a feasible way to explore the effective treatment of cardiovascular diseases from the spleen and stomach. at the same time, increasing evidence also shows that intestinal flora is involved in the cardiovascular pharmacological effects of chinese medicine. for example, the study has revealed that the efficacy of shenling baizhu powder in the treatment of cardiovascular disease of spleen deficiency syndrome is related to the structural changes of intestinal flora. ding weijun et al. established the spleen deficiency mouse model by gavage with radix et rhizoma rhei and given shenling baizhu powder for treatment. the results showed that shenling baizhu powder could significantly increase the content of intestinal bifidobacterium, reduce the number of enterococcus and escherichia coli, and foster probiotics. they indirectly inhibited the opportunistic pathogens and pathogenic bacteria, and played a good role in regulating the recovery of the dynamic balance of intestinal flora. 5. summary and prospect the pathogenesis of heart failure is complex, and the mortality and re-hospitalization rate are high, which are still difficult problems in the medical field. in recent years, with the deepening of research on intestinal flora, the correlation between heart failure and intestinal flora has been gradually found, which provides a new idea and direction for the treatment of this disease. due to the blood stasis of gastrointestinal circulation, there are changes in the morphology and function of the intestinal tract as well as changes in the composition and metabolites of the intestinal flora in heart failure. the continuous aggravation of heart failure can further aggravate the imbalance of intestinal function and the disorder of intestinal flora, thus forming a vicious circle. chinese medicine can cut off the vicious circle in many ways, restore the steady state of intestinal microorganisms, and alleviate the metabolic disorders and inflammatory reactions caused by the imbalance of intestinal flora. due to the advantages of multiple targets and low toxicity, chinese medicine has been widely used for the prevention and treatment of heart failure. although more and more studies have confirmed that chinese medicine can treat heart failure by regulating the intestinal flora, most of them remain in the phenotypic studies and lack of further exploration of the specific mechanism. at the same time, due to the complexity of chinese medicine components and the diversity of intestinal flora, the interaction between them also needs further study. it is hoped that the advantages mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 4; july-august 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 19 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe of traditional chinese medicine can be continuously exerted in the future to provide a more effective method for the treatment of heart failure [32]. acknowledgement shaanxi provincial science and technology plan project (2021jm-481). references guo jintao, meng qingshu, fan huimin, liu zhongmin. v research progress on the role of intestinal flora imbalance in heart failure [j]. advances in cardiology, 2018, 39 (04): 619-622. doi: 10. 16806/j. cn ki. issn. 1004-3934. 2018. 04. 028. nagatomo y, tang w h. intersections between microbiome and heart failure:revisiting the gut hypothesis [j]. j card fail, 2015, 21(12):973[980]. guo shasha, chen haoyu, li yan, su wenge. exploration of the correlation between intestinal microecology and heart failure based on the theory of "correlation between heart and spleen" [j]. journal of shandong university of chinese medicine, 2020, 44 (03): 267-271. doi: 10. 16294/j. cn ki. 1007-659 x. 2020. 03. 009. zhang guang, luo fuli, dong bicheng, wu guoqing. research progress on correlation between regulation of intestinal flora and ckd in tcm and western medicine [j]. asia pacific traditional medicine, 2021, 17(09):176-179. wu wenjuan, wu jizhen, huang gairong, qian peng, zhang guojun. study on the correlation between intestinal flora imbalance and heart failure in elderly patients with idiopathic pulmonary fibrosis [j]. chinese journal of geriatric cardio-cerebrovascular diseases, 2022, 24(01):14-16. [6] jia shuwei, wu zhenli. intestinal flora imbalance and heart failure [j]. journal of microcirculation, 2019, 29(04):74-77. iacob s, iacob dg. infectious threats, the intestinal barrier, and its trojan horse:dysbiosis[j]. front microbiol, 2019, 10:1676. wu ningbo, sun hongxiang, zhao xiaoyun, et al. map3k2-regulated intestinal stromal cells define distinct stem cell niche[j]. nature, 2021, 592(7855):606-610. guo chunjun. immune activation kickstarts the gut microbiota[j]. cell host microbe, 2021, 29(3): 318-320. sandek a, swidsinskia, schroedl w, et al. intestinal blood flow in patients with chronic heart failure:a link with bacterial growth, gastrointestinal symptoms, and cachexia[j]. j am coll cardiol, 2014, 64(11):1092-1102. pasini e, aquilani r, testa c, et al. pathogenic gut flora in patients with chronic heart failure [j]. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 4; july-august 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 20 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe jacc heart fail, 2016, 4(3):220-227. jia shuwei, wu zhenli. intestinal flora imbalance and heart failure [j]. journal of microcirculation, 2019, 29(04):74-77+82. deng xinyi, jiang hong, li xianlun. research progress on the association of intestinal flora with heart failure [j]. china medical journal, 2020, 55(12):1301-1303. xiong yanhua, zeng wenping, fang juan. relationship between the severity of chronic heart failure and intestinal flora in the elderly [j]. china journal of microecology, 2021, 33 (06): 662-665+669. doi: 10. 13381/j. cn ki. cjm. 202106008. li guojing, liu lingmei. research progress on the relationship between intestinal flora changes and heart failure [j]. internal medicine, 2021, 16 (05): 643-645. zhong shishun. intestinal mucosal barrier dysfunction and bifidobacterium [j]. foreign medicine (physiology, pathology and clinical), 2003, (04):432-435. qian shaohuan, kang pinfang, wang hongju. research progress of intestinal flora and cardiovascular disease [j]. journal of qiqihar medical college, 2020, 41(08):1000-1002. tang w h, wang z, fan y. prognostic value of elevated levels of intestinal microbe-generated metabolite trimethylamine-n-oxide in patients with heart failure[j]. journal of the american college of cardiology, 2014, 64:1907-1914. goverse g, molenaar r, macia l, et al. diet-derived short chain fatty acids stimulate intestinal epithelial cells to induce mucosal tolerogenic dendritic cells[j]. j immunol, 2017, 198(5):2172-2181. chen mingtai, li meihuan, zhang jian, zhong zhang, luan jienan. exploration of the relationship between cardiovascular disease and intestinal microecology based on the theory of "the heart and the small intestine exterior-interior" [j]. world chinese medicine, 2020, 15(19):2920-2926. zhang zhonghe, xia hao. research progress on the relationship between short-chain fatty acids and cardiovascular disease [j]. journal of chinese pla medicine, 2020, 32(10):112-116. chen xi, li hanyu, hu xiaomin, et al. current understanding of gut microbiota alterations and related therapeutic intervention strategies in heart failure[j]. chinese medical journal, 2019, 132(15): 1843-1855. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 4; july-august 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 21 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe vinolo ma, rodrigues hg, nachbar rt, et al. regulation of inflammation by short chain fatty acids [j]. nutrients, 2011, 3(10):858-876. yang fei, wang congyu, wang lin, wang junkui, liu fuqiang, ji xincai. advances in the study of heart failure and intestinal flora imbalance [j]. journal of clinical internal medicine, 2020, 37(02): 142-144. von hs, schefold jc, jankowska ea, et al. ursodeoxycholic acid in patients with chronic heart failure:a doubleblind, randomized, placebo-controlled, crossover trial[j]. journal of the american college of cardiology, 2012, 59(6):585-592. zhuang jing, wang ruiping. exploration on the correlation between the theories of heart and spleen and the brain-gut axis [j]. china journal of traditional chinese medicine information, 2019, 26(09): 12-14. zhang chenyang, liu tianhao, wang wei, yao zheng, yi yang, xiao qian, chen wenhui. on intestinal microenvironment as an important biological basis for the treatment of liver disease from the spleen [j]. chinese journal of traditional chinese medicine, 2019, 34(07):2877-2880. he yunshan, hui huaying, tan zhoujin. the role of characteristic intestinal flora of spleen and stomach diseases in tcm diagnosis and treatment [j]. world chinese journal of digestology, 2019, 27(10): 605-610. jiang xiaoyan, xie weichang, zhou daqiao, li jian, guo shaoju, huang bin. effect of lichang decoction on intestinal microecology, metabolites and inflammatory factors in patients with ulcerative colitis of spleen deficiency and dampness stagnation type [j]. new traditional chinese medicine, 2019, 51(02):142-146. li qiuming, zhang yajie, zhang dafang, liu jia, li lijing. the microecological regulation of spleenstrengthening antidiarrheal granule on mouse model of spleen deficiency and imbalance of antibiotic intestinal flora [j]. china journal of basic medical science of traditional chinese medicine, 2010, 16(12):1119-1120. lin tianyao. study on the mechanism of cai's spleen-strengthening tongbian decoction in the treatment of constipation due to spleen deficiency and long-term clinical efficacy observation [d]. guangzhou: guangzhou university of traditional chinese medicine, 2017: zhao dandan, qu huiyan, yang tianshu, zhang xiaoqing, yang tao, zhou hua. overview of research on the regulation of intestinal flora in the prevention and treatment of heart failure by traditional chinese medicine [j]. journal of cardio-cerebrovascular diseases of integrated chinese and western medicine, 2021, 19(03):438-441. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 1 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe teaching english vocabulary to kindergarten children through physical activities rumeysa orhan, sibel karaman and ebru öztürkabstract abstract: language learning is a complex process that begins in early childhood. the mother tongue is the first language that children learn, and it is essential for their cognitive development. foreign language learning can also be beneficial for children, and it can help them to develop their cognitive skills, their cultural awareness, and their communication abilities. there are many different approaches to foreign language teaching, and the best approach for children will vary depending on their individual needs and learning styles. keywords: language learning, mother tongue, foreign language, cognitive development, cultural awareness, communication abilities introduction language is a social system that provides understanding among individuals (dilaçar, 1968). when people are still babies, they begin to learn their first language (l1) by first understanding and then speaking it. they start learning a foreign language / second language (l2) during the preschool period. the term “mother tongue” is believed to have derived from “lingua materna” in medieval latin, meaning the language of a mother (oksaar, 2003). günther and günther (2004) define the mother tongue as the language which an individual acquires from her mother and develops naturally during childhood. the language or languages learned after the mother tongue are referred to as foreign languages / second languages (lewondowski, 1990; larsen-freeman and long, 1991). according to lightbown and spada (2006), language learning is the individual's developmental knowledge in the target language. krashen (1982) states that the term language acquisition is preferred over language learning and that children can acquire a second language as well as the first language. chomsky argues that the ability to acquire a language is genetically inherent in human beings. he states that in spite of all the "stimulus poverty", it is possible for the human brain to acquire such a complex system as a language in a very short time and in a perfect way according to the principles of universal grammar which is inherent in the human brain (chomsky, 1981). there are four basic principles in foreign language teaching: listening, speaking, reading and writing. starting from the first stage of primary education, even from the preschool period, teaching a foreign language along with the mother tongue has become an issue that the world is increasingly focusing on. this paper was produced from the master’s thesis titled “teaching kindergarten children english vocabulary by total physical response in physical education courses” written in kırıkkale university, graduate school of health sciences, department of physical education and sports “. 1 kırıkkale university, graduate school of health sciences, kırıkkale / turkey. 2 kırıkkale university, faculty of sport sciences, kırıkkale / turkey. e-mail: rorhan@kku.edu.tr mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 2 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe nowadays, it is an undeniable fact that learning a foreign language is something ordinary for most of us. the question of learning at least a second foreign language is on the agenda. the increase in the importance of learning foreign languages has led scientists to create new language learning methods, to research which aspects of the target language should be taught, and to conduct research on different methods to be applied during language lessons. many psychologists and linguists, such as watson, piaget, bruner, vygotsky, chomsky have conducted much research on language teaching methods, developed different perspectives, and, as a result, found a variety of language teaching methods. in this context, for example, the grammar-translation method became a very popular language teaching method in the nineteenth and twentieth centuries and is still in use today (ur, 2012). according to this method, the important goal is to be able to read and understand literary works and other kinds of texts of the language. the focus is on grammar and translation. language and grammar rules are taught. however, writing, speaking, and listening skills are ignored (richards and rodgers, 2001). grammar-oriented and memorization-based methods were used more often in foreign language teaching in the past. modern methods emphasize the communicative aspect of the language. the aim of new methods is to establish the context for language learners to communicate in the target language and to create realistic classroom environments where students can express themselves verbally and in writing (demir, 2014). the language teaching methods developed in the last 30 years focus on verbal acquisition. thornbury (2004) draws attention to the importance of verbal knowledge. while grammar knowledge gives learners limited opportunities for expressing themselves, verbal knowledge eliminates such a restriction (demir, 2014). tpr is a teaching method developed in the 1970s focusing on verbal knowledge. the aim is to coordinate speech and action and combine language and body movements. it is still a popular method (asher, 2000). the objective of tpr is to teach the target language comprehensively and to develop basic communication skills. language learners are expected to follow the commands physically. tpr tpr was developed in 1965 by psychologist james asher. it is a method that aims to develop listeningcomprehension first and then verbal communication skills at the beginner’s level through physical actions by eliminating psychological pressure. in other words, it aims to teach the language through physical activities. actions and the use of the imperative mood are seen as the basis of language learning. the imperative mood is used as a linguistic tool directed by the teacher. while the students perform the movements shown by the teacher and watch what other friends do, the learning processes continue (demir, 2014). tpr is a foreign language teaching method focusing on the improvement of the comprehension skill first and then verbal skills through physical movements, without any pressure, at the beginner's level (asher, 1977). asher developed this methodology by making use of developmental psychology, learning theories, humanitarian education, and previous practices. tpr can be easily applied in the classroom. the teacher encourages children to recognize and respond to such simple instructions as sit, get up, hands up and so on. students first listen and then try to do as instructed (pinter, 2006). according to de cecco (1968), the simplest verbal behavior can be mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 3 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe defined as reacting to verbal stimulus through physical action. in this context, tpr can be described as a behavioral language learning theory. language learning, a coded program in human beings by birth, progresses as a result of a specific development program. babies, within the framework of this innate bio program, begin to move, get to know their environment, understand their parents and then start to speak their native language along with their psychomotor development. this process determines the most appropriate way of learning a second language / foreign language. asher argues that second language acquisition should follow the same way. in this acquisition process, children develop their ability to understand what they hear before they start speaking. the ability to understand what is heard is acquired through physical reactions to the verbal commands of the parents (asher, 1972). what distinguishes the tpr method from other methods is that listening-comprehension comes before speech. after learning how the target language works, speech begins automatically. students listen and respond to the instructions given by the teacher. in the end, the roles change, and the students begin to command. the teaching of imperative moods is of primary importance in tpr, which usually works better with young students. the teacher says "start running" and the student responds physically. the speech will not be perfect, but it is learned the way the mother tongue is acquired. no one can expect babies to talk. babies begin to perceive what they hear first, then respond physically, and finally speak when they are ready after a certain period of psychomotor development. one important advantage of tpr for preschool children is that it is not text-dependent. tpr can often be verbal. this is an excellent type of activity for mixed skill classes. it can be a rewarding method for children with dyslexia and other learning problems. one can use many other teaching techniques for young students in addition to tpr. it could be better to use different techniques with different children/groups. the advantages of tpr are its accessibility, vitality, and attractiveness to students. even though tpr works better especially with young students, it can be used for adults and even for the elderly. tpr is something that both teachers and students enjoy (dyson, 2012). anxiety is one issue that tpr focuses on. when there is anxiety between learning and what is to be learned, learning may become difficult. for successful language teaching, the level of anxiety must be lowered. according to asher, the fastest and least stressful way to understand the target language is to implement the commands given by the teacher without translating them into the mother tongue. the tpr method was developed to reduce stress and anxiety. tpr aims to reduce the pressure in language learning by improving listening and comprehension skills, matching language with applied actions. in this approach, the student tries to fulfill what the teacher commands. asher's method is directed to the right brain hemisphere, while other foreign language teaching methods are covered in the learning context of the left-brain hemisphere. this is because the child's native language is acquired through physical (motor) activities, which take place in the right-brain hemisphere (yavuz, 2011). tpr method focuses on verbal competence at the beginner’s level, while the development of speaking skill is left to its natural pace. adults should also acquire a second language through right-brain-based activities (asher, 2002). mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 4 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe verbal communication and physical movements are prominent in tpr. when you wave hands and say hello, the students will respond to you in a gentle and exciting way. now it is time to implement the tpr method. they can be instructed to do what the teacher says and does in the classroom or in the sports field. sporting activities, playing games involving physical actions, asking them to touch the part you determine on the floor or wall are all included in the tpr method (dyson, 2012). physical education and sports and tpr moving makes children happy. by moving, they begin to get to know their environment, discover new places, and recognize new people and objects. moving is their greatest source of joy and learning. therefore, the mobility of children, especially in early childhood, should not be restricted by their parents. on the contrary, it should be an important part of their development, and the range and diversity of movement should be enhanced (orhan, 2019). physical education and sports/play lessons provide opportunities for children to move, do sports and play games. physical education aims to encourage children to take up a sport as a habit, help them know about their bodies, keep them physically active and help them learn through movement. çelik (2008) defined physical education as educating people through physical activities. tpr helps teach a foreign language through physical movements. physical education and sports/play is a course in which the tpr method can be applied comfortably. the teacher demonstrates the target words to be taught, such as run, jump, and throw, and then asks the students to do the same. during the lesson, the students follow every command given by the teacher. thus, the foundation of learning a foreign language in a fun and healthy way can be laid. asher (1977) underlines that most of the grammatical structures of the target language and hundreds of phrases can be taught by skillful use of the imperative mood. tpr selects the target words among from the most commonly used words. since the participants of this study are preschool students, the target words of the english language teaching program consist of commonly used words. this study examines the effect of tpr on vocabulary teaching in physical education and play and investigates the success level of tpr in language teaching. material and method this is a quasi-experimental and quantitative study focusing on the effect of tpr teaching method on verbal competence. participants of the study were divided into experimental and control groups to both of which a pretest and a posttest were applied, and the results were analyzed in spss 23.0 program. research design in this study, the effect of tpr language teaching method on lexical competence was investigated. a pre-test consisting of 16 multiple choice and matching questions was applied to both groups before the 6-week teaching period began. the target words to be used in the study were selected from the pre-school english language teaching curriculum. the lesson plans were determined according to the target words, tpr, and communicative approach language teaching method. the experimental group was taught the determined the target words in accordance with the tpr method by play, physical exercise, and movements while the control group learned the same target words by verbal communication in the classroom environment in accordance with the communicative approach. when the 6week teaching program ended, a posttest consisting of 16 multiple choice and matching mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 5 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe questions was applied to both groups. the results of the tests were statistically analyzed to reveal which study group had a higher level of vocabulary learning. the findings demonstrated the importance of tpr on the teaching of vocabulary. data analysis firstly, the data were checked to see whether the distribution was normal. then the data, normally distributed, were analyzed using the paired t-test. participants a total of 32 kindergarten students aged 6 volunteered for this study. the control group consisted of 6 female and 10 male students while the experimental group was composed of 9 female and 7 male students. results table 1 shows the statistical analysis of the answers given by the control and experimental groups to the questions. it indicates that there is a significant difference between the total scores of the pre-test and post-test questions of the control and experimental groups (p<0.000). it suggests that the application of tpr in physical education and play classes significantly increases the language learning success of kindergarten students (p<0.01). the pretest mean for the control group was 17 ± 0.0; the post-test mean was 34.0 ± 0.00 and the variance was 0,000. the mean of the control group increased in the posttest, but the variance was the same as in the pre-test. although the pretest and posttest mean of the control group increased, the related t-test could not be performed due to the variance being 0,000. the pretest mean for the experimental group was 29 ± 0.0; the mean for the posttest 30,6667 ± 1,79947 and the variance was 3,238. it can be seen that the mean for the correct answers and standard deviation of the experimental group increased. table 1. control and experimental group total responses 95% confidence std. interval of the mean stdev error differences t sd p total total questions pretest -14,2592 1,4830 ,28541 -14,8459 -13,6725 49,960 26 ,000 (controltotal experimental) posttest table 2 shows the t-test statistics of the experimental group, which suggest that the total physical response method significantly increased the language learning of the kindergarten children as a foreign language teaching and learning method in physical education and play lesson (p<0.01). pairwise differences mean lower limit upper l imit mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 6 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe table 2. related t-test statistics for total scores (experimental group) 95% confidence std. interval of the mean stdev error differences t sd p mean lower upper limit limit pair experimental group post – experimental group pre 30,6667 1,7994 ,46462 12,6701 14,6631 29,415 14 ,000 table 3 shows the evaluation of the answers given by the students in the experimental group according to ttest results. the related t-test results for the experimental group show a significant difference (change in scores) between the pre-test and post-test on question basis (question 6, question 7, question 8, question 9 (p6, p7, p8, p9 <0.01)). the table demonstrates similar results for question 3, question 11, question 12, question 13, question 15 (p3, p11, p12, p13, p16> 0.05). table 3: related t-test statistics for experimental group on question basis pairwise differences mean stdev std. error mean 95% confidence interval of the differences lower upper limit limit t sd p pair 3 q pretest 3 q posttest 3 ,06667 ,25820 ,06667 -,07632 ,2096 1,000 14 ,334 pair 6 q pretest 6 q posttest 6 ,46667 ,51640 ,13333 ,1807 ,7526 3,500 14 ,004* pair 7 q pretest 7 q posttest 7 1,06667 ,25820 ,06667 ,9236 1,2096 16,000 14 ,000* pair 8 q pretest 8 q posttest 8 -,93333 ,25820 ,06667 -1,0763 -,7903 -14,000 14 ,000* pair 9 q pretest 9 q posttest 9 -,93333 ,25820 ,06667 -1,0763 -,7903 -14,000 14 ,000* pair 11 q pretest 11 q posttest 11 ,13333 ,35187 ,09085 -,06152 ,3281 1,468 14 ,164 pairwise differences mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 7 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe pair 12 q pretest 12 q posttest 12 ,13333 ,35187 ,09085 -,06152 ,3281 1,468 14 ,164 pair 13 q pretest 13 q posttest 13 ,13333 ,35187 ,09085 -,06152 ,3281 1,468 14 ,164 pair 15 q pretest 15 q posttest 15 ,13333 ,35187 ,09085 -,06152 ,3281 1,468 14 ,164 pair 16 q pretest 16 q posttest 16 ,06667 ,25820 ,06667 -,07632 ,2096 1,000 14 ,334 discussion this study was conducted to investigate the effectiveness of tpr in foreign language teaching. the total number of the kindergarten students participating in the study, all aged 6, was 32 and 16 of them were in the experimental group while 16 were in the control group. the students in the experimental group were taught english words by using tpr in physical education and play lessons while the students in the control group learned the same vocabulary by means of classical methods. the study lasted 8 weeks. the 1st and the 8th weeks were spared for the pre-test and post-test applications respectively and the remaining 6 weeks were the teaching period. the results of the study indicated that the students in the experimental group were more successful in learning the target english words and structures than the students in the control group (p<0.01). in addition, it was observed that the lessons were more entertaining, and the students were more concentrated with the children in the experimental group. similar results were found in nilgün yavuz's (2011) research called “using total physical response-storytelling method in teaching japanese”. various studies conducted by james asher, the founder of tpr, in the last two decades show that there is a significant difference in the scores of the students educated by tpr. for example, in a study conducted on university students in the elementary level spanish class, tpr was applied to the experimental group while the control group was taught spanish through the traditional teaching methods. pimsleur spanish proficiency test was applied to both groups and it was found that there was a significant increase in the test scores of students who were taught through tpr (wolfe and jones 1982). a study in oman shows that tpr can be a successful approach to the education of young children. it helps language learning, as it is a fun and entertaining teaching method, creating a stress-free environment that makes students feel comfortable in a new language. on the other hand, this approach is not widely used because of the length of the curriculum, and lack of qualified teachers (al-harrasi, 2014). although the tpr method has many positive aspects, it has been criticized that it is insufficient in improving reading and writing skills. in the 1990s, blain ray added storytelling to the method because of the criticism that it was limited to the beginner level of vocabulary teaching. thus, he improved the tpr method and corrected the shortcomings, creating tprs, the teaching proficiency through reading and storytelling method. this method facilitates the teaching of vocabulary and grammar structures in stories. storytelling was supported by motor mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 8 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe activities, group work, role-playing techniques, and the use of visual and audio tools. thus, as new knowledge is coded into long-term memory and associated with daily life, it is easier to remember what is acquired. davidheiser (2001) states that the total physical response-storytelling method (tprs) is a natural way of learning the language and is better because it differs from standard teaching techniques, improving pronunciation and vocabulary memory, reducing anxiety, and encouraging active learning. braunstein (2006) discovered that even adult esl students expecting more traditional education respond positively to tprs. he reported that the students were enthusiastic about the class and that the method helped them remember words and understand english better. watson (2007) compared two high school groups at the elementary level using the tprs method. at the end of the study, he gave an oral and a written examination to the students he had separated as control and experimental groups. the results showed that the experimental group students learning with tprs were more successful than the control group students. conclusion to conclude, this paper demonstrates that tpr is effective in teaching kindergarten students a foreign language. tpr techniques used along with sports and games make learning a foreign language more entertaining and better and easier for children. in addition to a foreign language, maths (numbers, addition, subtraction) can be taught more easily to preschool students in physical education and sports through similar methods. references al-harrasi, k.t.s. (2014). using “total physical response” with young learners in oman, journal articles; reports – research. asher, j.j. (1972). children’s first language as a model for second language learning. modern language journal, 56, 133139; 1972. asher, j.j. (1977). learning another language through actions. the complete teacher’s guide book (6th ed.). los gatos: sky oaks productions, inc. asher, j.j. (2000). learning another language through actions. los gatos, california: sky oaks productions. asher, j.j. (2002). brainswitching, learning on the right side of the brain. los gatos, ca sky oaks productions, inc. braunstein, l. (2006). adult esl learners’ attitudes towards movement (tpr) and drama (tpr storytelling) in the classroom. catesol, 18:1, 7-20. chomsky, n. (1981). lectures on government and binding. dordrecht: foris. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 9 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe çelik, a. (2008). beden eğitimi öğretmenlerinin okul i̇çi ve okul dışı faaliyetlerde karşılaştıkları sorunların i̇ncelenmesi (trabzon i̇li örneği). yüksek lisans tezi. gazi üniversitesi eğitim bilimleri enstitüsü. davidheiser, .j.c. (2001). the abcs of tpr storytelling. dimension, 45-53. de cecco, j.p. (1968). the psychology of learning and instruction: educational psychology. englewood cliffs: prentice-hall. demir, ş. (2014). tprs dil öğretim metodun sözcük bilgisine olan etkisi. yüksek lisans tezi, dokuz eylül üniversitesi. dilaçar, a. (1968). dil, diller ve dilcilik. tdk yayınları. dyson, l. (2012). my little island, harlow, united kingdom. günther, b, günther h. (2004). erstsprache, zweitsprache, fremdsprache, weinheim und basel: betz. krashen, s. (1982). principles and practice in second language acquisition. alemany press. larsen-freeman, d., & long m. (1991). an introduction to second language acquisition research. new york: longman. lewandowski, t. (1990). linguistisches wörterbuch (1-3), heidelberg-wiesbaden: quelle und meyer. lightbown, p., spada, n.m. (2006). how languages are learned. oxford: oxford university press. oksaar, e. (2003). zweitspracherwerb. stuttgart: w. kohlhammer. orhan, r. (2019). çocuk gelişiminde fiziksel aktivite ve sporun önemi. kırıkkale üniversitesi sosyal bilimler dergisi, 9 (1): 157-176. pinter, a. (2006). teaching young language learners. oxford, united kingdom: oxford university press. richards, j.c., & rodgers t.s. (2001) approaches and methods in language teaching. cambridge, uk: cambridge university press. thornbury, s. (2004). how to teach vocabulary. essex:1 pearson education limited, isbn 0582-429668. ur, p. (2012). a course in english language teaching. new york: cambridge university press. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 10 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe yavuz, n. (2011). tüm fiziksel tepki-öykü anlatma yönteminin japoncanın öğretiminde kullanılması. dil dergisi, sayı: 152, nisan-mayıs-haziran. watson, b. (2009). a comparison of tprs and traditional foreign language instruction at the high school level. international journal of foreign language teaching, 5:1 (summer), pp. 21-24. wolfe, d.e., & jones, g. (1982). integrating total physical response strategy in a level i spanish class, reprinted from foreign language annals, 14, n. 4. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 5; september-october 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 21 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe comprehensive insights into microvascular angina: a comparative review of pathogenesis, diagnosis, and treatment" 1dr. wei li, shaanxi and 2dr. xin zhang, 1university of chinese medicine, xianyang, china 2department of cardiovascular medicine, xi'an traditional chinese medicine hospital, xi'an, china abstract: microvascular angina (mva) is a complex syndrome characterized by angina symptoms and objective myocardial ischemia without obstructive coronary artery disease. this condition, often overlooked in the past, is gaining recognition due to advancements in coronary artery examination methods. mva is associated with structural and functional abnormalities in myocardial coronary arteries with diameters less than 500 microns. this review explores the pathogenesis, diagnostic techniques, and western medicine treatment options for mva. a better understanding of mva's underlying mechanisms and effective diagnostic and therapeutic approaches is essential for managing this condition. keywords: microvascular angina, myocardial ischemia, diagnostic methods, pathogenesis, treatment options introduction microvascular angina (hereinafter referred to as mva) refers to the syndrome with typical or atypical symptoms of angina pectoris, accompanied by objective evidence of myocardial ischemia, and excluding subepicardial obstructive coronary artery disease and other cardiovascular diseases. from the perspective of pathophysiology, this disease is due to the pathological changes of the structure and function of the inferior myocardial coronary artery with a diameter of less than 500 microns [1]. with the continuous optimization of modern technology in coronary artery examination methods, the diagnostic rate of microvascular angina is also increasing. this article provides a review of the pathogenesis, diagnostic methods, and western medicine treatment of microvascular angina, in order to provide diagnostic and therapeutic ideas for this disease. 1. understanding of microvascular angina pectoris in 1967, likoff et al. reported a group of patients with typical labor angina pectoris, positive exercise test and normal coronary angiography, which was the first report of such diseases in history of medicine. subsequently, in 1973, kemp et al. [2] first named this condition x syndrome. in 1985, cannon renamed this disease microvascular angina. in 2013, the european society of cardiology guidelines for the treatment of stable coronary artery disease, the disease was named as abnormal microvascular function. the chinese expert group mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 5; september-october 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 22 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe failed to include the structural abnormalities of this disease due to microvascular dysfunction, and therefore recommended renaming microvascular dysfunction to coronary microvascular disease (cmvd). in 2020, the european society of cardiology (esc) and the european society for percutaneous cardiovascular intervention (eapci) jointly issued the "2020 european expert consensus on non obstructive coronary ischemic disease (inoca)", which refers to myocardial ischemia caused by coronary microcirculation disorders (cmd) as microvascular angina. due to limitations in diagnostic and treatment methods in the early stages, positive treadmill exercise tests are often used as a diagnostic basis for microvascular angina. with the development of diagnostic and treatment technology, people's understanding of such diseases has become clearer. in fact, microvascular angina can only be diagnosed if there is a coronary microcirculation disorder. however, microvascular angina is only a subtype of non-obstructive coronary ischemic heart disease, and there are many reasons that can cause non obstructive coronary myocardial ischemia, such as epicardial vasospasm, myocardial bridge, etc. [3]. 2. the pathogenesis of microvascular angina the pathogenesis of microvascular angina can be divided into two types: abnormal coronary microvascular function and microvascular structural remodeling [4]. simply put, one is functional and the other is structural [5], and both can exist simultaneously. 2.1. functional abnormalities abnormal function refers to abnormal vasomotor function of coronary artery microvessels. the main reasons are (1) injury of vascular endothelium: dysfunction of vasomotor function of vascular endothelial factor, which is manifested by decreased diastolic function and increased sensitivity to vasoconstriction stimuli. mainly due to abnormal production and release of endothelial dependent relaxing factor nitric oxide (no) [6] smooth muscle dysfunction: mainly because endothelial cell independent active factor stimulates receptors on smooth muscle cell membrane and intracellular signal pathways, thereby causing abnormal microvascular relaxation [7] microvascular spasm: some vasoactive substances can cause diffuse microvascular contraction and myocardial ischemia, but have no effect on the epicardial coronary artery. for example, the lack of estrogen level will affect the autonomic nervous function, and the dysfunction of autonomic nervous function will make the myocardium α abnormal activation of adrenergic receptor causes coronary microvascular contraction, which leads to myocardial ischemia [8]. 2.2. structural abnormalities coronary microvascular remodeling can be divided into three types: centripetal remodeling of arteriole, increase of vascular wall lumen ratio, decrease of myocardial capillary density, etc. [9]. the main reason may be: hypertensive ventricular hypertrophy, hypertrophic cardiomyopathy patients usually have the problem of hypertrophy of smooth muscle cells and excessive deposition of collagen fiber cells, which is easy to cause the thickening of vascular intima [10]. it is worth mentioning that the reconstructed arteriole will become extremely sensitive to the stimuli of vasoconstriction, which will lead to dysfunction of vasoconstriction. its response to mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 5; september-october 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 23 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe endothelial independent vasodilators (such as adenosine) can be manifested as a decrease in coronary flow reserve (cfr) and an increase in microcirculation resistance [11]. 3. risk factors traditional coronary heart disease risk factors such as hypertension, dyslipidemia, smoking and diabetes may cause coronary microvascular disorders. (1) hypertension: as mentioned earlier, hypertensive ventricular hypertrophy and hypertrophic cardiomyopathy can cause thickening of the intima of blood vessels, leading to the occurrence of microvascular structural abnormalities. studies have shown that patients with microvascular angina have a significant increase in interventricular septal thickness compared to normal individuals, and the more significant the increase in interventricular septal thickness, the higher the risk of developing coronary microvascular angina [12] dyslipidemia: lipoprotein a is a risk factor of cardiovascular system. studies have shown that the content of lipoprotein an in patients with microvascular angina is significantly higher than that in normal people, while apolipoprotein a is significantly lower. apolipoprotein a may be a protective factor [13-16]. some studies have also confirmed that lipoprotein associated phospholipase a2 (lp pla 2) can promote the release of inflammatory factors, reduce the production of nitric oxide, and lead to dysfunction of coronary microvascular endothelial cells. a retrospective study by zhang yi and others found that the increase of serum lp-pla2 and homocysteine (hcy) is an independent risk factor for coronary micro vascular disease in middleaged and elderly women [17]. in addition to traditional risk factors, risk variables related to inflammation also play a role in coronary microcirculation disorders [18,19]. interleukin-1 (il-1), interleukin 6 (il-6) tumor necrosis factor produced by microvascular smooth muscle cellsα (tnfα) when inflammatory cells infiltrate, such growth factors and cytokines will cause abnormal proliferation and migration of smooth muscle cells [20]. chen bin et al. [21] monitored the high sensitivity c-reactive protein (hs-crp) and coronary flow reserve (cfr) of 38 patients with microvascular angina using myocardial contrast echocardiography. the analysis results showed that the concentration of high sensitivity c-reactive protein was negatively correlated with coronary flow reserve. besides, compared with obstructive coronary artery disease, social psychological stress is more involved in the occurrence of non obstructive coronary ischemic heart disease. a meta-analysis showed a significant correlation between social and psychological factors and ischemic heart disease, including microvascular angina. in the female population with ischemic heart disease, patients are often accompanied by psychological disorders such as anxiety and depression [22]. microvascular angina, as a common type of ischemic heart disease, often coexists with psychological disorders such as anxiety and depression [23]. 4. epidemiology at present, there is no epidemiological data of coronary micro vascular disease with large sample data in china. the past small sample clinical trials showed that the incidence rate of coronary microvascular disease was between 45% and 60% in patients with no obvious obstruction in coronary angiography when there were signs of mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 5; september-october 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 24 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe myocardial ischemia. the incidence of microvascular angina in women is higher than that in men, especially in perimenopausal women [24,25]. 5. western medicine diagnosis and treatment plan for microvascular angina 5.1. diagnostic indicators based on the diagnostic protocols provided in chinese and foreign guidelines, it is divided into invasive assessment and non-invasive assessment. at present, there is no direct method for observing human coronary microcirculation, and the existing evaluation indicators mainly rely on functional indicators: (1) cfr coronary flow reserve refers to the ratio of the average peak flow rate in the maximum congestive state to the resting average peak flow rate under the action of various vasoactive stimuli (such as adenosine). it comprehensively reflects the blood flow status of the epicardial coronary artery and coronary artery microcirculation. the normal value of cfr is 3-5, and less than 2 indicates insufficient myocardial perfusion. (2) index of microcirculatory resistance (imr) refers to the distal coronary artery pressure under maximum congestion × average conduction time in congested state. imr ≥ 25 indicates microvascular dysfunction. (3) fractional flow reserve (ffr) is the ratio of distal coronary artery mean pressure to aortic pressure in congested state, which can be used to evaluate whether blood flow is restricted in patients with obstructive coronary heart disease. ffr ≤ 0.8 indicates abnormalities. 5.1.1. invasive assessment it includes guide wire direct invasion test and acetylcholine excitation test. diagnostic options include thermaldilution and doppler technology based guidewire. there is evidence to suggest that the doppler may better reflect the state of insufficient microvascular perfusion than the thermaldilution [26]. currently, the intracoronary doppler flow guidewire is the gold standard for measuring cfr in traumatic techniques.the invasive diagnostic criteria for microvascular angina given in the guidelines are: diagnostic guide wire and adenosine test: ffr>0.8 (non-obstructive)+cfr<2.0, imr ≥ 25 (microcirculation disorders)+acetylcholine provocation test: no or<90% of the internal diameter decreases, angina symptoms, ischemic ecg changes (indicating that there is myocardial ischemia without epicardial vasospasm). 5.1.2. non invasive assessment a variety of non-invasive techniques, including ecg exercise tolerance test, transthoracic doppler echocardiography (ttde), myocardial contrast echocardiography (mce), myocardial perfusion imaging, positron emission tomography (pet), and cardiac magnetic resonance imaging (cmr), can be used to detect local myocardial ischemia. pet is considered as a non-invasive gold standard for the diagnosis of coronary micro vascular disease due to its high accuracy. myocardial contrast-enhanced echocardiography (mce) is widely used in clinical practice due to its real-time bedside operation, relatively low cost, and ability to quantitatively and qualitatively evaluate myocardial blood flow perfusion. the non-invasive diagnostic criteria provided in the guidelines are: objective evidence of myocardial ischemia in resting or under load conditions exists, and cfr mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 5; september-october 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 25 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe values<2.0 are measured and calculated using non-invasive examination equipment to illustrate coronary microcirculation disorders; if cfr ≥ 2.0, the stimulation test of acetylcholine is feasible. if there is no spasm of the epicardial coronary artery but angina pectoris symptoms and ecg blood deficiency st-t changes occur, microvascular angina pectoris can also be diagnosed. 5.2. medicine treatment 5.2.1. traditional treatment: (1) control of risk factors: angiotensin converting enzyme inhibitors (acei) and angiotensin receptor blockers (arb) are the first choice for patients with hypertension, statins can be used for patients with hypercholesterolemia, active control of blood glucose in patients with diabetes can improve coronary microvascular endothelial function, and obesity can improve cfr by weight loss [27]; (2) improvement of myocardial ischemia: drugs for stable microvascular angina are mainly used to reduce myocardial oxygen consumption, such as β-blockers. if β-blockers are not tolerated, ivabradine can be used instead [28].drugs such as acei, arb, and ranolazine have the effect of increasing cfr values and improving small vessel remodeling. for perimenopausal female patients with stable microvascular angina, estrogen supplementation can be combined. at present, studies [29] have reported that endothelial function is impaired in postmenopausal women with microvascular angina, and administering exogenous estradiol can increase peripheral blood flow in normal postmenopausal women. calcium antagonists are recommended for angina pectoris, which is mainly caused by microvascular spasm. nicorandil can effectively dilate subepicardial coronary arteries and coronary arteriole, so it should be the first recommended drug for coronary microvascular angina [30]. 5.2.2. new drug treatments (1) long term supplementation (6 months) of l-arginine (a precursor of no) can improve endothelial function, coronary blood flow, and symptoms in non-obstructive cad patients, but does not include cfr oral administration of selective eta receptor antagonist (zibotan) can antagonize endothelin-1 induced vasoconstriction, thereby improving vascular endothelial function [31]. (3) phosphodiesterase is highly expressed in vascular smooth muscle cells, and inhibiting its secretion can promote vascular smooth muscle relaxation. oral phosphodiesterase inhibitor can rapidly increase cfr value of patients, and has anti-inflammatory and antiplatelet effects [32]. 6. etiology, pathogenesis and treatment of traditional chinese medicine there is no name for microvascular angina in traditional chinese medicine, and there is currently no unified classification. according to its clinical symptoms, it should be classified into categories such as "chest pain" and "heartache". it shares similarities with traditional chest pain, but also has different characteristics. mva patients are often associated with collateral obstruction. traditional chinese medicine believes that the causes of mva related collateral lesions include the following four points: (1) the collateral itself is thin and curved, resulting in delayed circulation of qi and blood, which is prone to pathological changes of stasis [33]; (2) the pathogenic factors mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 5; september-october 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 26 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe of phlegm and dampness in the blood are often sticky and greasy, which can easily stagnate in the collaterals, leading to poor circulation of qi and blood in the veins due to external cold pathogenic factors, the heart yang is insufficient, and the cold pathogenic factors of the six evils have the characteristics of attracting and stagnating. therefore, the two colds interact with each other, causing the collaterals of the heart to be congested and urgent, and the qi and blood to be blocked [34] qi is the leader of blood, and the operation of blood in the collaterals mainly depends on the promotion of qi. if psychological stress is too high, anxiety and gas stagnation may occur, which may lead to unfavorable operation of qi, inability to promote blood operation, and blocked collaterals. wu yiling, an expert in collateral diseases in china, pointed out that according to the "theory of pathological changes in the venation vascular system", the concepts of venation, middle and small arteries, and microcirculation are highly consistent, so the abnormal function of the collateral homeostasis is similar to the vascular endothelial dysfunction called by modern medicine. collateral deficiency is a state of contraction, contraction, and spasms caused by various factors such as external pathogens, excessive emotions, and overwork. it is one of the main pathological changes in collateral diseases. modern medicine believes that a decrease in no concentration and an increase in et concentration in blood vessels are one of the pathological foundations of coronary artery spasm and endothelial dysfunction [35]. the urgency of collaterals is basically similar to the vasospasm in modern medicine, and vascular endothelial dysfunction and vasospasm can lead to blood hypercoagulability, microthrombosis formation, and even myocardial ischemia and necrosis [36]. this is consistent with the theory of "phlegm stasis obstructing collaterals" in traditional chinese medicine. in summary, phlegm turbidity, qi stagnation, and blood stasis are the basic characteristics, so in terms of treatment, the characteristics of traditional chinese medicine are to regulate qi, dissipate phlegm, and promote blood circulation and unblock collaterals. 7. summary and outlook in summary, with the development of modern diagnostic and treatment technologies, the relevant pathogenesis and diagnosis and treatment plans of microvascular angina have become increasingly perfect, gradually evolving from the initial "x syndrome" to the widely recognized "microcirculation function and structural disorders". however, many underlying mechanisms have not yet been fully elucidated, and further development and popularization of modern diagnostic and treatment technologies are needed. more and more studies show that microvascular angina plays an important role in non-obstructive ischemic heart disease, and is closely related to cardiovascular diseases such as hypertrophic cardiomyopathy, diabetes heart disease and hypertensive heart disease. therefore, the prevention and treatment of microvascular angina is an important issue that urgently needs attention. we hope to raise the attention of clinical colleagues to microvascular angina disease through this discussion, update relevant concepts, and conduct large-scale epidemiological investigations if necessary to optimize diagnostic plans and form a more standardized and complete diagnosis and treatment system. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 5; september-october 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 27 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe references chilian wm. coronary microcirculation in health and disease. summary of an nhlbi workshop. circulation, 1997, 95: 522-528. kemp h. left ventricular function in patients with the anginal syndrome and normal coronary angiograms american journal of cardiology, 1973, 32(3):375-376. kunadian v, chieffo a, camici p g, et al. an eapci expert consensus document on ischaemia with nonobstructive coronary arteries in collaboration with european society of cardiology working group on coronary pathophysiology & microcirculation endorsed by coronary vasomotor disorders international study group [j]. eur heart j, 2020:ehaa503. doi:10. 1093/eurheartj/ehaa503. ong p, camici pg, beltrame jf, et al. international standardization of diagnostic criteria for microvascular angina[j]. int j cardiol, 2018, 250 (1):16-20. mejía-renteraí h, van der hoeven n, van dehoef t p, et al. targeting the dominant mechanism of coronary microvascular dysfunction with intracoronary physiology tests[j]. int j cardiovasc imaging, 2017, 33(7):1041-1059. doi:10. 1007/s10554-017-1136-9. wu yihang, deng cuiyun. research progress of pathogenesis and treatment of microvascular angina [j]. china & foreign medical treatment, 2017, 36 (14): 196-198. halcox jp, schenke wh, zalos g, et al. prognostic value of coronary vascular endothelial dysfunction[j]. circulation, 2002, 106(6):653-8. baumgart d, haude m, gorge g, et al. augmented alpha-adrenergic constriction of atherosclerotic human coronary arteries[j]. circulation, 1999, 99(16):2090-7. huang baotao, chen mao. interpretation of the newly released european expert consensus document on ischaemia with non-obstructive coronary arteries:improving the ability of hierarchical diagnosis and treatment,and strengthening the joint management of general practitioners and specialist physicians[j].chinese general practice,2021(02):125-131. camici pg, olivotto i, rimoldi oe. the coronary circulation and blood flow in left ventricular hypertrophy [j]. mol cell cardiol, 2012, 52(4): 857-64. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 5; september-october 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 28 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe sorop o, merkus d, de beer vj, houweling b, pistea a, mcfalls eo, boomsma f, van beusekom hm, van der giessen wj, vanbavel e, duncker dj. functional and structural adaptations of coronary microvessels distal to a chronic coronary artery stenosis. circ res 2008; 102:795–803. grover r, leipsic ja, mooney j, et al. coronary lumen volume to myocardial mass ratio in primary microvascular angina [j]. cardiovasc comput tomogr, 2017, 11 (6): 423-428 hermans mp, ahn sa, rousseau mf. the mixed benefit of low lipoprote in (a) in type 2 diabetes [j]. lipids health dis, 2017, 16 (1): 171. gulere, guler gb, kizilirmak f, et al. evaluation of adiponectin and li-po-protein(a)levels in cardiac syndrome x[j]. herz2015, 40:291-297 hermansmp, valensi p, ahn sa, et al. [hdl-c/apoa-i]: a multivessel cardiometabolic risk marker in women with t2dm [j]. diabetes metab res rev, 2018, 34 (1): e2950. mishrammuthuramu i, kempen h, et al. administration of apo a-i (milano)nanoparticles reverses pathological remodelling, cardiac dysfunction, and heart failure in a murine model of hfpef associated with hyperten sion [j]. sci rep, 2020, 10(1):8382. zhang yi, zhang yingying, zhang tao. study on the diagnostic value of lipoprotein-associated phospholipase a2 combined with homocysteine for microvascular angina pectoris in middle-aged and elderly women[j]. chinese modern doctor, 2022, 60 (18): 11-15. schroder j, mygind nd, frestad d, michelsen m, suhrs he, bove kb, gustafsson i, kastrup j, prescott e. proinflammatory biomarkers in women with non-obstructive angina pectoris and coronary microvascular dysfunction. int j cardiol heart vasc 2019;24:100370. jakob schroder, naja dam mygind, daria frestad, et al. pro-inflammatorybiomarkers in women with nonobstructive angina pectoris and coronary microvascular dysfunction [j]. ijc heart and vascular, 2019, 24: 1-7. chen y f, wu k j, wood w g. paeonia lactiflora extract attenuating cerebral ischemia and arterial intimal hyperplasia is mediated by paeoniflorin via modulation of vsmc migration and ras/mek/erk signaling pathway[j]. evid based complement alternat med, 2013, 2013:482428. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 5; september-october 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 29 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe chen bin, wang wei, lv jun, et al. the effect of inflammatory response on coronary blood flow reserve function in patients with microvascular angina [j]. shaanxi medical journal, 2010, 39 (8): 990-992. mommersteeg pmc, maas ahem. genderverschillen in psychologische klachten bijischemische hartziekte gender differences in psychological complaints in ischemic heart diseases [j]. ned tijdschr geneeskd, 2018, 162:d2961. jaskanwal d. sara, mbchb, r. jay widmer, et al. prevalence of coronary microvascular dysfunction among patients with chest pain and nonobs-tructive coronary artery disease [j]. jacc cardiovasc interv, 2015, 8(11):1445-1453. thomas j. ford, eric yii, novalia sidik, et al. ischemia and no obstructive coronary artery disease prevalence and correlates of coronary vaso motiondisorders. circ cardiovasc interv, 2019, 12: 1-10 volterrani m, rosano g, coats a, et al. estrogen acutely increases peripheral blood flow in postmenopausal women [j]. american journal of medicine, 1995, 99(2):119-122. nerla r, tarzia p, sestito a, et al. effect of bariatric surgery on peripheral flow-mediated dilation and coronary microvascular function. nutr metab cardiovasc dis, 2012, 22: 626-634. mumma b, flacke n. current diagnostic and therapeutic strategies in microvascular angina. curr emerg hosp med rep, 2015, 3: 30-37. crea f, camici pg, bairey merz cn. coronary microvascular dysfunction:an update[j]. european heart journal, 2014, 35(17):1101. lanza ga, parrinello r, figliozzi s. management of microvascular angina pectoris. am j cardiovasc drugs, 2014, 14: 31-40. teresa padro, olivia manfrini, raffaele bugiardini, et al. esc working group on coronary pathophysiology and microcirculation position paper on ‘coronary microvascular dysfunction in cardiovascular disease’. cardiovascular research, 2020; 116(4): 741–755. bairey merz cn, pepine cj, shimokawa h, et al. treatment of coronary microvascular dysfunction [j]. cardiovasc res, 2020, 116(4):856-870. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 5; september-october 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 30 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe taqueti vr, di carli mf. coronary microvascular disease pathogenic mechanisms and therapeutic options: jacc state-of-the-art review [j]. j am coll cardiol, 2018, 72(21):2625-2641. chang chengcheng, wei cong, wu yiling. “minute collaterals and microvessels” concept and its clinical guiding significance in meridian and collateral theory [j]. journal of traditional chinese medicine, 2016, 57 (01): 7-11. liu miao, lv xiaodong, pang lijian, liao jianbing, wang wenxuan. pathogenesis of ’lung cold collaterals’ in acute stage of idiopathic pulmonary fibrosis [j]. china journal of traditional chinese medicine and pharmacy, 2019, 34 (06): 2373-2376. wu yiling. traditional chinese medicine theory of collateral diseases and cardiovascular and cerebrovascular diseases [m], beijing, china science and technology press, 2001. wu yiling. chracters and changes of pathological mechanism in patients with collateral disease [j]. journal of diffcult and complicated cases, 2004 (05): 282-284. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 13 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe the relationship between undergraduate student attitudes toward disabled persons and disability sport volunteerism 1michael david lee, 2mary elizabeth lee, 3melissa ann lee 1university of california, irvine 2department of physics, university of massachusetts usa 3assistant professor of psychiatry and behavioral sciences abstract disability sports are designed for people with disabilities to participate in physical activity and competition. they have evolved from a rehabilitation focus to include recreation and competition. the modification of rules, regulations, and equipment has allowed disabled athletes to participate in a variety of sports. the benefits of disability sports include improved rehabilitation, reduced stress, increased independence, and social interaction. keywords: disability sports, rehabilitation, recreation, competition, modification of rules, benefits of disability sportsvolunteerism. introduction the world is inclusive of, in a very general context, non-disabled and disabled persons. of the 7.4 billion persons (u.s. census bureau, 2016) living on the earth, there is an estimated one billion (15%) of those persons living with some form of disability (world health organization (who), 2016). in the u.s. alone, 19% of the population lives with some form of disability (u.s. census bureau, 2012). the distinction between non-disabled and disabled persons, in essence, is driven by a person’s ability, or lack thereof, to be self-sufficient in navigating major daily life activities (americans with disabilities act, 1990).due to this distinction, persons who have either been labeled and/or self-identified as having some form or variation of disability have struggled to overcome a number of challenges such as social exclusion, discrimination, and accessibility. the three aforementioned challenges, along with others, have been demonstrated in the context of sport, thus limiting disabled persons’ ability to be fully engaged in sporting activities with non-disabled persons. in response to these challenges, disability sports were formed to address the growing desire and need for disabled persons to become physically active and have the opportunity to compete athletically (depauw & gavron, 2005). the term disability sport(s) is the inclusion of various sports designed for, or specifically practiced by, people (athletes) with disabilities (i.e. physical, sensory, intellectual) (depauw & gavron; sportanddev.org, 2013). historically, the disability sport movement in the united states began as a form of rehabilitation for many of the men and women injured during and following world war ii (“a brief history,” 2014; french & hainsworth, mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 14 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 2001, le clair, 2012).following world war ii, disability sport has progressively moved to include recreation and competition in addition to its original rehabilitation focus. the recreation and competition aspect of disability sport has modified/adapted the rules, regulations and equipment of most of the existing sport activities to meet the needs of disabled persons/athletes. for example, specially designed wheelchairs in sports such as basketball, rugby, tennis, and dancing allow participants to engage in the sport without sacrificing the overall essence of the activity. as a result of modifications to various sporting activities, disabled athletes are able to draw on the many benefits sport provides, such as: improved rehabilitation, experience of less stress, increased independence, higher academic or employment achievement, reduced dependency on pain and depression medication, fewer secondary medical conditions (disabled world, 2016), the acquisition of life skills (rohwer, 2013) and the occasion for socialization. according to coakley, hallinan and mcdonald (2011), socialization is an active process of learning and social development occurring as individuals interact with others in the involvement of the formation of ideas about who we are and what is important in our lives. sport, in the process of socialization, can produce positive or negative results in all stages of human growth. on the negative side, because of the spirit of competition, sport can facilitate unsportsmanlike conduct and violence while on the positive side, sport can create and support a person’s social identity (rosewater, 2009) as it reflects and reinforces societal norms. disturbingly, societal norms from various parts of the world reflect the continued marginalization, segregation, stigma and social exclusion of disabled persons (international federation of social workers, 2016). unfortunately, the sport industry has been no exception to the social injustices that facilitate to marginalize certain groups as it grants insight to sensitive issues such as racism, sexism, classism (macri, 2012) and ableism, a discriminatory term used in favor of able-bodied people (ableism, 1981). disabled individuals continue to face challenges socially as the perpetuation of negative stereotypes, attitudes, and perceptions, and thus these aforementioned factors impede the progressive of improved integrated socialization between those with and those without disabilities. the continued exclusion deprives disabled persons’ opportunities to engage and develop relationships with others, which is essential to their social development and overall well-being (right to play, 2008; right to play international, 2008). since disabled persons remain members of society, it is essential they be treated as individuals and not their disability, as well as has increased opportunity for improved quality of life and participation in sporting activities. sport contributes to normalization and affords disabled persons to have a forum to share personal experiences and enjoy camaraderie with others (right to play).nondisabled persons having opportunity to work alongside disabled persons would thereby facilitate experiences promoting improved understanding and increased sensitivity whereby the development of more favorable attitudes and perceptions toward disabled persons by the nondisabled. this investigation examined the attitudes of undergraduate sport science students toward disabled persons and whether their attitudes led to actual volunteer involvement in disability sport events. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 15 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe undergraduate students’ attitudes toward and participation with disabled persons despite the many milestones, such as the americans with disabilities act of 1990 advancingcivil rights and advocacy for disabled persons, disability still seemingly evokes discomforting attitudes and awkwardness. much of the discomfort may stem from a lack of understanding that can be combated by both more public education and daily interactions (aiden & mccarthy, 2014).according to aiden and mccarthy, attitudes are a complex set of beliefs, feelings, values and dispositions that characterize the way a person thinks or feels about certain people or situations. they are often the result of experiences, social factors and learning primarily developed during a person’s formative years that clearly influence show the person behaves. concerning disability, there is a large body of research documenting attitudes towards disabled persons, from childhood to adulthood. for most nondisabled children and adults, they are fairly segregated from their disabled peers. thus, the challenge of encouraging positive attitudes, behaviors, and engagement of nondisabled persons toward disabled persons. an earlier study by rosenbaum, armstrong, and king (1988) examined children’s expressed attitudes toward their handicapped peers. the authors developed a 36-item questionnaire called the chedokemcmaster attitudes toward children with handicaps [catch] to measure the affective, behavioral intent and cognitive domains of children aged 9 to 14 years of age. findings suggested that girls had more positive interactions with their handicapped peers than the boys and that the age (9 to 14 years) of the child did not matter in their attitude of their disabled peers. donaldson, helmstetter, donaldson and west (1994) examined 142 nondisabled students enrolled in seven tenthgrade social studies classes. the students were engaged in a developed unit of a series of social studies activities designed to promote increased awareness, understanding, sensitivity, acceptance and interaction with disabled persons. attitudes and contact with peers were measured using the acceptance scale: secondary level (version b) (voeltz, 1981). findings for the study indicated that students’ attitudes towards disabled persons improved pretest to posttest. in addition, students, six months later, showed significant improvement in acceptance and increased contact with disabled students. as young adults, undergraduate students encounter a varying array of persons different from them; thereby, broadening their world context. among these encounters are disabled persons (i.e. physical, learning/intellectual, visual, speech, health-related, etc.). on the collegiate campus alone in the 2011-2012 academic year, according to the u.s. department of education (2015), 11% of undergraduate students reported having a disability. unfortunately, every disabled student in high school is not college qualified, may delay entry to college and if the disabled student does attend college, he/she may not report their status or seek services while enrolled (wolanin& steele, 2004). therefore, more disabled students could exist on u.s. college campuses without anyone knowing. this would also make it more likely that nondisabled students will have some but limited interactions with disabled students at some point during matriculation. lack of interactions of nondisabled students toward disabled students and related issues are sure to reveal their attitudes and perceptions. after reviewing research in the field, bruder and mogro-wilson (2014)concluded that in the current state of disability studies, the attitudes, beliefs and knowledge of university students (and faculty) on university disabilityrelated issues was pertinent. the authors surveyed 881 undergraduate students (freshmen through mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 16 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe seniors), who mainly lived on campus and where more than half majored in liberal arts and the sciences. participants completed a survey focused on three main areas: 1) interactions with disabled persons, 2) opinions regarding disability-related issues, and 3) community/classroom treatment and provision for disabled persons. results indicated that the majority of undergraduates occasionally felt admiration, pity, awkwardness, and/or embarrassment when occasionally encountering a disabled person. also reported was 54% of the students had been taught how to approach and interact with individuals having disabilities, five in ten indicated lack of enthusiasm about encounters with disabled persons, twenty-six percent indicated uncertainty of how to respond to a service animal (i.e. appropriateness in petting) and fifty-five percent said they had limited relationships with disabled persons. because of the very limited interactions between the students and disabled persons, it would stand to reason why their attitudes toward disabled persons are not highly favorable. miller and cordova (2002) examined the effectiveness of two specially designed college courses on changing student attitudes towards disabled persons. in addition, an additional course was used as the control course. the two specially designed courses provided students with advanced information concerning relationships between disabilities and recreational activities whereas the control course provided information pertaining to sport and recreational activities not related to disabled persons. fifty-eight participants completed the interactions with disabled persons scale (idp) (gething, 1991) designed to measure dimensions underlying negative attitudes toward disabled persons. results indicated no significant differences between groups pretest; however, significant differences existed between the two specially designed courses and the control course. from these results, the inference is that students who received information regarding disabled persons had increased positive attitudes towards disabled persons after taking the classes. rice (2009) examined undergraduate student attitudes toward disabled persons. the 295-participant sample for the study comprised students from sections of introduction to special education and political science courses. instructors were asked at the beginning of each semester (fall and spring) to administer the mental retardation attitude inventory-revised (mrai-r) (antonak & harth, 1994) in class. study findings demonstrated a significant interaction between students mean score on the mrai-r, course and gender. the findings suggested that students enrolled in the special education course had increased favorable attitudes towards disabled persons with intellectual disabilities and females, regardless of major, had more positive attitudes than the males. stovall and sedlacek (2015) surveyed 244 undergraduate students assessing their attitudes toward physically disabled students. three forms (a neutral, b blind, and c wheelchair) of the situational attitude scale – handicapped (sash) were randomly administered to participants over a three-day period. the situations included as questions on the sash developed from the literature and pilot studies. differences in attitudes among the three forms were significant. the authors reported that students generally had negative attitudes toward people who were blind or in wheelchairs when close contact was involved, but were more neutral or positive towards disabled students in less intimate settings. attitudes toward blind students were more negative than attitudes towards students in wheelchairs in the following three situations: student seating next to you, student accepted to a university, student-offering help with assignment. situations where students preferred blind students to those in wheelchairs were noted in the following: if the participant’s sister were asked mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 17 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe to marry, the student insisted on receiving help, asked out on a date, mysterious experiences and meeting a blind person at a party. the women responded differently than the men with the women being more positive about their involvement situations regardless if the student was blind or in a wheelchair. hergenrather and rhodes (2007) developed a study to determine the influence of social context of university students on attitudes towards disabled persons. the authors used the disability social relations generalized (dsrgd) scale to understand the multidimensionality of attitudes towards disabled persons. the instrument measured three subscales representing dating, marriage and work. thirty-seven juniors and seniors were involved in a 30-minute training on instruction of modeling behavior and role playing addressing the purpose of the dsrgd, how to approach students to determine interest and eligibility for completing the dsrgd, and provision of both the informed consent and the dsrgd. the representing sample for the study included 1,013 students of varying ethnic backgrounds. there was a statistically significant difference between males and females as females had more positive attitudes towards disabled persons than the males. no statistically significant differences were found with race/ethnicity or age. ford, elliott, and lee (2015) investigated undergraduate sport science students’ attitudes toward disabled persons, their disability sport awareness and spectator interest. the attitudes toward disabled persons (atdp) survey and additional questions related to awareness and spectator interest were used to obtain data. the findings suggested that sport science students, regardless of gender or classification, have similar, positive views regarding disabled persons, and they are aware of some disability sports; yet, have low interest in spectating disability sport events. overall, most research supports undergraduate students beginning with seemingly unfavorable attitudes towards disabled persons, that is, until they are educated on disability related issues in addition to having meaningful interactions. early accounts of unfavorable attitudes towards disabled persons were demonstrated in ancient greece. greeks upheld ideal physical beauty and prowess for the human body in every facet of greek culture, especially, sport; thus, insensitivities toward disabled persons presented itself in the forms of mistreatment and mockery in sport, as such with the hephaestus’s olympian feast (rimmerman, 2012). following this time, there seems to be limited historical and statistical evidence regarding attitudes and perceptions toward disabled persons and their sport engagement. even more limited is research on persons who volunteer with disabled persons to facilitate sport promotion and engagement among disabled persons. noted is for those who engage or interact with disabled persons where they possibly gain respect for the challenges and barriers disabled persons face. they also may come to realize that disabled persons are not that much different than nondisabled persons thus the potential desire to want to assist them as volunteers in sport. volunteerism among college students and in disability sport the continued efforts (i.e. education, awareness, etc.) of mainstreaming disabled persons into society and sport is slowly progressive due to limited experiences and athletic opportunities, lack of reasonable accommodations, ostracization for having the disability or complete exclusion from sport participation (lakowski, 2009). despite the challenges and barriers to sport participation disabled persons face, a growing number of organizations such asthe adaptive sports foundation, disabled sports usa, international paralympic committee, and the special olympics, focuson providing opportunities for disabled persons to engage in sport. along with the growth of mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 18 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe disability sport organizations, mostly non-profit, is the need for more volunteers to be in contact with disabled persons. however, it is the attitudes and beliefs persons have toward disabled persons that affect whether or not they choose to become involved in disability sport. influence of undergraduate student attitudes and beliefs toward disabled persons come from their academic training, interactions with both peers and faculty/administrators, as well as the amount of time spent in contact time engaged in community service opportunities focused on disabled persons. overall, higher educational institutions, in an effort to foster civic responsibility and expand narrow life perceptions, encourage and most times mandate that students volunteer in community projects/organizations. berger and ackerman (1994) reported that students who participated in community/service learning activities cited gaining considerably from their service experience and that the experience “put things in perspective” regarding their own lives. according to the 2006 corporation for national & community service report, dote, cramer, dietz, and grimm stated that 2.7 million college students volunteered in 2002. this number grew to 3.3 million (30.2%) in 2005. the authors went on to say that the growth was generated primarily by youth who attended high school or were firstyear college students during the 9/11 terrorist attacks. unfortunately, by 2010, the percentage of college students volunteering declined to 26.1(brumble, 2012).part of the reason for the decline in student volunteering is students working more hours each week (dote, cramer, dietz, & grimm) as well as the lack of personnel and dedicated resources to engage students in community-based efforts (soria, troisi, & stebleton, 2012).the authors of the 2006 cooperation for national & community service report reported that college student volunteering was either episodic (service of fewer than two weeks per year with their main service organization) or occasional (service of three to eleven weeks per year with their main service organization). amongst the large number of college students who volunteer, most of their volunteer contact time is spent educational or youth services (31.6%), followed by religious organizations (23.4%), and then social or community service (16.3%) activities. other types of organizations (i.e. hospital/health care; civic, professional, political, or international; sports, hobby, cultural arts; public safety, etc.) where students volunteer, each accounted for less than 11% of the total percentage of where students volunteered (dote, cramer, dietz, & grimm, 2006). volunteerism with disabled persons falls into the category of social and community service; however, there is no disaggregated data to represent the actual number of students volunteering with disabled persons, much less disability sport. the challenge then becomes to make concerted efforts to engage more college students in volunteer/contact time with disabled persons, overall, and in sport so accessible data is reflected in related literature and research. to date, there exists a very limited amount of literature discussing college students and their volunteering and/or contact with disabled persons. however, one article, in particular, provides an example of a collaborative effort between the department of recreation, tourism, and hospitality management of the university of north carolina at greensboro (uncg) and the greensboro parks and recreation department who sought to establish not only contact but also significant engagement between nondisabled college students with disabled high school students. the collaboration espoused what is termed “inclusive volunteering.” inclusive volunteering supports both mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 19 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe nondisabled and disabled persons actively engaged in the improvement of their communities by placing them in positions to be recognized as community assets. both the nondisabled and disabled students met weekly for two hours volunteering in various parks around greensboro completing projects such as trail building, weeding, mulching and building bridges, gates and signs (stroud, miller, schleien, & adams, 2006). the authors reported that many of the university students had little, if any, contact with disabled persons prior to the program. following the experiences, students reported increased confidence in their interactions with the disabled students, increased awareness of disability related issues and developed meaningful relationships with their disabled peers. although literature exists for volunteerism in sport, the amount of research dedicated to volunteerism in disability sport pales in comparison. one relevant and comprehensive study by fitzgerald and lang (2009) focused on sports volunteering and disability for the english federation of disability sport by the carnegie research institute at leeds metropolitan university. the review aimed to draw out key issues and identify gaps in the knowledge and understanding of this topic in the united kingdom (uk). based on two policy streams of civil renewal and social inclusion, the uk designed efforts to encourage voluntary activity within sport. numerous nationally driven initiatives promoting sport volunteerism in the uk included some of the following: • trailblazers – a pre-games office-based volunteer opportunity where volunteers perform administrative duties prior to the game, • games time olympic volunteer programme–volunteers served as assistance for the london 2012 olympic and paralympic games, • step into sport – volunteers 14 to 19 years of age begin and sustain leadership and sport volunteerism. • respect athlete mentor programme – elite athletes from various sports offer mentoring and support to disadvantaged young people in schools and community. development and application of similar initiatives presented by fitzgerald and lang (2009)can assist disability sport organizations in the united states develop effective volunteer programs and strengthen current volunteer policies. two research studies investigated volunteer engagement within a disability sport context. the first by brooke-holmes (2005) examined two riding for disabled association (rda) groups where the central volunteering motivation was the opportunity to help disabled people enjoy horse riding or carriage driving. the author found that volunteers expressed three main motivations: altruism and giving benefit to others; friendship and social affiliation; and longterm involvement with and loyalty to the group. the second by kay and bradbury (2009) studied young people ages 16 and older who were apart of the step into sport program which resulted in positive impacts on the volunteers who worked with disabled youth. although there is limited research on volunteerism and disability sport, there is a great dearth of research on college student volunteerism in disability sport. being that disability sport is not a new concept; it is however, becoming more of a visible sector of the sport industry because of major sport events such as the special olympics, the paralympics and the national wheelchair games. although these events exist on a large scale, the interest and volunteerism in this area by college students is very low. college students who are interested in sport and sport careers usually do not consider disability sport as a viable volunteer or employment option. students are rather excited in pursuit of entry into the mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 20 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe well-known professional sports of football, basketball, and baseball. if they are not considering a career in professional sports, then the mindset is on intercollegiate athletics. these two sport sectors tend to generate a great deal of revenue for the sport industry as a whole and the excitement, money, fame and notoriety that comes with it only encourages more and more students to desire gainful employment in these areas. it is rather unfortunate that more students do not volunteer with disability sport activities. according to ford, elliott, and lee (2015), students within sport science programs or related disciplines seemingly have yet to appreciate the growing volunteer opportunities to meet the needs of disabled persons. students enrolled in sport-type degree programs tend to lean toward volunteering for sports exclusive of disabled persons; therefore, the academy and the sport industry must address the training and expectations of sport science students in an effort to increase involvement and career choice within disability sport. one of the important pieces of increasing the number of students who volunteer in disability sport is to first discover and address their perceptions and attitudes toward disabled persons. from this information, discussion can then focus on how those attitudes and perceptions may or may not lead to their volunteerism in disability sport. method of study a convenience sample of 203 undergraduate students enrolled in a sport science program at a local historically black college and university (hbcu) participated in this investigation. students were provided informed consent forms and instructions on how to complete the survey questionnaire. upon completion of the questionnaire, participants were instructed to leave their survey questionnaire in a designated envelope at the front/back of the respective classroom. the survey questionnaire used for this investigation was a modified version of the attitudes towards disabled persons (atdp) scale developed by yuker, block and young (1986) which consisted of 20 items pertaining to a respondent’s attitude toward disabled persons. in yuker, block and young’s original development of the scale, the authors used a likert scale of +3 indicating strongly agree to -3 indicating strongly disagree; however, in the current study, the likert scale was modified to reflect a score of 6 indicating a respondent’s strong agreement with the statement to a score of 1 indicating a respondent’s strong disagreement with the statement. the modified scale improved clarity of results from data analysis. interpretation of higher scores indicated that the respondent perceived that disabled persons are not different from nondisabled persons while lower scores indicated the respondent perceived disabled persons different from nondisabled persons. in addition to the attitudes towards disabled persons (atdp) scale, participants were asked demographic questions pertaining to their gender and classification. they were also asked questions regarding their awareness of, interest in, and volunteer for disability sport events. the information from the collected questionnaires were entered and analyzed by the statistical package for social sciences (spss) version 22.0. all descriptive data expressed the means ± standard deviations for chosen variables. in addition, an independent t-test was calculated to examine the comparison between student volunteerism and gender with responses from the attitudes toward disabled persons (atdp). lastly, a logistic regression analysis was conducted to examine variables predicting disability sport volunteerism. the statistical significance level was set at p < 0.05. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 21 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe findings in summary, of the total 203 sport science majors who participated in the study, 74.4% of students were classified as either a junior or senior, had a mean age of 20.3 years (sd=.55) and were majority female (51.7%).regarding respondent’s experience and participation in disability sport events,only 18.7 percent of respondents volunteered in any disability sport events. independent t-test revealed that female students reported having a more favorable attitude (m = 69.10, sd = 13.10) toward disabled persons (higher atdp scores) than male students (m = 66.34, sd = 10.66); however, there was no statistical significant difference between the groups. another independent t-test revealed students with volunteer experiences with disability sport events had favorable attitudes toward persons with disabilities (higher atdp scores)(m = 68.56, sd= 11.90)compared to non-volunteer experienced students (m = 63.82, sd = 11.50), t(201)=2.230, p < .05. a logistic regression analysis was conducted to predict how attitude toward disabled person influenced a student respondent’s actual disability sport event participation in one of two forms: 1) as a spectator or 2) as a volunteer using independent variables, atdp scores and gender as predictors. a test of the full model against a constant model was statistically significant, indicating that the predictors as a set reliably distinguished between volunteer experienced students and non-volunteer experienced students (χ2 = 6.006, p<.05 with df=2). prediction success overall was 81.3 % which has been identified as being acceptable. the wald criterion demonstrated only atdp scores made a significant contribution to prediction (p=0.36). gender was not a significant predictor. discussion this investigation examined undergraduate sport science students’ attitudes toward disabled persons to determine whether those attitudes predicted volunteer involvement in disability sport. the students completed the attitudes towards disabled persons (atdp) scale used to determine student attitude toward disabled persons and influence on volunteer behavior in disability sport. although, a statistically significant difference did not exist for gender, the results supported the expectation that females would have significantly more positive attitudes than males. the rationale for this hypothesis is that results from studies (tait & purdie, 2010; hergenrather & rhodes, 2007; jones & stone, 1995; fielder & simpson, 1987; royal & roberts, 1987; stovall & sedlacek, 1983; livneh, 1982; chesler, 1965) have found that among college undergraduates, females tend to have had more favorable attitudes and greater empathy toward disabled persons. in research by fitzgerald and lang (2009), they reported from the 2005 citizenship survey that women were more likely to volunteer than men, which in this case would support the reasoning why females may have the more favorable attitude toward disabled persons partly due to their involvement. in addition, the current study confirmed the expectation that students who volunteered with a disability sport event would have a more favorable attitude toward persons with disabilities than those who have not volunteered. the confirmation of this rationale is present in research studies (parasuram, 2006; yazbeck, mcvilly, & parmenter, 2004; eichinger, rizzo, & sirotnik, 1991) that speak to the effect of favorable attitudes when nondisabled persons are engaged in contact with disabled persons. amsel and fitchen (1988) explored the effects of contact of non-disabled students with disabled persons and found that students who had contact with disabled mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 22 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe persons were more comfortable and more at ease during their interaction. thus, the current study merely confirms research similar to amsel and fitchen about the effect of contact between disabled persons and nondisabled persons.the regression model suggested that gender was not a predictor of disability sport volunteerism. when examining gender and volunteerism on a macro –level, according to the 2015 bureau of labor statistics data on volunteering in the united states, 21.8 percent of men and 27.8 percent of women (which dropped from 28.3%) volunteered from september 2014 to september 2015. even though the inference is that women continue to volunteer at a higher rate than men volunteer; the data does not indicate a substantial difference between the groups. in the assessment of why women may volunteer more than men volunteer, the answer could be found in the traditional roles of men and women where women volunteers were not employed and men who volunteered had fulltime jobs (taniguchi, 2006). the current state of the workforce includes both men and women with full-time jobs, whether single or married, with or without children or elderly family members to take care of. this dynamic change in the workforce makes volunteering more difficult for women than men. thus, as the workforce continues to see a rise in women becoming more self-sufficient by working full-time jobs and taking care of the family, the gap percentage between men and women volunteering will grow closer. concerning disability sport, student volunteerism and gender, it can be inferred that the macro-trend will be similar on this micro –level. in the current study, the predictor of volunteerism in disability sport was a person’s attitude toward disabled persons. overall, students attitudes were favorable towards disabled persons; however, only 18.7 percent of them actually volunteered. this disconnect may be explained by a few factors: 1) time to volunteer (hartnett & matan, 2014), 2) internal and external marketing of disability sport events on college campuses, 3) lack of actual disability sport events on college campuses, 4) lack of transportation to get to and from a disability sport event (brookeholmes, 2005), 5) lack of interest in disability sport, and 6) limited campus and community opportunities. a disturbing commentary is that the students in the study were sport science majors where coursework includes topics on disability and sport in various settings. disability sport would offer them a practical experience in theory application. there are limitations to this study. first, the lack of prior research on undergraduate student volunteerism with disability sport left the researchers without an established framework. without this framework, the researchers had to define the needs for this study topic. therefore, this study was an effort to begin further study and measurement of the subject area. second, participants were all upperclassmen undergraduates majoring in sport science. there may be a difference in attitudes towards disabled persons and disability sport volunteerism between graduate students, undergraduate upper and underclassmen and students from other majors.third, only two variables, gender and atdp scores, were selected for potential predictors for students volunteering with disability sport events, whereas, further investigation of other variables may assist in the development of a model that may explain a more holistic approach to getting students to be disability sport volunteers. prior research has examined attitudes and perceptions of undergraduate students towards disabled persons. if the attitudes are negative, then the person’s cognitive and emotional components need addressing (pickens, 2005). mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 23 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe to challenge a student’s attitude and resulting behavior, techniques such as providing new and ongoing information and ways of involvement regarding disabled persons and disability sport must be readily accessible.academic institutions and related training programs should therefore, strive to engage in more direct opportunities to partner with organizations that promote persons with disabilities as well as increase support for disability sport events (ford, elliott, & lee, 2015).additionally, the right to play (2008) organization recommended the following to improve relationships with disabled persons in the education and sport settings: • education of physical education teachers about disability • provision of educational toolkits to teachers discussing adaptations and inclusion • ensured visibility of teachers and coaches on staff with disabilities (at the university level this would include staff, faculty, and administrators) • establishment of programs and cooperatives educating individuals on adaptive sport, especially in the university system • inclusion of disabled persons in educational materials as sport participants • make disabled persons campaign target groups in sport • provide information on accessible sport facilities • plan national sports days or events highlighting inclusion • encourage service providers and sport clubs to target disabled persons for inclusion in activities • support inclusion of disabled persons in sport leadership positions (i.e. coach, teacher, etc.) knowing that there is a large number of disabled persons in the world that may directly or indirectly participate in disability sports, it stands to reason that college students, especially majors of sport and sport-related disciplines be prepared to proficiently engage with disabled persons and this can occur through disability sport volunteerism locally, nationally, and internationally. these opportunities will facilitate increased awareness, advocacy, and involvement.it is evident that volunteers are needed in disability sport as the special olympics alone relies on more than 750,000 volunteers and coaches (special olympics, 2016)to assist in the implementation efficiency of the event. the small percentage of students who actually volunteered in disability sport events in this study demonstrated the very need for more research, education and training of disability and the opportunities that exist in disability sport. increased and on-going efforts such as community educationare needed to ensure that sport participation are inclusive, thus eliminating the perpetuation of discriminatory attitudes. by appropriately socializing nondisabled persons with disabled persons, using sport as a means, a reduction in its stigma will result. thereby, more persons would potentially be more willingly to volunteer in events that focus on the disabled persons. overall, the volunteer plays an important role in empowering the disabled person to become a more independent, involved member in the community. both sides, nondisabled and disabled, can continue to journey toward understanding of the other; hence, becoming more apt to addressing the inequities that exist between the groups, especially in sport. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 24 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe references a brief history of disability sports. (2014). retrieved from http://www.disabilitysport.org.uk/a-brief-historyofdisability-sports.html ableism. entry 1. (1981). in oxford english dictionary online. retrieved from http://www.oed.com/view/entry/240190?redirectedfrom=ableism#eid aiden, h. & mccarthy, a. (2014). current attitudes towards disabled people. scope.retrieved from http://www.scope.org.uk/scope/media/images/publication%20directory/current-attitudestowardsdisabled-people.pdf americans with disabilities act of 1990, pub. l. no.101-336, 104 stat. 328 (1990). amsel, r., & fitchen, c. (1988). effects of contact on thoughts about interaction with students who have a physical disability. journal of rehabilitation, 54(1), 61-65. antonak, r. f., &harth, r. (1994). psychometric analysis and revision of the mental retardation attitude inventory. intellectual disability, 32, 272-280. berger, f., & ackerman, m. (1994). community service and the hospitality curriculum. higher education, 35(4), 86-95. brooke-holmes, g. (2005). volunteer recruitment and retention in the riding for disabled association – future perfect? unpublished ma dissertation, coventry university. bruder, m. b., &mogro-wilson, c. (2014). student and faculty awareness and attitudes about students with disabilities. review of disability studies: an international journal, 6(2). brumble, m. (2012). fewer college students volunteer their time. usatoday. http://usatoday30.usatoday.com/news/education/story/2012-01-22/college studentsvolunteering/52744806/1 chesler, m.a. (1965). ethnocentrism and attitudes toward the physically disabled. journal of personality & social psychology, 2(6), 877-882. coakley, j., hallinan, c., & macdonald, b. (2011). sport and socialisation: who plays and what happens to them. in sports in society (2nd ed., pp.). mcgraw-hill: north ryde, n.s.w. depauw, k., &gavron, s. (2005). disability sport. champaign, il: human kinetics. mailto:topacademicjournals@gmail.com http://www.oed.com/view/entry/240190?redirectedfrom=ableism#eid http://www.scope.org.uk/scope/media/images/publication%20directory/current-attitudes-towards-disabled-people.pdf http://www.scope.org.uk/scope/media/images/publication%20directory/current-attitudes-towards-disabled-people.pdf http://www.scope.org.uk/scope/media/images/publication%20directory/current-attitudes-towards-disabled-people.pdf http://usatoday30.usatoday.com/news/education/story/2012-01-22/college american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 25 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe disabled world. (2016). disability sports: information on sport for the disabled. retrieved from http://www.disabledworld.com/sports/ donaldson, r., helmstetter, e., donaldson, j. & west, r. (1994). influencing high school students’ attitudes toward and interactions with peers with disabilities. social education, 58(4), 233-237. dote, l., cramer, k., dietz, n., & grimm, r. (2006). college students helping america. washington, dc: corporation for national and community service. eichinger, j., rizzo, t., & sirotnik, b. (1991). changing attitudes toward people with disabilities. teacher education and special education: the journal of the teacher education division of the council for exceptional children, 14(2), 121-126. fielder, c. & simpson, r. (1987). modifying the attitudes of nonhandicapped high school students toward handicapped peers. exceptional children, 53(4), 342-349. fitzgerald, h., & lang, m. (2009). a review of the literature on volunteering, disability and sport. project report. carnegie research institute: leeds metropolitan university. french, d., &hainesworth, j. (2001). “there aren’t any buses and the swimming pool is always cold”; obstacles and opportunities in the provision of sport for disabled persons. managing leisure, 6, 35-49. ford, d., elliott, g., & lee, m. (2015). persons with disabilities and sport: undergraduate students’ perception and awareness. the north carolina journal, 49(1). gething, l. (1991). interaction with disables persons scale. journal of social behavior and personality, 9, 23-42. hartnett, b., & matan, r. (2014). “so volunteerism is declining: now what?” retrieved from http://sobelcpa.com/sites/default/files/volunteerism%20is%20declining.pdf hergenrther, k., & rhodes, s. (2007). exploring undergraduate student attitudes toward persons with disabilities: application of the disability social relationship scale. rehabilitation counseling bulletin, 50(2), 66-75. international federation of social workers. (2012). people with disabilities. retrieved from http://ifsw.org/policies/people-with-disabilities/ jones, g., & stone, d. (1995). perceived discomfort associated with working with persons with varying disabilities. perceptual and motor skills, 81, 911-919. mailto:topacademicjournals@gmail.com http://sobel-cpa.com/sites/default/files/volunteerism%20is%20declining.pdf http://sobel-cpa.com/sites/default/files/volunteerism%20is%20declining.pdf http://ifsw.org/policies/people-with-disabilities/ american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 26 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe kay, t. & bradbury, s. (2009). youth sport volunteering: developing social capital? sport, edudication and society, 14(1), 121-140. lakowski, t. (2009). athletes with disabilities in school sports: a critical assessment of the state of sports opportunities for students with disabilities. boston university international law journal, 27, 283. le clair, j. (2012). disability in the global sport arena: a sporting chance. taylor-francis: new york, ny. livneh, h. (1982). on the origins of negative attitudes towards people with disabilities. rehabilitation literature, 43, 338347. macri, k. (2012). not just a game: sport and society in the united states. inquiries,4(8), 1. miller, j., & cordova, j. (2002). changing attitudes toward people with disabilities. paleastra, 18(3), 16-22. parasuram, k. (2006). variables that affect teachers’ attitudes towards disability and inclusive education in mumbai, india. disability and society, 21(3), 231-242. pickens, j. (2005). attitudes and perceptions. in organizational behavior in health care. (pp. 43-75). sadbury, ma: jones and bartlett publishers. rice, c. (2009). attitudes of undergraduate students toward people with intellectual disabilities: consideration for future policy makers. college student journal, 43(1), 207-215. right to play. (2008). harnessing the power of sport for development and peace. retrieved from http://www.un.org/wcm/webdav/site/sport/shared/sport/sdp%20iwg/chapter5_sportanddisability.pd f right to play international. (2008). annual report 2008. ontario, canada. retrieved from http://www.righttoplay.com/moreinfo/aboutus/documents/2008%20annual%20report.pdf rimmerman, a. (2012). social inclusion of people with disabilities. cambridge university press. rohwer, c. (2013). benefits of sport for people with disabilities. retrieved from http://www.health24.com/fitness/exercise/benefits-of-sport-for-people-with-disabilities-20130531 rosenbaum, p., armstrong, r. & king, s. (1988). determinants of children’s attitudes toward disability: a review of evidence. children’s health care, 17(1), 32-39. mailto:topacademicjournals@gmail.com http://www.un.org/wcm/webdav/site/sport/shared/sport/sdp%20iwg/chapter5_sportanddisability.pdf http://www.un.org/wcm/webdav/site/sport/shared/sport/sdp%20iwg/chapter5_sportanddisability.pdf http://www.health24.com/fitness/exercise/benefits-of-sport-for-people-with-disabilities-20130531 american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 27 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe rosewater, a. (2009). the 2009 team-up for youth monograph series, learning to play and playing to learn: organized sports and educational outcomes. retrieved from https://www.californiahealthykids.org/articles/play.pdf royal, g. p., & roberts, m. c. (1987). student’s perceptions of and attitudes toward disabilities: a comparison of twenty conditions. journal of clinical child psychology, 16, 32-39. sport and development. (2013). milestones in apa and sports for people with disabilities. retrieved from http://www.sportanddev.org/en/learnmore/sport_and_disability2/background___sport___disability/miles t ones_in_apa_and_sports_for_people_with_disabilities_/ soria, k., troisi, j., &stebleton, m. (2012). reaching out, connecting within: community service and sense of belonging among college students. higher education in review,9, 66-85. stovall. c., & sedlacek, w. (2015). attitudes of male and female university students toward students with different physical disabilities. research report #10-81. stovall, c.,,& sedlacek, w. (1983). attitudes of male and female university students toward students with different physical disabilities. journal of college student personnel, 24(4), 325-30. stroud, s., miller, k., schleien, s., & adams, b. (2006). a winning recipe for volunteerism. parks and recreation, 4, 4954. special olympics. (2016). steady growth of special olympics means reaching more people with id. retrieved from http://www.specialolympics.org/news_and_stories/stories2012/2011_reach_report_shows_growth_ wo rldwide.aspx tait, k., & purdie, n. (2000). attitudes toward disability: teacher education for inclusive environments in an australian university. international journal of disability, development and education, 47(1). taniguchi, h. (2006). men’s and women’s volunteering: gender difference in the effects of employment and family characteristics. nonprofit and volunteer sector quarterly, 35(1), 83-101. u.s. census bureau. (2016). u.s. and world population clock. retrieved from http://www.census.gov/popclock/ u.s. bureau of labor statistics. (2015). volunteering in the united states, 2015. retrieved from http://www.bls.gov/news.release/volun.toc.htm mailto:topacademicjournals@gmail.com http://www.specialolympics.org/news_and_stories/stories2012/2011_reach_report_shows_growth_worldwide.aspx http://www.specialolympics.org/news_and_stories/stories2012/2011_reach_report_shows_growth_worldwide.aspx http://www.specialolympics.org/news_and_stories/stories2012/2011_reach_report_shows_growth_worldwide.aspx http://www.census.gov/popclock/ american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 28 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe u.s. census bureau. (2012). nearly 1 in 5 people have a disability in the u.s., census bureau reports. retrieved from https://www.census.gov/newsroom/releases/archives/miscellaneous/cb12-134.html u.s. department of education, national center for education statistics. (2015). digest of education statistics, 2013 (2015-011),chapter 3. voeltz, l. (1981). the acceptance scale [a scale] secondary level version b]. syracuse, ny world health organization. (2016). world report on disability. retrieved from http://www.who.int/disabilities/world_report/2011/report/en/ yazbeck, m., mcvilly, k., & parmenter, t. (2004). attitudes toward people with intellectual disability: an australian perspective. journal of disability & society, 15(2), 97-111. yuker, e., block, j. r., & young, j. (1986). the measurement of attitudes toward disabled persons. albertson, ny: human resources center, 170. wolanin, t. & steele, p. (2004). higher education opportunities for students with disabilities: a primer for policymakers. the institute for higher education policy. washington, dc. mailto:topacademicjournals@gmail.com https://www.census.gov/newsroom/releases/archives/miscellaneous/cb12-134.html http://nces.ed.gov/programs/digest/d13/ch_3.asp http://www.who.int/disabilities/world_report/2011/report/en/ american journal of medical and physical education vol.9, issue 1; january-february 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 1 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe from silence to resurgence: tuberculosis reactivation following covid-19 – a singular case analysis 1nino g. javakhishvili, 2david l. kipshidze and 3mariam n. abashidze 1department of infectious disease, tbilisi state medical university, tbilisi, georgia 2intensive care unit, tbilisi state medical university, tbilisi, georgia 3department of neurology, tbilisi state medical university, tbilisi, georgia. doi: https://doi.org/10.5281/zenodo.10598098 abstract: tuberculosis (tb) stands as a prominent global health threat, persisting as a leading cause of mortality on a worldwide scale (world health organization, 2022a). caused by the infectious agent mycobacterium tuberculosis, tb spreads through respiratory droplets when an infected individual coughs or sneezes. while primarily affecting the lungs, tb can extend its impact to various organs and systems within the body (centers for disease control and prevention, 2022). this research aims to shed light on the diverse facets of tb, focusing on its two principal manifestations: latent tb infection and active tb disease. latent tb infection characterizes individuals who carry the tb bacteria but remain asymptomatic and do not transmit the disease. however, the latent form poses a risk of progressing into active tb disease, particularly in cases where the individual's immune system becomes compromised (centers for disease control and prevention). the urgency of addressing tb is underscored by its potential to transition from latent to active, thereby elevating the risk of transmission and severe health consequences. the study delves into the dynamics of tb infection, emphasizing the critical importance of early detection and intervention to mitigate the escalation from latent to active tb. furthermore, it explores factors contributing to the weakening of the immune system, which serves as a pivotal link between latent tb and the development of active disease. by elucidating the intricate interplay between latent and active tb, this research not only contributes to a deeper understanding of the disease but also provides insights crucial for public health strategies and interventions. the overarching goal is to inform targeted measures that can effectively curb the spread of tb and reduce its impact on global health. keywords: tuberculosis (tb), latent tb infection, active tb disease, mycobacterium tuberculosis, immune system compromise introduction mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.9, issue 1; january-february 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 2 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe tuberculosis (tb) is a significant global health concern and remains one of the leading causes of death worldwide (world health organization, 2022a). it is an infectious disease caused by the mycobacterium tuberculosis. tb is spread through the air when an infected person coughs or sneezes. it primarily affects the lungs, but can also affect other parts of the body (centers for disease control and prevention, 2022). tb can present in two main forms: latent tb infection and active tb disease. latent tb infection occurs when a person has been infected with the tb bacteria but does not yet have active disease or symptoms. in this case, the bacteria are dormant and cannot be spread to others. however, people with latent tb infection are at risk of developing active tb disease if their immune system becomes weakened (centers for disease control and 2 med. case stud. prevention, 2022). covid-19 infection can increase the risk of tb reactivation due to a combination of factors. these factors include immune system suppression, as well as disruptions to tb diagnosis, treatment, and prevention services (world health organization, 2022b). tuberculous meningitis (tbm) is one of the most severe manifestations of extrapulmonary tb. cns-tb represented the 13.91% of all cases of meningitis and 4.55% of all cases of tb (navarro-flores et al., 2022). the pathophysiology is primarily driven by three components, which also explain the clinical symptoms (rich and mccordock, 1933; dastur et al., 1995). thick gelatinous exudate, which is especially apparent at the basal region of the brain, eventually produces a fibrous mass that encases nearby structures. as a result, periventricular infarcts and cranial nerve palsies are developed. spasm, constriction, thrombosis, and occlusion of intracerebral arteries are all possible effects of tuberculous vasculitis and the concomitant inflammatory vascular changes (chan et al., 2005). the intracranial vasculitis is expected to have a major impact on the remaining neurologic deficits (poltera, 1977). clinical approach and diagnostic tools, including csf analysis and radiographic imaging, are equally important to diagnose tb meningitis (lewinsohn et al., 2017). the treatment for tuberculous meningitis is very complex. commonly, the combination of isoniazid, rifampin, pyrazinamide and ethambutol/streptomycin/ fluoroquinolone is given for an extended period of time. however, sometimes drug resistance is found which leads to adjustments in treatment (donald, 2010; world health organization, 2017). this case describes the development of tuberculous meningitis in a patient with covid-19. case presentation 39-year-old male presented to the emergency department on june 4, 2022, with fatigue, fever, shortness of breath, nausea, and vomiting. he tested positive for covid-19. a cardiopulmonary examination showed clear lung fields and normal heart sounds. neurological assessment showed signs of ataxia, vertigo, and horizontal nystagmus; however, a head ct scan has not shown any pathological features. two days later, the patient developed new clinical signs, including facial asymmetry with loss of the left nasolabial fold, right-sided ptosis, spontaneous rotatory nystagmus, dysphagia, dysarthria, and trouble coordinating. jaw jerk and gag reflexes were both diminished. reduced deep tendon reflexes were present in all extremities, more so on the left. he also suffered from neck rigidity. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.9, issue 1; january-february 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 3 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe a head mri revealed hyperintensity in the brainstem and left cerebellum (figures 1 and 2). csf analysis revealed lymphocytosis, decreased glucose, and elevated protein. adenosine deaminase levels and csf pcr for tuberculosis were both positive as well. following the lumber puncture, treatment with dexamethasone, vancomycin, and ceftriaxone was started immediately due to an increased suspicion of meningitis. after the patient's cerebrospinal fluid results confirmed tb meningitis, the treatment regimen was adjusted to streptomycin, rifampicin, isoniazid, pyrazinamide and dexamethasone. the following day, the patient was diagnosed with purulent endobronchitis based on an x-ray and bronchoalveolar lavage. soon after, he developed a cytokine storm and was taken to the intensive care unit, where he was intubated, sedated, and mechanically ventilated. due to a protracted need for breathing support, he underwent tracheostomy placement. the patient was taken off the ventilator on july 9th, 2022, but continued to receive oxygen through a tracheostomy. on august 1, 2022, the patient was discharged with stable vital signs. oropharyngeal and cardiopulmonary examinations revealed no abnormalities. during neurological examination, the patient was spatially and temporally oriented and was able to follow simple commands. pupils were equally round and lightresponsive. however, he still displayed dysmetria and babinski reflex on the left side, along with horizontal nystagmus, as residual neurological deficit. the patient was advised to take rifampicin and isoniazid for 9 months. ethics section informed consent was obtained from the patient prior to data collection, ensuring their comprehensive understanding of the study's objectives, potential implications, and the confidentiality of their sensitive medical information. the patient was provided with detailed information about the case report, including its purpose, methodology, and the intended use of medical records and clinical details. it was explicitly communicated that participation in the study was entirely voluntary, and the patient could opt out at any stage without affecting their medical care or rights. emphasis was placed on the de-identification of all data, ensuring the anonymity of the patient. the patient was reassured that the patient's personal and medical information would be treated with the utmost confidentiality and solely utilized for the purpose of this case report. discussion based on this case, it is apparent that even a benign case of covid-19 may eventually lead to severe consequences, such as tb reactivation. the timely identification of early neurological manifestations allowed for prompt evaluation and diagnosis of tb meningitis, mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.9, issue 1; january-february 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 4 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe figure 1. mri revealed hyperintensity in the brainstem. figure 2. mri revealed hyperintensity in the left cerebellum. which prevented further delays in treatment. so, despite the severity and complexity of the presented case, the overall outcome was positive. however, it should be mentioned that the patient still developed a residual neurological deficit. conclusion in conclusion, this case highlights that the potential complications and challenges associated with covid-19 infection extend beyond the impact of a single infectious megrelishvili et al.3 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.9, issue 1; january-february 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 5 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe agent. the combined effects of multiple factors can significantly affect various organ systems, including the nervous system. covid-19 affects several organ systems, thus any symptom could be attributed to it and underlying pathology may go unnoticed. the immune system suppression induced by covid-19 can increase the risk of tb reactivation, thereby complicating diagnosis and treatment. therefore, it is crucial to consider the possibility of tb reactivation in covid-19 patients, particularly those from regions with high tb prevalence. therefore, timely detection and prompt treatment of tb are essential to prevent severe complications and improve clinical outcomes in these patients. conflict of interests the authors have not declared any conflict of interests. references centers for disease control and prevention (2022). tuberculosis (tb). retrieved from https://www.cdc.gov/tb/topic/basics/default.htm chan kh, cheung rt, lee r (2005). cerebral infarcts complicating tuberculous meningitis. cerebrovascular diseases 19:391. dastur dk, manghani dk, udani pm (1995). pathology and pathogenetic mechanisms in neurotuberculosis. radiologic clinics of north america 33:733. donald pr (2010). cerebrospinal fluid concentrations of antituberculosis agents in adults and children. tuberculosis (edinb) 90:279. lewinsohn dm, leonard mk, lobue pa (2017). official american thoracic society/infectious diseases society of america/centers for disease control and prevention clinical practice guidelines: diagnosis of tuberculosis in adults and children. clinical infectious diseases 64:e1. navarro-flores a, fernandez-chinguel je, pacheco-barrios n (2022). global morbidity and mortality of central nervous system tuberculosis: a systematic review and meta-analysis. the journal of neurology 269:3482. poltera aa (1977). thrombogenic intracranial vasculitis in tuberculous meningitis. a 20 year "post mortem" survey. acta neurologica belgica 77:12. rich ar, mccordock ha (1933). pathogenesis of tuberculous meningitis. bulletin of the johns hopkins hospital 52:5. world health organization (2017). guidelines for treatment of drugsusceptible tuberculosis and patient care, update. http://apps.who.int/iris/bitstream/10665/255052/1/9789241550000eng.pdf?ua=1 (accessed on june 08, 2017). mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.9, issue 1; january-february 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 6 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe world health organization (2022a). global tuberculosis report 2022. retrieved fromhttps://www.who.int/publications/i/item/9789240061729 world health organization (2022b). tb disease burden. in global tuberculosis report 2022. retrieved from https://www.who.int/teams/global-tuberculosis-programme/tbreports/global-tuberculosis-report-2022/tbdisease-burden/2-2-tbmortality mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.9, issue 2; march-april 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 1 | american journal of medical and physical education | https://topjournals.org/index.php/ajmpe teenage pregnancy among secondary school female students in igbo-etiti local government area, enugu state raphael e ochiaka department of human kinetics and health education email: raphael,ochiaka@esut.edu.ng doi: https://doi.org/ 10.5281/zenodo.11086078 abstract: the study investigated teenage pregnancy among female secondary school students in igbo-etiti local government area, enugu state. three research questions and one hypothesis were formulated to guide the study. descriptive research design was adopted for the study. a sample of 312 female students was used for the study which was drawn from a population of 6000female students from 15 public secondary schools using a two-stage sampling procedure. a structured questionnaire titled ”teenage pregnancy questionnaire (tpq)” which was validated by three experts, two of which were from human kinetics and health education department and one from the department of maths and computer was used for data collection. data collected with the help of three research assistants were analyzed using frequency count and percentages. the findings revealed among others that; peer group pressure, poverty and lack of parental care were factors responsible for teenage pregnancy, drop out of school, low educational achievement and unplanned marriage are consequences of teenage pregnancy and use of contraceptives, guidance and counseling are ways to control teenage pregnancy among secondary schools students in igbo-etiti lga. it was concluded that poverty, peer group pressure and lack of parental control for their female wards are responsible for teenage pregnancy among female students in igbo-etiti lga. based on the conclusion, it was recommended among others that the state government through the post primary school management board, enugu state should organize seminars and workshops for female secondary school students on the causes, consequences and control measures of teenage pregnancy among the female students. keywords: teenager, teenage pregnancy, secondary school teenage students. introduction teenage pregnancy is a major public health issue. the problem confront many high, middle and low income countries globally. teenage or adolescent pregnancy means pregnancy in women between 10 to 19 years. teenage pregnancy has been called an epidemic worldwide. teenagers are the greatest number of people found in most secondary schools. they are those young persons within the age of 10 and 19 years. according to living webster encyclopedic dictionary of the english language (2014), these years fall within the adolescent period, at this period the individual seeks for those ties within the opposite sex and to secure identity. these behaviours may not be of their biological setting rather of societal expectations. as a result of the biological mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.9, issue 2; march-april 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 2 | american journal of medical and physical education | https://topjournals.org/index.php/ajmpe instinct at this period, they may have high tendency to indulge in pre-marital sex, which may leave her in perpetual regret. this health problem seems to be popular among the female teenagers in the forms of teenage pregnancy (festus, 2019). these young people may be entangled in this due to the hindrance which may erupt as a result of exhibition of obnoxious behaviour encouraged by the media. globally, million women under the age of 20 give birth representing up to one-fifth of all births and 529,000 women die due to pregnancy and child birth related complications every year (dev raj.rabi, arnudha, van teijlingen & chapmen, 2016). teenage pregnancy is a major concern to world communities with u.s being at the top with almost 1, 000,000 teenage pregnancies each year (williams, 2022). the united state has highest pregnancy and births among adolescents (coley & lansdale 2017). according to the inter-pres service (2021), the global rate for teenage pregnancy for the year 2011 was 52, 9 pregnancies, per 1, 000 female adolescent. in 2000, the total number of teenage pregnancies in the united state was 821, 81 (84 pregnancies per 1000 people), as compared to canada whose total rate of teenage pregnancies in 2000) was 38 pregnancies per 1000 people (chengaxhu 2020). in england there are nearly 90, 000 teenage conceptions per year around 1 7,700 girls under the age of 16 and 2,200 of girls aged 14 or under (holgate evans & yuen, 2021). the department of health (united kingdom) in macleod (2020) reported that in england and wales, more women in their early twenties find themselves with unwanted pregnancies that end in abortion. the united state has the highest teenage birth rate of all developed countries (crosson-tower, 2015). according to inter-press service (april, 2015), teenage pregnancy accounted for 40 percent of maternal deaths in sierra leone where early marriage is supported by traditional practice. seventy percent (70%) teenage girls' in sierra leone' are married (world health organization, 2018). the w.h.o figures showed that the global average number of pregnancies for every 1, 000 girls in the 15-19 age group is 65. the rate of early marriage and pregnancy has decreased sharply in indonesia and malaysia, although it remains relatively high in the former. in african, the sexual behaviour of urban adolescents in nigeria and liberia is now very similar to that of people in the same age category in the usa and europe (unicef, 2017). in the same continent (arica), girls are often married at a younger age and are under pressure to give birth to children. according to (uncef, 2017) bangladesh has aimed16 percent of fifteen-year old. girls who are pregnant or already have children, whereas 75 percent of girls in the democratic republic of congo and over half of all girls in afghanistan and bangladesh are married before the age of 13. the survey conducted by a leading international organization called” save the children” stated that annually 13million children are born to women under the age of 16 years and more than 90 percent in developing countries. it is also that the highest rate of teenage pregnancy in the world was found in the sub saharan african (achu, 2016). being a teenager is one of the most wonderful and exciting times, as they grow from childhood to adulthood, it can be confusing and disturbing time too. at this period, young person begin to have their own opinion about what to do, what they want, what they want to wear, where to go and how to behave. this period is regarded as a period/time of increased emotional tension resulting from physical and psychological chance in the child (alkinson, 2021). the above assertion further explained that the adolescent developmental tasks represent the total problems and must be solved during the transition from childhood to adulthood. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.9, issue 2; march-april 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 3 | american journal of medical and physical education | https://topjournals.org/index.php/ajmpe teenage pregnancy has claimed the lives of many female students in nigeria secondary schools. nzeagu (2016) noted that a degree of desperation follows and abortion either self-administered, or done by an unqualified person (doctor) is often considered. health professionals are not consulted for pregnancy test, care or termination of fetus which often result because of the teenagers want to free herself from rejection by relatives and friends as well the shame the pregnancy would bring to her and the family. research shows that teenage pregnancy could result due to various factors which include; economic factors such as quest for materialism, insufficient money for essential provisions and needs. moreover, a social factor is another factor that contributes to teenage pregnancy, for example, influences of peer -group, unrealistic false marriage promises from boys and sexual permissiveness in the society, (duvall, 2018). religious factors also contribute to teenage pregnancy like lack of moral disciplines, lack of fear of god, lack of moral instruction. nevertheless educational factors cannot be over emphasize for instance, the system of day school which permits students to roam about without supervision by the school authority. ignorance of safe and unsafe period of menstrual cycle, insufficient sex education and lack of knowledge of family planning practices. also, cultural factors also contributes to teenage pregnancy and they are as follows; inability of parent to discuss sex matters with their children's, quest for early marriage among girls. teenage pregnancy has it consequences such as unable to finish their education. it also leads to being infected with sexual transmitted infections (stis) to young people in secondary school and outside school. apart from medical consequence, lower access to higher education, high divorce rates, premature death of women, population growth, week and unhealthy children and single motherhood are all negative consequence of teenage pregnancy. furthermore, teenage pregnancy brings shame and distress to the teenagers and their parent, it also result to discrimination among his or her peer group. another consequence of teenage pregnancy is that they are being deprived of the right to choose their life partner, it becomes necessary to carry out this study on teenage pregnancy, so as to help the teenager girls avoid been victims of unwanted pregnancy. it is against this background that the researcher intends to find out teenage pregnancy among secondary school students in igboetiti local government of enugu state. in these recent years, there is high incidence of teenage pregnancies in our society. teenage pregnancy has made some of young girls to lose their life through abortion which is done by unqualified doctors. most teenagers who are involved in this act are usually unable to complete their education, teenage pregnancy is generally regarded as social and moral problems which often results in shame and distress to the teenagers and most often abortion and consequently death. this is worrisome, hence the need for the study. purpose of the study the main purpose of the study was to ascertain the teenage pregnancy among secondary school students in igbo-etiti local government area of enugu state. specifically, the study sought to: 1 find out the factors responsible for teenage pregnancy among secondary schools students in igbo-etiti local government area of enugu state. 2. determine the consequences of teenage pregnancy among secondary school students in igbo-etiti local government area of enugu state mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.9, issue 2; march-april 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 4 | american journal of medical and physical education | https://topjournals.org/index.php/ajmpe 3. find out possible control measures of teenage pregnancy as perceived by secondary school students in igbo-etiti local government area of enugu state. of teenage pregnancy. it also looks at parents reactions to teenage pregnancy. research questions the following research questions were formulated to guide the study. 1. what are the factors responsible for teenage pregnancy among female secondary school students in igbo-etiti local government area of enugu state? 2. what are the consequences of teenage pregnancy among female secondary school students in igbo-etiti local government area of enugu state? 3 what are possible control measures to teenage pregnancy among female secondary school students in igbo-etiti local government area of enugu state? method. research design was used because it facilitates the description of situation in its current state and solicits information directly from the respondents, which makes the information from re 000 female students from 15 secondary schools in igbo-etiti local government area of enugu state. the sample size for the study consisted of 312 students in igbo-etiti local government area of enugu state which was determined by the use of taro yamane (1964) formula. two-stage sampling procedure was used to draw the sample. firstly, 6 schools were sampled out of 15 secondary schools in the area using simple random sampling technique. secondly, also simple random sampling techniques was used to draw 52 students from the selected 6 secondary schools making a total of 312 students. a structured questionnaire titled “teenage pregnancy questionnaire (tpq)” was the instrument used for data collection. the questionnaire consists of two sections -a and b. section a contained items that solicit information on the personal data of the respondents. section b has 4 parts, which carry a two point rating scale of “yes” and “no” that deals on teenage pregnancy. the validation of the research instrument was done by 3 experts, 2 from the department of human kinetics and health education and 1 from the department of maths and computer, all in faculty of education. reliability of the instrument was established through the use of cronbach alpha statistics which yielded reliability value of 0.75 confirming the reliability of the instrument. the questionnaire was administered on the sport with the help of 3 trained research assistants. three hundred and twelve (312) copies of the instruments were administered on the sampled female students but 300 was returned and qualified for analysis, the data collected were analysed using frequency counts and percentages. results research question1: what are the factors responsible for teenage pregnancy? among secondary school students in igbo-etiti local government area enugu state. the above research question was answered using the responses of secondary school student as shown in table one below. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.9, issue 2; march-april 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 5 | american journal of medical and physical education | https://topjournals.org/index.php/ajmpe table 1: percentage response distributions of the respondents on factors responsible for teenage pregnancy among female sec secondary schools students in igbo-etiti lga s/n items yes % no % dec 1. peer pressure 210 70 90 30 agree 2. influence of pornographic films 78 25 222 75 disagree 3. poverty 200 67 100 33 agree 4. lack of sex education 62 21 238 79 disagree 5. lack of self-control 98 33 202 67 disagree 6 lack of parental care 187 62 113 38 agree 7 7 broken homes 78 25 224 75 disagree 7 broken homes 78 25 224 75 disagree table 1 shows 7 factors responsible for teenage pregnancy of female sec school students. the table indicates that 3 of the items (peer group pressure, poverty and lack of parental care) are factors responsible for teenage pregnancy. this is shown by their percentage of 70%, 67% and 62% respectively. research question 2 what are consequences of teenage pregnancy among secondary school students in igbo-etiti local government area enugu state? table 2: percentage response distribution of the respondents on consequences of teenage pregnancy among female secondary schools students in igbo-etiti lga s/n items yes % no % dec 8. rejections by parents 102 34 198 66 disagree 9. poor production of res blood call 62 21 238 79 disagree 10. drop out from school 220 73 80 27 agree 11. infection (sti) 85 28 215 72 disagree 12. low educational achievement 281 94 1 9 6 agree 13. high rate infant mortality 83 8 292 97 disagree 14. unplanned marriage 284 95 16 5 agree table 2 shows 7 items on consequences of teenage pregnancy of female sec school students. the table indicates that 3 of the items (drop out of school, low educational achievement and unplanned marriage) are consequences of teenage pregnancy. research question 3: what are possible control measures to teenage pregnancy in secondary schools? mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.9, issue 2; march-april 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 6 | american journal of medical and physical education | https://topjournals.org/index.php/ajmpe table 3: percentage response distribution of the respondents on control measures of teenage pregnancy among female secondary school students in igbo-etiti lga. s/n items yes % no % decision 19. parent cares and attends to their children 36 12 240 80 disagree 20. use of contraception 220 73 80 27 agree 21. guidance and counseling 208 69 92 31 agree 22. avoidance of bad friends 264 88 36 12 agree 23. through religious organization 102 34 98 66 disagree 24. attending on seminars teenage 62 21 238 79 disagree pregnancy 25. through complete abstinence 98 33 202 67 disagree table 3 shows 7 items on control measures to teenage pregnancy of female sec school students. the table indicates that 3 of the 7 items (use of contraceptives, guidance and counseling and avoidance of bad friends) are control measures to teenage pregnancy discussion of the findings the finding pertaining to research question 1 showed that peer group pressure, poverty and lack of parental care are factors responsible for teenage pregnancy among female secondary school students in igboetiti local government area, enugu state. this findings, agree with the views of golden (2008) who stated that peer group influence is a critical factor influencing the behavior of teenagers especially sex behaviours. they provide the norms or standards of operations for teenage girls especially when their parents fails to discuss sex issues with them. meanwhile, ojo and femi (2008), noted that most teenagers find accommodations for themselves early in life. this exposes them to rich men for financial gains, which may lead to pregnancy by sleeping with these men in exchange of money the findings pertaining to research question 2 shows that low educational achievement and unplanned marriage are the consequences of teenage pregnancy. this finding is expected because a pregnant student supposed to withdraw from school immediately she is found to be pregnant. pregnancy disrupts the educational career of the teenage girls, this may be temporary or permanent. furthermore, teenage pregnancy hampers the mental prospect of the girls involved. a girl in this type of situation no longer marry the man of their dream, because they will be forced to marry any man available and willing to marry them at that point. most parent portrays that attitude of disappointment on the teenager over pregnancy and by not supporting them financially. this finding are in-line with eze (2021), who stated that the parents of the teenage girl may be disappointed and at such may decide to stop sponsoring her educations and social needs, because they see the previously help rendered or fees paid as wasted. the finding pertaining to research question 3 indicates that the use of contraceptives, guidance and counseling and avoidance of bad friends are control measures to teenage pregnancy among female secondary school mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.9, issue 2; march-april 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 7 | american journal of medical and physical education | https://topjournals.org/index.php/ajmpe students in igbo-etiti local government area. this finding is expected because use of the fact that use of contraceptive ensues 70% protection of pregnancy. this finding disagree with paul (2018), which stated that complete abstinence is a complete effective method for preventing conception. conclusions from the findings of the studies it was concluded that peer group influence, poverty and lack of parental care are the principal factors responsible for teenage pregnancy among female secondary school students and that that use of contraceptives, guidance and counseling and avoidance of bad friends are the control measures to teenage pregnancy. recommendations the following recommendations were made based on the findings of this study. 1. education through workshops and seminars on teenage pregnancycauses, consequences and control measuresshould be organized every term in schools for female secondary school students. 2. religious leaders-should advocate more emphases on moral discipline through moral instruction, which can be delivered through teenage girls in the institution. 3. health counselors should be assigned to every school and community so that they can give sex education to teenagers who are the vulnerable segment of the community, references alkinson, r. (2015). sexual standards and behaviours: introduction to psychology. oxford and 13th publishing co. bola, r. o. (2016). teenage pregnancy: the problem that has gone away. chang'ach, j. k. (2020). impact of teenage pregnancy on the education of the girl child: a case study of keiyo south district, keiyo, marakwet county, kenya. international journal of social science tomorrow. crosson-tower, c. (2015). exploring child welfare: a practice perspective (4th ed.). pearson education, inc. david, f. (2015). the sexual enlightenment of children. mosby company. dev, r. a., rabi, b., amudha, p., van teijingen, e., & glyn, c. (2016). factors associated with teenage pregnancy in south asia: a systematic review. retrieved from http://www.hsj.c.s.l.2005 festus, a. e., & standford, g. p. (2019). safety education. mcgraw-hill book company. golden, m. (2019, july 7). sex education and the youths. daily time. harris, r. j. (2016). magic, morals, and health. maryland college park. holgate, h. s., evans, r., & yuen, f. k. o. (2021). teenage pregnancy and parenthood: global perspectives, issues, and interventions. routledge. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.9, issue 2; march-april 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 8 | american journal of medical and physical education | https://topjournals.org/index.php/ajmpe inter press service. (2021, november 2). teen pregnancy: buak global downward. ips inter press service. kola, p. (2008). guidance needs of nigerian adolescents. louis, j. o. (2016). juvenile vagrancy: a sociological study of juvenile vagrants in the cities of kanpur and inknew. asia publication house. ojo, a., & femi, c. o. (2018). marriage and adolescents in the tropics. macmillan nigeria ltd. oke, a. (2019). secondary school health education. harper and brothers. traffers, p. (2017). adolescent pregnancy: issues in adolescent health and development. world health organization. unicef. (2017). nation master com. home encyclopedia statistics. williams, d. c. (2022, january 10). sex education: mothers have a big role to play. nigeria observer, p. 10. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 29 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe stadiums technical reports in brazil: a tool for safety and security 1mariana da silva santos, 2pedro henrique de souza lima, 3joão victor da costa nunes 1romance studies, trinity college of arts & sciences 2diretor de produtos aaagv são paulo, são paulo, brasil 3federal university of viçosa abstract this paper reviews the development of stadium safety regulations and legislation in england, following the hillsborough disaster in 1989. the taylor report, which was published in the aftermath of the disaster, made a number of recommendations for improving stadium safety, including the introduction of all-seater stadiums. these recommendations were implemented, and stadium safety in england has improved significantly since the hillsborough disaster. however, there are still some concerns about safety at football matches, and further improvements are needed. keywords: stadium safety, hillsborough disaster, taylor report, all-seater stadiums, fifa, uefa 1. introduction concerns over stadium safety, regulations and legislation are developed by governments or even by football match organizers and these have as a common factor the emergence of actions after the occurrence of serious events involving attending fans. internationally, to highlight governmental action, we focus on england, which through a request made to lord justice taylor, conducted an investigation to determine the causes of the hillsborough (sheffield) tragedy in april 1989 during the semifinals of the fa cup between liverpool and nottingham forest. on this occasion, large groups of people entered the stadium after forcing open the access gate, intended only for exit purposes. this mob of people ended up crushing the other fans against the fences, which led to the collapse of the structure. the incident resulted in the deaths of 96 people, most of them due to suffocation, and over 700 were injured (reis, 2014). a result of the investigations into the tragedy was the taylor report, which included reviews, notes, interpretations and 76 recommendations for english football, highlighting problems and measures that should be implemented, such as: reform/adaptation of rundown sports facilities; crowd and overcrowding control measures; special training for police and agents involved in events; redrafting of safety standards for stadiums and seating requirements for all fans in stadiums (sir norman chester centre for football research, 2002). based on this evidence, english football started to restructure itself in 1980 (proni, 2002). concerning organizing entities and mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 30 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe their documents on standards for football stadiums, the international football federation (fifa) has a technical specifications document with recommendations and technical requirements which is currently in its fifth edition (fifa 2011). since 2000, the european football union (uefa) possesses an instructional document on safety which contemplates stadiums, the binding safety and security instructions (uefa, 2004, 2006a). effective 2006, uefa added a more specific recommendations document, the uefa stadium infrastructure regulations (uefa, 2006b), of which the latest edition was published in 2010 (uefa, 2010). finally, uefa released the guide to quality stadiums in 2011 in order to ensure the quality and safety in the stadiums of its associate members (uefa, 2011). all these initiatives aim to provide safety and comfort to the general public, media professionals and athletes, in addition to "standardizing" the minimum requirements for a stadium to receive matches in competitions run by the organizations. the situation is very different in the americas. the south american football confederation (conmebol) did not make as much headway as uefa, failing to develop stadium standards even for its main competition, the copa libertadores da américa, whose regulation only requires a minimum 10.000 seating capacity to host matches in the early stages of the continental tournament, mandatory artificial lighting, and emergency generators in case of power failure (conmebol, 2016). in brazil, the brazilian football confederation (cbf) also does not have a specific guide or recomendations. nevertheless, it does have an internal system through a stadiums inspection commission designed to carry out stadium inspections with the help of engineers and architects (cbf, 2015). regulations and standards for stadiums in brazil originate from the federal government, and as in england, were implemented after incidents with attending fans. the main incidents took place at maracanã stadium in rio de janeiro in 1992, when the collapse of a stand killed three people and left 90 wounded; in são januário stadium, also in rio de janeiro in 2000, a fence broke due to overcrowding, wounding 175 fans; and finally in fonte nova stadium in salvador, bahia in 2007, seven people died due to the collapse of the stands (estado de são paulo, 2007). real (2003) stresses that after the neglect, particularly that of the football administration bodies towards fans, a legislation destined to regulate the sporting spectacle as a whole was needed. thus, with the creation of federal law no. 10.671/03 (brazil, 2003), the fan statute (edt), brazil entered a new realm in terms of protecting and defending fans’ rights. issues addressed by this legislation included requirements for safety, hygiene, accessibility and comfort in football stadiums. within this line of action, article 23 mentions in its wording the term “stadium technical reports”, which were regulated following sanctions by edt through a presidential decree and specifically by orders issued by the ministry of sports, which included the following documents: safety report, engineering inspection report, fire prevention and firefighting report, sanitary and hygiene conditions report, and structural stability report. however, this legal device is not well known by the public and this legal instrument’s effectiveness is not known in detail.therefore, it is important to broaden the discussion on the "reports system" in order to encourage its use, in addition to producing new knowledge in the subject areas of sports governance (organization and legislation), which may be added to actions involving its applicability in the daily routine of football competitions, not only in brazilian territory but also in competitions in south america and worldwide. in this context, we propose to mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 31 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe contribute to scientific production through this article, whose general goal is to examine brazilian legislation concerning stadium technical reports. specific objectives: (i) to review and understand current laws; (ii) to disclose the operation of the legal instrument within the legal and sports system; (iii) to develop a flowchart model of actions for the enforcement of the legislation; (iv) to identify cases involving reports and use of stadiums; and (v) to check how the instrument has served to benefit the fans. 2. materials and methods this study has an exploratory nature, as explained by gil (1999). this model is intended to clarify, expand and modify concepts or ideas on a particular subject. therefore, in research such as this paper, in which the subject matter is rarely examined in academia, to use quantitative techniques and probe samples in field studies in order to establish a database and format statistical calculations rarely applies. thus, to use documents and literature as its main strategy in pursuit of consistent responses makes this paper more reliable, especially when paired up against other data sources, such as books and articles (appolinário, 2009; gil, 1999). under this approach we applied bibliographical and documental research methods, which are set apart due to the origin of the applied sources. bibliographical research draws on contributions generated by different authors on the subject, generally secondary sources such as books, magazines/newspapers, legal documents, conference proceedings, journal articles, dissertations, theses, etc. on the other hand, documental research takes specific materials such as databases, reports, letters, newspaper articles, recordings, videos, websites, letters or other documents, which have not yet received analytic treatment in order to provide evidence and/or justifications to support research proposals (sa-silva; almeida & guindani, 2009). in line with the principles of sá-silva almeida & guindani (2009), we categorized and classified the collected material as follows: 1. legislation (federal law decree and orders by the ministry of sport); 2. academics (books and articles); 3. documents of organizing entities (material produced by cbf); 4. newspaper reports of widely accessed online newspapers. in category 4 we examine the time lapse from the seasons of 2013, 2014 and 2015, selecting cases of known and unknown stadiums in brazil in order to broaden the sample. next, in possession of the qualitative data, "the researcher must interpret them, synthesize information, determine trends, and to the possible extent, make the inference" (sá-silva; almeida & guindani, 2009, p.10). thus, we performed the analysis of qualitative data by deepening, creating links or even expanding our perspective regarding the proposed objectives. 3. report regulations the first documents that confirmed any information on stadiums came from state and local laws originated from common urban construction sites through the so-called operation permits, operation licenses, occupancy permits, fire brigade inspection certificate (avcb), fire department license permits, project against fire and panic, sanitary surveillance licenses and sanitary surveillance certificates, among others. nevertheless, they are limited and vary according to state and local laws within brazil. through federal law number 10.671/03 (brazil, 2003), the stadium technical reports topic is first seen in the following wording of article 23 and paragraphs: mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 32 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe art. 23. the entity in charge of the competition organization shall submit to the state prosecutor’s office and the federal district, prior to the event taking place, the technical reports issued by competent bodies and authorities for inspection of the safety conditions of the stadiums to be used in the competition. § 1. the reports shall address stadiums’ effective seating capacity, as well as their safety. § 2 a sports entity shall not be allowed to host games for at least six months, without loss of other applicable sanctions, if: i – a number of tickets greater than the stadium’s seating capacity has been put on sale; or ii – a number of people greater than the stadium’s seating capacity has been allowed inside its premises (brazil, 2003). while examining article 23, the positive points perceived are the involvement of competition organizing entities and the prosecutor’s office, the commitment to certifying the number of attending fans at stadiums, penalties for overcrowding and for excess tickets put on sale for matches. the negative points that stand out are the article’s lack of objectivity, since it does not define when the reports should be submitted to the prosecutor’s office or any deadline, lack of clarity on what would be the competent authorities issuing the reports and, furthermore, what are the actual reports. subsequently, article 23 of the edt was regulated by decree no. 6.795 (brazil, 2009a) only six years later, in march 2009, the contents of which clarify which reports are to be issued. the documents according to its article 2, § 1, are: safety report, engineering inspection report, prevention and fire fighting report, and sanitary and hygiene conditions report. on the other hand, they still have nott clarified which are the competent authorities to issue reports or if there even are technical report "models", or, furthermore, how those should be developed. the decree also mentions that a fifth report may exist, the structural stability report. consequently, the ministry of sports published in july 2009 order number 124/09 me (brazil, 2009b), which includes the first specific legislation on technical reports in brazil. in this order, the ministry of sports explains some of the cited flaws, in addition to including the technical report models in four annexes: art. 3 the technical reports set out in annexes i, iii and iv of this order shall be issued respectively by the persons designated by the commanders of the military police and the state fire department and by the competent local sanitary inspection organ. single paragraph. the reports addressed in annex ii, as well as the structural stability report addressed in the sole paragraph of article 2, shall be established by legally qualified professionals previously registered for this purpose at their local crea (brazil, 2009b). three of the four annexes are: 1 safety report, iii prevention and fire fighting report, and iv – sanitary and hygiene conditions report. with questionnaire-type models to fill out, they have a maximum expiration date of one year. the exception is annex ii – engineering inspection report, which has a maximum expiration date of two years and is an interpretative document with a defined script for the responsible engineer to follow and fill out according to his understanding. however, article 2 of the order includes the term structural stability report, and thus the issues involving the author/agent that should issue it and how much each one should be a model remain unanswered. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 33 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe with the publication in july 2009, during the brazilian football season, in other words, with national and state competitions in full swing, the reports received a 90-day term to enter into force in definite terms (brazil, 2009b). this action leads us to consider the need for more time in order to adjust the reports’ documentation at all currently operating stadiums in brazil. nevertheless, as a result of order 185/09 me (brazil, 2009c) of 19 october, the deadlines and texts of the previous delivery were amended: art. 1 art. 3 of order no. 124 of july 17, 2009 comes into effect with the following amendment: art. 2 this order shall come into effect on the date of its publication. art. 3 the technical reports set out in annexes i, iii and iv of this order shall be issued respectively by the persons designated by the commanders of the military police and the state fire department and by the competent sanitary inspection authority effective beginning january 18, 2010. sole paragraph. the reports addressed in annex ii, as well as the structural stability report referred to in the sole paragraph of art. 2, shall be prepared by legally qualified professionals previously registered for this purpose at a local crea and shall be effective beginning february 22, 2010. (nr) (brazil, 2009c).thus, the implementation of technical reports in 2009 failed to become a reality, becoming a pledge for 2010. after an extension term, the safety, fire prevention and firefighting, sanitary and hygiene reports came into effect on january 18, 2010. nevertheless, the launch date of the engineering inspection report, annex ii, was delayed once again to april 23 of that year, through order 28/10 me (ministry of sports) (brazil, 2010a). in this sense, it is understood that this last measure resulted from two facts: the complexity of the engineering inspection report, after all, since an engineer becomes the expert in charge of approving certain stadiums, the registration and training of these professionals requested by the regional engineering and architecture councils would take some time. at the end of 2010, order 238/10 me and annexes were published (brazil, 2010b). at this time, annexes i and iii, safety and fire prevention and firefighting underwent minor amendments with the addition of new topics, as well as legislation, through article 2 and paragraphs mentioning, once again, the structural stability report, yet this time setting out an expiration term, date and conditions for its enforcement. § 1 the structural stability report is mandatory for stadiums with a capacity equal to or greater than forty thousand fans, for those which have undergone expansion work or adaptations that require structural changes, and also for those with a history of structural problems. § 2 the structural stability report is valid for 5 (five) years, for the purposes of this order, and shall be required 180 (one hundred and eighty) days effective from its publication date. § 3 at any time or during the engineering inspection, should any abnormality or problem that compromises the stability of the structure be detected, the immediate elaboration of a structural stability report will be required, which, in the aforementioned cases, the deadline for its elaboration of the previous paragraph will not apply (brazil 2010b). this legislation remained in force until december 31, 2015, four years later, because in october 2015 the ministry of sports published order 290/15 me (ministry of sports) and annexes (brazil, 2015), including new types of reports: i safety report; ii – engineering inspection report, accessibility mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 34 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe and comfort; iii – fire prevention and fire fighting and panic report; iv – sanitary and hygiene conditions report. thus, order 238/10 me (ministry of sports) (brazil, 2010b) was revoked and the new types of reports have been in effect since january 1, 2016. despite having been introduced recently, the new reports include questionnaire-^ptype models with multiple choice answers, estimated results for approval in their contents and brings deadline recommendations for restrictions to be set forth by the issuer, such as 30 days to hire a security manager for the stadium. there is also the submission of documents required for issuing the report, as is the case for the fire fighting and panic projects approved by the state fire department. therefore, we believe that the process became more demanding regarding conditions for amendments and norm compliance and, on the other hand, more bureaucratic and consuming as a result of the number of restrictive items brought forth in the reports. while reflecting on the described timeline one can say that stadium technical reports came into effect in brazil during the 2010 season, effective april, after some extended deadlines. as a criticism, there is no doubt that this matter took a long time to become a reality, with six years between publication of the edt, regulation by ministry of sport orders and decrees highlighting the slow pace of the brazilian legal system, perhaps due to lack of interest in the subject. this opinion supports amaral & bastos’s observations (2011), when they cite the delay in the enactment of laws and their implementation, leaving room for a breach of the rules established for stadiums in brazil. 3.1 report system according to what brazilian law prescribes, the reports shall be submitted by organizers of football competitions; however, there is a proceeding for sending the reports to the state prosecutor’s office and the federal district. thus, a flowchart model was created setting forth a sequence for carrying out the activity within the legal and sports system: figure 1: report system flowchart mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 35 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe the flowchart proposes a sequence of practical actions aimed at the enforcement of technical reports. thus, it establishes the figure of the stadium administrator/owner, which is broken down into public (municipal, state or federal government) and private entities represented by leaseholders and companies and authorized to manage stadiums as the most interested parties in keeping up-to-date reports. subsequently, competent authorities are called on to carry out inspections at the stadium, whose end results are technical reports falling into the following categories: approved, approved with restrictions or not approved. in these last two cases, there is a requirement for an adjustment that is paramount to the operation of the stadium, such as: recovery of a column that supports the stands, or even simpler adjustments like installing handrails and indoor signage. in such cases the restriction must be met in order for the stadium to be approved and, thus, released for use. the system in question appears to be objective. however, is the role of the competition organizers merely that of sending reports? should they not get acquainted with and take measures related to its content? issues such as these are not clear in the legislation, which generates further questions: who is responsible for keeping charge of reports’ due dates? who is responsible for analyzing and verifying restrictions for each report? who oversees the reports? who would be responsible for these "powers"? irrespective of being in writing or not, this responsibility is understood to belong to the final recipient, the prosecutor’s office. but is it really a responsibility only of the prosecutor’s office? do the federations and cbf not have some share of responsibility over this matter or should they be included in some way? 3.2 cases and benefits for fans in this section the discussion is aimed at showing case studies portrayed by the media in which technical reports were of utmost importance to define whether a football match should take place or not, in line with the use of sports equipment. the first occurrence took place at maracanã stadium in september 2013, at which time the rio de janeiro prosecutor’s office demanded the submission of a new engineering inspection report, since the one that had been submitted by cbf did not meet the minimum requirements set forth in annex ii of the ministry of sport’s order 238/10 (o dia newspaper, 2013). the stadium was being used since its reopening in may of that year in matches of the brazilian championship by riobased clubs. despite having undergone renovation and, additionally, still being prepared for hosting the grand final of the fifa world cup 2014 and, thus, not posing structural risks for fans, it was made to submit the appropriate report in order to continue being used. this demand showcases inspection controls at stadiums, which is something that ultimately benefits/ensures fans’ safety. secondly, we focus on the interdiction of josé abreu bianco (biancão) stadium in ji-paraná/rondônia, with a match scheduled for the 2013 brazil cup and local championship. the stadium was interdicted by the state prosecutor’s office due to constraints such as security cameras and adjustments on the size of fences. these restrictions were demanded by the security report issued by the military police. the stadium was re-evaluated by the same and released for use by the prosecutor’s office after the demands were met (plantão esportivo, 2013). in this scenario, the demand for cameras is for stadiums with a capacity of 10,000 fans (brazil, 2003), which was not the case here. nevertheless, renovation work on the gates mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 36 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe should have been carried out and inspected, providing improved safety for the fans, thus constituting a cycle of corrective and effective actions for the sports equipment, which did not come through, leaving doubts over the real benefits for fans. in the third situation, the actions were carried out more completely since the arena stadium in juruá, in the city of cruzeiro do sul, acre, had its reports prepared, which outlined problems with the stadium’s structure in july 2013, requesting the non-use of the equipment. thus, the prosecutor’s office upheld the interdiction (ac24horas, 2013) and, in addition, the prosecutor’s office and the acre football federation signed a conduct adjustment contract (tac) in order to ensure the stadium was used only after confirmation of the case solution (renovation works) through new reports. furthermore, the tac included a daily r$ 10,000 fine in case of noncompliance. in light of the above, one can observe the preventive action carried out by the prosecutor’s office based on the diagnosis set out through the technical reports, which is consolidated by the tac and through financial compensation, perhaps the only way to ensure improvements are carried out in the stadium and, therefore, benefit the fans. it can be concluded that in this case, the stadium effectively underwent renovation works since it hosted state championship matches beginning march 2015. another incident took place in may 2014 in piauí, in alberto silva stadium (albertão), the state’s main sports arena. the albertão had been previously interdicted by the prosecutor’s office for not having the fire fighting and panic project approved by the fire department, among other irregularities, such as lack of fire hydrants and hoses. however, a new fire prevention and firefighting report was submitted, clearing the stadium for approval without restrictions. thus, the prosecutor’s office sent local experts to the stadium, who once again verified the lack of a fire department approved project, as well as lack of fire hydrants and hoses in all areas, lack of a lightning protection system, signaling, evacuation plan and alarm, which led to upholding the interdiction (o dia portal, 2014). the stadium was used in matches for the 2015 brazil world cup in march and april. we found a case in which the prosecutor’s office was not the leading agent for stadium interdiction or veto. in november 2014, palmeiras intended to inaugurate the allianz parque stadium in a match against atlético mineiro for the brazilian championship; however, the safety and fire prevention and firefighting technical reports were not yet ready (espn, 2014). as a result, without the reports having been submitted to the são paulo state football federation and cbf, the match was not confirmed, and the stadium officially opened on november 29 for the match between palmeiras and sport. under these conditions, one can observe that the law has been enforced without any kind of restriction and the stadium administrator is required to meet the legal requirements, despite it being a new, modern stadium and apparently not offering so many risks. another case happened in são paulo, the state that has the largest number of stadiums in brazil (cbf, 2016). according to a story published by the estadão newspaper on december 29, 2014, the são paulo state football federation decided to interdict, in other words, to temporarily close 31 stadiums pertaining to clubs that competed in the a1, a2 and a3 (first, second and third divisions) divisions of the são paulo state championship, mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 37 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe which represented over 50% of stadiums pertaining to 60 participating clubs. among the banned stadiums were traditional arenas such as canindé, owned by club portuguesa de desportos, and nabi abi chedid, owned by club bragantino, which were required to submit to the federation the fire department inspection permit, in addition to the four reports required by law, before the start of the competition (o estado de são paulo newspaper, 2014). while assessing this occurrence it is worth highlighting its uniqueness and rigorousness, particularly concerning the ratio of interdictions and immediately prior to a championship as important and competitive as the paulista (são paulo state), which started in february 2015. thus, one of the consequences was the replacement of these stadiums in the league table and overburden of matches on others whose reports were up-todate. this also served as a warning sign for stadium administrators and clubs planning on receiving box office revenues, who were now required to pay greater attention to both legal requirements and the importance of submitting technical reports. in contrast, the benefit to fans takes place through the compliance with the legislation and in ensuring that competition stadiums have been inspected and certified by competent authorities. we verified a case in the copa sul-americana in august 2015 when brasília, a brazilian club, should have submitted the fire prevention and firefighting technical reports, as well as the sanitary and hygiene conditions reports for the mané garrincha stadium (used in the 2014 fifa world cup) in order to participate in the competition. nevertheless, the federal district state government (gdf) failed to submit the reports to cbf, and as a result, the stadium was vetoed and the match scheduled for valmir bezerra stadium in the city of gama (amora, 2015). by said situation, the analysis continues pointing to the full compliance with the law by cbf, conmebol’s representative. however, if we look at it closely, one can perceive the total ignorance and indifference on gdf’s behalf concerning the issue, reflected by its mismanagement of the 2014 world cup’s most expensive stadium. we understand that the reports serve as decision-making tools for the prosecutor’s office and competition organizers by offering an overview of the stadiums. in the aforementioned cases, one can perceive that the government is the only entity detaining legal capacity to inspect, re-evaluate or even demand that restrictions be met so that improvements take place in stadiums, thus ensuring safety, comfort and accessibility conditions to fans. 4. final considerations stadium safety firstly and directly affects football and sports championships, but it also ends up protecting major events of various kinds that commonly take place in stadiums (concerts, lectures, rallies, space rentals and general entertainment). the reports certify, among other points, the fire prevention system and emergency exits, which in large cities are a significant concern. it is why stadium administrators must now keep the reports up-todate in order to profit while hosting football matches. therefore, all events are benefited. during the study, it was possible to ascertain that the legislation has been in force for six years, has set standards and norms defined through its own models for each report, and received its final implementation deadlines within the brazilian scene. in this regard, agents directly involved in this issue are state football mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 38 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe federations, the brazilian football confederation, stadium administrators and owners, the military police, the fire department, the sanitary surveillance, engineers, architects and state public ministries. despite the mandatory compliance by organizers of professional football competitions, which are required to submit the technical reports to the state public prosecutor’s office before the start of the competition, the legislation is not clear as to who should oversee the technical reports so that they are effective in meeting fans’ needs concerning safety, hygiene and comfort conditions. this fact is highlighted by proven examples in which improvements are guaranteed only through the tac, ensuring that the stadium remains idle until the problem is resolved. nevertheless, we defend that the prosecutor’s office be in charge of this position as the process supervisory agent. on the other hand, even though the report system has flaws in its actions, it symbolizes a breakthrough in issues ranging from safety to fans’ comfort. it is interesting to observe how a gauge of this magnitude did not exist in brazil, the so called "football nation", and still seems absent in south america in general. thus, how many tragedies and, consequently, deaths could have been avoided? the reports system is undergoing changes with the inclusion of order 290/15, which changed the models known until then since 2010. the reports underwent increases in content, page numbers, document submissions and manner of filling out the form through the inclusion of suggested deadlines for meeting restrictions, such as, for example, the 120 days required for fixing physical barriers between stadium sectors lacking them. another example is the engineering inspection, accessibility and comfort report (former engineering inspection report), which now has 331 pages, as opposed to its former 97 pages. throughout all these changes we can observe that the main goal of the reports, which is to certify stadium conditions for fans, is upheld; however, since the testing year is 2016, we are actually left in the dark concerning progress or setbacks within the process. 5. references ac 24 horas. (2013). arena do juruá stadium to remain interdicted until submission of technical reports. acre, july 15. retrieved on november 15, 2015 at: http://www.ac24horas.com/2013/07/15/estadio-arena-dojurua-vai-continuarinterditado-ate-apresentacao-de-laudos-tecnicos-2/. amaral, c. m. s.; bastos, f. c. (2011). stadium regulation and management in brazil. pensar a prática. goiânia, 4(3), 1-17. amora, d. (2015). with incomplete reports, stadium used in world cup suffers veto for match in brasília. folha de são paulo, august 15. retrieved on january 31, 2016 at: http://www1.folha.uol.com.br/esporte/2015/08/1669232-sem-laudos-estadio-dacopa-e-vetado-para-jogoem-brasilia.shtml. appolinário, f. dictionary of scientific methodology: a guide for the production of scientific knowledge. são paulo: atlas, 2009. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 39 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe brazil. (2003). law nº 10.671, may 16th. fans’ rights defense statute. brazil. (2009a). decree nº 6.795, march 16th. brazil. (2009b). ministry of sports. portaria 124/09, july 17th. brazil. (2009c). ministry of sports. portaria 185/09, october 19th. brazil. (2010a). ministry of sports. portaria 28/10, de 19 de fevereiro. brazil. (2010b). ministry of sports. portaria 238/10, de 09 de dezembro. brazil. (2015). ministry of sports. portaria 290/15, de 27 de outubro. cbf (2016). national register of football stadiums – cnef. 6th review. rio de janeiro. cbf. (2015). national stadium inspection commission meets at cbf. rio de janeiro, july 15th. retrieved on january 29th, 2016 at: http://www.cbf.com.br/noticias/campeonato/comissao-nacional-de-inspecaodeestadio-reune-se-na-cbf#.vogxvburliu. conmebol. (2016). bridgestone libertadores cup regulations. espn. (2014). without report, palmeiras requests game at allianz parque, but são paulo state federation discards the possibility. são paulo, october 29th. retrieved on december 22nd, 2015 at: http://espn.uol.com.br/noticia/453600_sem-laudo-palmeiras-pedejogo-no-allianz-parque-mas federacaopaulista-descarta. fifa. (2011). football stadiums: recommendations and technical requirements. 5th edition. switzerland, zurich. gil, a. c. (1999). social research methods and techniques. 5th edition. são paulo: atlas, 1999. o dia. (2013). rio without a stadium? maracanã may be interdicted. rio de janeiro. retrieved on august 25th, 2015 at: http://odia.ig.com.br/esporte/2013-09-17/rio-sem-estadiomaracana-pode-ser-intertidado.html. o estado de são paulo. (2007). other tragedies in stadiums marked brazilian football. são paulo, november 26th. retrieved on november 22nd, 2015 at: http://esportes.estadao.com.br/noticias/futebol,outrastragedias-em-estadiosmarcaram-o-futebol-brasileiro,85783. o estado de são paulo. (2014). são paulo state federation interdicts 30 stadiums in a1, a2 e a3 series. são paulo, december 29th. retrieved on december 10th, 2015 at: mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 2; march-april 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 40 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe http://esportes.estadao.com.br/noticias/futebol,federacao-paulista-interdita-30estadios-nas-series-a1-a2e-a3,1613376. portal o dia. (2014). albertão stadium remains interdicted by justice resolution. teresina, may 16th. retrieved on december 20th, 2015 at: http://www.portalodia.com/esporte/esporte/estadio-albertaopermaneceinterditado-por-determinacao-da-justica-203517.html. plantão esportivo. (2013). palco do estadual e copa do brasil, biancão é interditado pelo mp/ro. porto velho, march 12th. retrieved on january 10th, 2016 at: http://www.plantaoesportivo.com/noticia/2013/03/12/palco-do-estadual-ecopa-do-brasil-biancao-einterditado-pelo-mp-ro.html. reis, h. h. b. (2013). football spectators and the problematic of violence related to the organization of the football spectacle. revista paulista de educação física. são paulo, v.17(2), 85-92. reis, r. m. (2014). brazilian football championship management: economy, market, media and tv. curitiba: editora prismas. sá-silva, j. r.; almeida, c.; guindani, j. f. (2009). documental research: methodological and theoretical clues. revista brasileira de história & ciências sociais. rio grande do sul, year i(i), 01-15. sir norman chester centre for football research (2002). football stadia after taylor. leicester: university of leicester. uefa (2004). binding safety and security instructions. nyon. uefa (2006a). uefa safety and security regulations. nyon. uefa (2006b). uefa stadium infrastructure regulations. nyon. uefa (2010). uefa stadium infrastructure regulations. nyon. uefa (2011). uefa guide to quality of stadiums. nyon mailto:topacademicjournals@gmail.com 050816-cr098.docx american journal of medical and physical education vol.8, issue 4; july-august 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 1 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe unraveling the wisdom of "jingyue quanshu phlegm drinks" in traditional chinese medicine 1dr. wei zhang, 2prof. li mei, and 3dr. xin chen 1north china university of science and technology 2tangshan hospital of traditional chinese medicine 3shandong university of traditional chinese medicine abstract: phlegm, as described in traditional chinese medicine, represents a pathological manifestation arising from disruptions in bodily fluid metabolism, characterized by its sticky, viscous nature and tendency to obstruct the normal flow of bodily functions. its presence can lead to various health issues, including disturbances in cognition, impaired blood flow, and even the development of tumors. this article delves into the historical and theoretical aspects of phlegm-related conditions, shedding light on their multifaceted nature. keywords: traditional chinese medicine, phlegm, bodily fluid metabolism,,pathological manifestation, health implications 1. introduction the "phlegm" described by traditional chinese medicine is the pathological product of body fluid metabolism disorders and qi and blood stasis. it is characterized by poor flow, stickiness, foul secretion, accumulation of condensation, pathogenic weirdness. and it also has the characteristics of disturbing the mind, blocking the flow of blood, blocking the brain, leading to tumor formation by the accumulation [1]. there were first records of "water drinking" and "ji drinking" in the neijing. zhang zhongjing of the eastern han dynasty in his synopsis of the golden chamber pioneered the name of phlegm drinking disease, but it has its limitations detailed in drinking and slightly in phlegm. in the theory of various diseases described the etiology, pathogenesis and types of sputum in detail. renzhai zhi zhi fang pointed out that "phlegm and drinking, by self, its shape is also different, the nature of phlegm is viscous, drinking is water" [2]. zhang jingyue's discussion on phlegm retention is detailed and thorough. he advocated that phlegm retention and body fluid are of the same origin, both of which are changed by cereal essence. if it is positive, it will be collected in the blood gas, strong body, and supplement the battalion and ying-wei. if it is not positive, it will cause the disease of zangfu, and the imbalance of body fluid will lead to phlegm and salivation [3]. zhang believed that although phlegm and drink belong to the same species, their essence is also different. drinkingis a kind of waterdampness, its texture is clear and thin, mostly due to the feeling of cold dampness, lost in transport by the spleen and stomach, or stay in the limbs, chest and skin. phlegm is mainly composed of condensed body fluid, its quality is thick and sticky, and it is often caused by feelin of the fire and mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 4; july-august 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 2 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe heat. it can be produced even if the five viscera are damaged, and it can be found everywhere with the rise and fall of human qi [4]. the disease of phlegm retention can occur repeatedly, and even spread to the whole body, showing symptoms such as wheezing, chest tightness, vomiting, limb numbness, head dizziness, and so on. it is inseparable from the five zangfu, nine orifices and three jiao of human body. according to modern medicine, phlegm turbidity is closely related to obesity, hyperlipidemia, abnormal carbohydrate metabolism, and abnormal hemorheology, and accumulation drink is close to airway mucus hypersecretion, pleural effusion, and pericardial effusion in respiratory diseases [5]. 2. data and methods 2.1. data collection and specifications collect the prescriptions involved in jingyuequanshu · phlegm retention, and the name of the drug in the prescription shall uniformly refer to the chinese pharmacopoeia. for example, "wheat gate winter" is unified as "wheat winter", "white poria" cocos" is "poria", "raw licorice" is unified as "licorice" and so on. 2.2. data processing and verification using office excel 2019, the database of 111 prescriptions was established according to the software requirements. and upload the data to the "tcm inheritance computing platform v3. 0". inorder to avoid possible errors in the single entry, after all the entry, two people will check theinput data to ensure the correct data. 3. results and analysis 3.1. frequency of medication statistics on the frequency of 111 prescriptions in jingyuequanshu · phlegm retention. the drugs with frequency ≥8 were imported into the excel table and the following conclusions were drawn, drugs with frequency ≥8 had 20 flavors, as shown in table 1. table 1: analysis of medication frequency in jingyuequanshu · phlegm retention (frequency ≥8) order number medicinal frequency order number medicinal frequency 1 pinellia ternata 50 11 radices saussureae 11 2 poria cocos 47 12 rhizoma alismatis 11 3 pericarpium citri reticulatae 39 13 bile arisaema 10 4 bighead atractylodes rhizome 34 14 angelica sinensis 10 5 liquorice 30 15 rhizoma zingiberis 10 6 ginseng 27 16 rhizoma arisaematis 10 7 ginger 27 17 fructus aurantii immaturus 9 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 4; july-august 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 3 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 8 prepared licorice 22 18 syzygium aromaticum 9 9 radix rehmanniae praeparata 19 19 fructus ziziphi jujubae 8 10 scutellaria baicalensis 11 20 cinnabar 8 3.2. four gas, five flavors and channel tropism by analyzing the summary of each flavor of medicine, we can derive the distribution of all the four gas, five flavors and channel tropism, export the results to excel, and draw a radar chart. the results showed that warm chinese drugs were applied the most (367 times), followed by flat (146 times) and cold (125 times), see figure 1; pungent chinese drugs were applied the most (358 times), followed by sweet (312 times) and bitter (311 times), see figure 2;1hinese drugs attributed to the spleen meridian were applied the most (501 times), followed by the lung meridian (452 times) and the stomach meridian (309 times), see figure 3. figure 1: four gas statistical radar chart figure 2: five flavors statistical radar chart figure 3: channel tropism statistical radar chart diagram mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 4; july-august 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 4 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 3.3. efficacy statistics the efficacy frequency of the drugs used in the 111 prescriptions was counted, and the results were exported to excel to draw the bar chart, as shown in figure 4.. the analysis results show that:the deficiency supplementing formula were used most frequently, followed by phlegm-expelling formula (107 times) and carminative formula(85 times). figure 4: efficacy statistics 3.4. analysis of square rules based on association rules the "number of support" was set to 11, and the confidence level was set to 0. 8. 29 groups of drug combinations with frequency ≥ 11 were obtained, and the results are shown in table 2, and the core drug combinations were networked and displayed in figure 5. 7 association rules with confidence level ≥ 80% were obtained, and the results are shown in table 3. table 2: analysis of core combinations of medicines used in jing yue quan shu phlegm drink (support ≥11) no. drug combinations frequency no. drug combinations frequency 1 pinellia ternata, pericarpium citri reticulatae 26 16 pericarpium citri reticulatae, radix glycyrrhizae preparata 13 2 poria cocos, pericarpium citri reticulatae 26 17 poria cocos, pericarpium citri reticulatae, liquorice 13 3 pinellia ternata, poria cocos 26 18 rhizoma atractylodis macrocephalae, liquorice 13 4 poria cocos, rhizoma atractylodis macrocephalae 24 19 rhizoma atractylodis macrocephalae, dried ginger 12 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 4; july-august 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 5 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 5 poria cocos, liquorice 20 20 poria cocos, pericarpium citri reticulatae, rhizoma atractylodis macrocephalae 12 6 pinellia ternata, ginger 19 21 pericarpium citri reticulatae, radix glycyrrhizae preparata 12 7 pinellia ternata, poria cocos, pericarpium citri reticulatae 19 22 poria cocos, pericarpium citri reticulatae, ginseng 12 8 poria cocos, ginseng 18 23 pinellia ternata, poria cocos, liquorice 12 9 rhizoma atractylodis macrocephalae, ginseng 18 24 poria cocos, radix glycyrrhizae preparata 12 10 pericarpium citri reticulatae, liquorice 16 25 pinellia ternata, dried ginger 11 11 pinellia ternata, liquorice 15 26 poria cocos, rhizoma atractylodis macrocephalae, liquorice 11 12 poria cocos, rhizoma atractylodis macrocephalae, ginseng 15 27 pinellia ternata, ginseng 11 13 pericarpium citri reticulatae, rhizoma atractylodis macrocephalae 15 28 liquorice, ginseng 11 14 pericarpium citri reticulatae, ginseng 14 29 pericarpium citri reticulatae, ginger 11 15 poria cocos, ginger 13 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 4; july-august 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 6 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe figure 5: network diagram of medication combination core associations (support 11, confidence 0. 8) table 3: analysis of medication association rules (80% confidence) no. rules confidence level 1 pericarpium citri reticulatae, ginseng->poria cocos 0. 86 2 rhizoma atractylodis macrocephalae, liquorice->poria cocos 0. 85 3 rhizoma atractylodis macrocephalae, ginseng->poria cocos 0. 83 4 poria cocos, ginseng->rhizoma atractylodis macrocephalae 0. 83 5 pericarpium citri reticulatae, liquorice->poria cocos 0. 81 6 pericarpium citri reticulatae, rhizoma atractylodis macrocephalae>poria cocos 0. 8 7 pinellia ternata, liquorice->poria cocos 0. 8 3.5. analysis of new prescriptions based on k-means clustering the "number of clusters (k)" was set to 4, and the extracted combinations yielded 4 possible potential core drug combinations. the results are shown in table 4. the schematic diagram of k-means algorithm and regression model is shown in figure 6. table 4: new combinations of medicine clustering analysis in jing yue quan shu phlegm drink no. new combination 1 pinellia ternata, poria cocos, rhizoma atractylodis macrocephalae, pericarpium citri reticulatae, liquorice, ginseng 2 ginger, pinellia ternata, rhizoma arisaematis, poria cocos, pericarpium citri reticulatae, radix glycyrrhizae preparata 3 ginseng, radix glycyrrhizae preparata, poria cocos, angelica sinensis, rhizoma atractylodis macrocephalae 4 arisaema cum bile, rheum officinale, kanziol, semen armeniacae amarae, semen brassicae, bezoar mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 4; july-august 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 7 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe figure 6: cluster analysis regression model fig 4. discussion to sum up the results of this study, the main ideas of jing yue's treatment of phlegm drink are: reinforcing premodial qi, simultaneous application of cooling and tonifying therapy, yin and yang mutual aid, disease presentation and root cause are not treated simultaneously, warmly invigorating spleen and stomach. jing yue's treatment of phlegm focuses on nourishing vitality, if it is strong, the phlegm will be less, if the vitality is declined the cereal essence and body fluid can become phlegm [6]. it is important to distinguish the essence of vitality, strong vitality, the spleen and stomach can be transported properly, making the water and grain essence micromatter into qi, blood and body fluidtransfusion in the whole body. as is known to all, the lung plays an important role in the transportation of phlegm and drinking. combined with the combination of highfrequency medication, we can understand the idea of jingyue. those who damage the lung should be given qitonic drugs, and the lung qi is full, and the remaining dirty gas is flourishing. and modern studies show that ginseng has the effect of improving memory, anti-aging and regulating immunity [7]. in addition, the wide use of licorice, hot licorice, its taste to sweet, cool and warm. pharmacological studies show that licorice has anti-tumor, antiinflammatory sterilization, anti-virus, anti-heart failure, immune regulation and anti-fibrosis [8]. pay attention to the use of cleaning and supplementing, has been certified by many scholars [9-10], the phlegm drinking described in zhongjing is actually a drinking certificate, he put forward "sick phlegm drink, should mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 4; july-august 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 8 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe warm medicine and it" for the later treatment of phlegm drink. pinellia pinellia and tangerine peel compatibility can warm phlegm drinking, clinical commonly used to treat cough phlegm, qi nausea and other evidence, pinellia pinellia [11] has significant antitumor effects, while tangerine peel [12] has good effects on lowering blood lipid and reducing phlegm. combined with heat-clearing drugs, such as scutellaria baicalensis in high-frequency drugs, its taste is bitter and cold, qi is light than taste, bitter than cold, which belongs to the micro yang in yin. many studies [13] have shown that baicalein, han baicalein and its glycosides have pharmacological activities such as anti-tumor, anti-virus, anti-inflammatory, antioxidant, liver protection and neuroprotection. pay attention to the harmony of yin and yang. the treatment of yang deficiency, the medicine of tonifying kidney and nourishing essence is equipped with nourishing qi and warming yang medicine to achieve the effect of harmonizing yin and yang. pharmacological studies [14] show that the active ingredients of prepared rehmannia have the function of anti-aging and enhancing body immunity. this not only reflected jing yue's thought of cultivating and reinforcing yinessence, but also reflected his wonderful principle of the mutualism of yin and yang. just as jingyue said, "the use of nourishing yin is the cultivation of yang. the best way to help yang isto cultivate yin and yang" [15]. the treatment of phlegm should investigate the deficiency and treat both the symptoms and the root cause [16]. solid phlegm disease light shallow, to go quickly, insufficient for fear, and empty phlegm always by the deficiency of the viscera, gradually become, the disease is difficult totreat, remove also slow. through the analysis of core drug combination and association rules, jingyue makes good use of four gentleman soup for virtual phlegm, studies [17] have shown that sijunzi decoction has pharmacological effects on promoting the absorption of intestinal nutrientsand improving body immunity. and the man is young and strong, or because of the wine and meat thick taste, or because of the physical gas hot and heat, or because of wind resistance closed muscle cou, or because of the liver gas on the reverse obstruction, causing phlegm drink, itsvitality is full, appropriate elimination, can be attacked. witness its thought [18] "without deficiency evidence and phlegm, dispel its damp stagnation phlegm since clear, appropriate two chen soup lord". modern studies [19] believe that, phlegm and dampness is the pathological factor of metabolic diseases, and erchen soup can intervene in the process of metabolic diseases through dryness, dampness and phlegm. all five viscera can produce phlegm, but the source of phlegm is nothing more than spleen and kidney, highfrequency traditional chinese medicine, poria cocos, sweet and light taste, flat qi. sex drop and infiltration, yang in the yin also. atractylodes, sweet taste, temperature, yin in yang, blood in gas. its nature is warm and dry, so it can replenish qi and replenish yang and blood, warm stomach and valley, benefit jin fluid, long muscles, solid spleen and stomach, dehumidification and transport phlegm. atractylodes macrocephala, sweet and pungent in taste, iswarm, with yin in yang and blood in qi. it is warm and dry in nature, so it can benefit the qi and nourish the yang and generate blood, warm the stomach and eliminate grain, benefit the fluids, grow muscles, strengthen the spleen and stomach, remove dampness and transport phlegm, eliminate floating and dispel swelling. pharmacological research points out that [20] poria cocos can strengthen the spleen by intervening intestinal flora, mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 4; july-august 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 9 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe while rhizoma atractylodis macrocephalae [21] has the function of protecting liver, regulating immunity and spleen and stomach. therefore, the first phlegm warm spleen strong kidney, phlegm is not treated and go. four new prescriptions were obtained based on k-means clustering analysis: (1) pinellia ternata-poria cocosrhizoma atractylodis macrocephalae-pericarpium citri reticulataeliquoriceginseng, (2) ginger-pinellia ternatarhizoma arisaematis-poria cocos-pericarpium citri reticulataeliquorice, (3) ginseng-liquorice-poria cocosangelica sinensis-fructus ziziphi jujubae-rhizoma atractylodis macrocephalae, (4) arisaema cum bile-rheum officinale-kanziol-semen armeniacae amarae-semen brassicae-bezoar. in this paper, the author shows the medication rule of zhang jingyue to treat phlegm retentionthe author's research on the treatment of sputum drinking disease is still unsatisfactory. first of all, the cognitive aspect is relatively narrow, mostly theoretical expression, and the lack of in-depth analysis and summary in the specific application, secondly, zhang jingyue's overall academic thought is inseparable. this research is devoted to the book of jingyue quanshu, which ignores the mining and analysis of the relevant contents of zhang's other works, and more attention should be paid to the internal relevance of his academic thoughts. references lin qijia. theoretical study on the method of dispelling phlegm and opening the orifices and its application [d]. china academy of traditional chinese medicine, 2018. li xc, zhang j. examination on the origin and clinical application of phlegm drinking [j]. shanghai journal of traditional chinese medicine, 2018, 52(01): 40-42. yang hui, sun shixiao. an introduction to the understanding of "phlegm" in chinese medicine [j]. heilongjiang traditional chinese medicine, 2014, 43(03): 11-12. ma jy. study on the academic thought of zhang jinyue on the treatment of phlegm [d]. gansu college of traditional chinese medicine, 2014. ji xiuli. analysis of the concept of phlegm-drinking and clinical significance and research ideas on the disease caused by drinking evil [j/ol]. journal of beijing university of traditional chinese medicine,2022,45(05):513-518. liu yaping, pan guijuan. the diagnosis and treatment of phlegm in jing yue quan shu [j]. chinese journal of traditional chinese medicine, 2007(07): 427-429. huang rongrong, qian ying, xiang ming. advances in the immunomodulatory effects of ginsenoside rh2 [j]. chinese journal of immunology, 2019, 35(23): 2936-2941. lian xiaolong, ling ying, zhang shanglong, ma qinghuan, yan xiao, zhang nan, ye liqiao, deng yi. progress of anti-tumor mechanism and combined anti-tumor research of active ingredients of glycyrrhiza glabra [j]. chinese journal of experimental formulary, 2022, 28(11): 238-245. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 4; july-august 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 10 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe yu t, ding m, yu qq, xue hr. a further discussion on "those who suffer from phlegm-drinking should be harmonized with warm medicines" [j]. chinese journal of basic chinese medicine, 2022, 28(02): 177179. wang yl, zhou h, zhou q, ou ly, wu yr, wu ruoxia, zhang z, guo ym, tian xuefei. exploring professor zhou heng's treatment of phlegm-drinking disease based on the theory of the coup de trois [j]. sichuan traditional chinese medicine, 2021, 39(08): 1-4. li zhe, xuan jing, zhao zhenhua, zhang yongqing. progress in the study of chemical composition and pharmacological activity of panax quinquefolium [j]. journal of liaoning university of traditional chinese medicine, 2021, 23(11): 154-158. zhang x t, zhang y, zhang dy, meng j, sun y, wang sm, and cao h. research progress on the concoction of chen pi [j/ol]. chinese journal of experimental formulary: 1-13 [2022-05-11]. zheng minmin, liu jie, zhao qing. progress and prospects of biological research on the medicinal plant scutellaria baicalensis [j/ol]. biotechnology bulletin: 1-14 [2022-09-16]. zhu yan, xu chang. advances in the pharmacological effects of active ingredients of radixrehmanniae [j]. asia-pacific traditional medicine, 2011, 7(11): 173-175. wang sp, lu sj, hao xe. exploring the treatment of yin in yang and yin in yang [j]. shandong journal of traditional chinese medicine, 2004(08): 456-457. li yao. study on the conceptual interpretation and application rules of expectorant method [d]. chinese academy of traditional chinese medicine, 2014. zou menglong, chen yalu, ning xin, huang xiaoyan. knowledge mapping analysis of sijunzi tang application research [j]. world chinese medicine,2023, 18(4):4. zhang jiebin. jingyue's complete works [m]. shanghai: shanghai ancient books publishing house, 1991: 56. zhao t, zhan lb. research progress on the mechanism of action of er chen tang in metabolic diseases [j/ol]. world science and technology modernization of chinese medicine, 2021(04): 998-1005. zhang dandan, ye xiaochuan. exploring the mechanism of action of poria aqueous extracts for spleen strengthening based on intestinal flora and metabolomics [j]. chinese journal of traditional chinese medicine, 2021, 36(07): 3994-4001. zuo j, zhang jl, hu xy. advances in chemical composition and modern pharmacological effects of atractylodes macrocephala [j]. journal of liaoning university of traditional chinese medicine, 2021, 23(10): 6-9. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 5; september-october 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 1 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe herbal allies for your gums: a look at modern natural medicine for periodontal care dr. wei zhang, department of stomatology, hospital of xinjiang medical university, urumqi, china abstract: chronic periodontitis (cp) is a prevalent chronic infectious disease that affects a significant portion of the global population, leading to tooth loss and impaired oral health. current clinical treatments for periodontal disease involve basic interventions, local drug therapy, and post-treatment prevention strategies. however, the use of conventional treatments such as chlorhexidine and antibiotics may disrupt oral flora and contribute to the development of drug-resistant pathogens. as a result, there is a growing interest in natural, plant-derived oral care products as alternative solutions. natural medicines, including acacia arabica, aloe vera, neem, turmeric, lemongrass, camellia, and comfrey, offer promising antibacterial, anti-inflammatory, antiseptic, and antifungal properties, along with potential wound-healing benefits. this review explores the use of these natural products as topical therapeutic agents for the management of periodontitis, shedding light on their efficacy, safety, and potential to enhance periodontal health. keywords: chronic periodontitis, oral care products, natural medicines, plant-derived agents, periodontal health introduction chronic periodontitis (cp) is a chronic infectious disease and the leading cause of tooth loss in our adult population, cp affects 10-15% of the world's population and is caused by bacterial inflammation in the gum pockets that can destroy the tissues around the teeth[1]. treatment therefore aims to prevent further progression of the disease, with the aim of reducing the risk of tooth loss, minimizing the symptoms and sensation of the disease and possibly restoring lost periodontal tissue[2]. the current clinical treatment of periodontal disease consists of basic treatment, supplemented by local treatment with drugs and post-treatment prevention and treatment. in the adjunctive treatment of periodontitis, chlorhexidine and antibiotics can control plaque and gingivitis, but it can imbalance the oral flora. the development of multidrug-resistant pathogens and the need for economical, safe and effective products has led to the development of plant-derived alternative oral care products. natural medicines have recently attracted increasing interest. there is a growing public interest in natural or herbal health care products, especially for patients with chronic diseases[3]. natural products including acacia arabica, aloe vera, neem, turmeric, lemongrass, camellia and comfrey have antibacterial, anti-inflammatory, antiseptic and antifungal properties and may promote wound healing[4]. therefore, this paper provides a review of topical therapeutic agents for periodontitis. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 5; september-october 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 2 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 1. chronic periodontitis pathogenic factors periodontal disease is a chronic inflammatory disease in which plaque biofilm is the initiating factor. as the disease progresses, periodontal tissues are gradually destroyed, resorption of alveolar bone occurs, and clinical symptoms such as bleeding and recession of the gums, loosening and even loss of teeth occur. it is due to the exposure of the host periodontal tissue to a microbiota that adheres to the teeth in the form of biofilm-long known as plaque. the bacteria (and possibly other microorganisms such as viruses, fungi and parasites) interact with each other and with the host. the development of periodontitis is accompanied by a dramatic change in the composition of the subgingival flora, and in most cases a different gram-negative flora emerges than the one enriched during gingivitis. among the enriched flora are the classically described red complexes, including fosetanella (formerly known as fosetylomycetes), porphyromonas gingivalis, and the dense spirochete of dental tartar[5]. over time, the resulting dysregulated microbiota, combined with dysregulated host inflammation, promotes the growth of specific microorganisms within the biofilm, producing substances that exacerbate inflammation and, in some patients, lead to tissue destruction and tooth loss. 2. antibiotic drugs to assist in the treatment of periodontitis in severe chronic periodontitis, recent randomized clinical trials[6,7] and a systematic review and metaanalysis[8,9] reported significant improvements in scaling and root planing outcomes when antibiotics were administered systemically or topically as an adjunctive therapy. in a recent systematic evaluation of a total of 28 double-blind randomized controlled trials investigating the benefit of systemic antibiotics as an adjunctive therapy to scaling and root planing in the treatment of moderate to severe periodontitis, this meta-analysis reported a statistically significant reduction in mean full-mouth probing depth of 0.448 mm and a statistically significant increase in attachment level of 0.389 mm in the antibiotic control group at 6-month follow-up. this improvement appeared to persist at the 12-month follow-up (i.e., a 0.485-mm decrease in probing depth and a 0.285-mm increase in attachment level). these improvements were further supported by a reduction in probing bleeding and a reduction in periodontal pocket depth. amoxicillin and metronidazole had the most dramatic improvements[10]. for localized sites with deep periodontal pockets, administration of topically delivered antibiotics (i.e., minocycline microspheres[11,12]) or antimicrobial medications (i.e., chlorhexidine chips[13,14]) may be considered. however, they also have adverse effects such as staining of the teeth or mucosa, cytotoxicity, and can imbalance the normal oral flora with long-term use, so they should not be used for long periods of time either. 3. probiotics and vaccines to assist in the treatment of periodontitis probiotics have recently received a lot of attention as a potential method of preventing periodontitis. probiotics are defined by the food and agriculture organization/world health organization as "living microorganisms" that confer health benefits to their hosts. many mechanisms have been proposed to explain the benefits of probiotics. probiotics can reverse inflammation-induced epithelial damage by stimulating the upregulation of structural proteins. these probiotics may also colonize and proliferate to deprive pathogenic bacteria of nutrients and thus inhibit their growth. probiotics may also produce antimicrobial products that inhibit gram-negative mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 5; september-october 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 3 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe bacteria, such as acetic acid and lactic acid. in addition, probiotics may influence the host to downregulate pathways that may damage host tissues while upregulating other pathways that inhibit the growth or virulence of pathogens[15-17] . another type of periodontitis that is thought to be preventable is the development of vaccines. vaccines have long been used in medicine as an effective public health intervention to prevent disease. periodontal vaccines are a topic of research from the 1970s and are a proposed method of preventing periodontitis based on its multiple microbial etiology. several research groups have reported a periodontal vaccine under development that targets antigens of specific oral gram-negative anaerobic pathogens[15] . 4. natural medicine to assist in the treatment of periodontitis the relationship between herbal medicine and oral microecology has become a hot research topic in recent years, where herbal medicine, as a natural agent with low side effects and wide sources, has shown good efficacy in the management of oral diseases such as caries, periodontal disease, oral mucosal disease and even oral tumors [18]. a systematic evaluation assessed the effectiveness of herbal oral care products in reducing plaque and gingivitis, and the use of adjunctive plant-derived active ingredients in the management of patients with periodontitis can be an alternative to chemicals because of their significant benefits in clinical outcomes and lack of associated side effects, and can be recommended as an alternative[19]. the main natural drugs that are currently used in periodontal disease treatment studies are comfrey, honeysuckle, pentaphyllum, propolis, bitter ginseng, and red peony. 4.1 lithospermum the xinjiang native herb soft comfrey, the best quality among comfrey, contains the fat-soluble naphthoquinone component comfreyin and its derivatives as its main active ingredients to exert antiinflammatory effects[20]. as a traditional chinese herb, comfrey has anti-inflammatory activity and its main constituent comfreyin inhibits the expression of pro-inflammatory mediators in the ischemic cortex, comfreyin inhibits il-6βor tnf-α-stimulated production of il-8, il-20 and ccl1 in hpdlc [21]. meanwhile, comfrey has antibacterial, antiviral and immunomodulatory effects[22], comfreyin can downregulate the expression level of toll-like receptor 4 stimulated by lipopolysaccharide, inhibit the secretion of il-1β, il-6 and tnf-α, and promote the secretion of il-10. treatment with comfrey polysaccharide inhibited the expression of tnf-α, il-18 and other related inflammatory factors expressed by lps-activated pbmc, possibly by suppressing the mapk signaling pathway of pbmc and thus the high expression of lps-induced inflammatory factors such as tnf-α[23]. huang et al. reported that comfreyin treatment inhibited erk phosphorylation while activating p38 in human lens epithelial cells mapk and jnk phosphorylation in human lens epithelial cells [24] and in addition, chen et al. found that shikonin activated the p145 mapk, erk and jnk pathways in prostate cancer cells (pc-38 and du3 cells)[25]. wang li et al. found that shikonin can promote osteoblast expression of opg through the opg/rankl signaling axis, directly promoting osteoblast osteogenic differentiation and indirectly inhibiting osteoclast differentiation to inhibit bone resorption and promote bone formation[26]. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 5; september-october 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 4 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 4.2 honeysuckle honeysuckle is sweet in taste and cold in nature, and chlorogenic and isochlorogenic acids are its important antibacterial components. honeysuckle has the effect of clearing heat and detoxifying, cooling wind and heat, and has a long-term inhibitory effect on many bacteria such as gram-positive bacteria, gram-negative bacteria and spirochetes, which can directly destroy toxins in the body. in an animal study, for the treatment of periodontitis, mechanical plaque control is still the preferred option, and the use of compound honeysuckle herbal mouthwash can achieve better results. the compound honeysuckle herbal mouthwash had no acute toxic effects on rats in the short term and had a significant reduction in inflammation in experimental periodontitis in rats[27]. 4.3 pentaphyllum it is bitter, sour, flat and non-toxic. pharmacological research shows that the main component in rhubarb is rhubarb anthraquinone derivative, which has antibacterial, anti-swelling and analgesic effects[28], and its antibacterial effect is achieved through the inhibition of bacterial nucleic acid respiratory process and biosynthesis. pentaphyllum is known to be antibacterial, detoxifying, astringent, precipitates coagulated proteins, and inhibits bacterial biofilm formation[29]. to date, several studies have demonstrated the clinical effects of ae on periodontitis. in an animal study, yang et al. found that porphyromonas gingivalis induced periodontitis in rats with significantly lower alveolar bone resorption levels and periodontal pocket depth after periodontitis. amcase protein expression was significantly higher in the disease group than in healthy controls. however, rhodopsin inhibited periodontal inflammation by down-regulating amcase expression in saliva and periodontal pocket tissue. rhodopsin significantly reduced rankl-stimulated osteoclast formation by regulating amcase [30-31]. 4.4 propolis propolis, also known as propolis, is a dark, dense and viscous combination of resins and waxes composed of active natural ingredients such as volatile oils, plant balsam, phenolic acids, flavonoids, aromatic alcohols, fatty acids, mineral salts and vitamins. it is collected by bees from trees, buds, flowers and other plant products. propolis has been shown to have antibacterial, anti-inflammatory, antioxidant, antiviral, antifungal, antitumor and hepatoprotective properties [32]. a study by bhat et al. showed the role of propolis in reducing dental biofilm accumulation. among 30 healthy students divided into 3 groups, the forever bright (propolis-containing) dental gel group had the lowest mean modified gingival marginal plaque index (mgmpi) score, which was significantly different from the other 2 groups. this double-blind randomized study showed that propolis-containing tooth gel or toothpaste was able to reduce the rate of biofilm accumulation. 4.5 bitter ginseng the active ingredients of bitter ginseng, bittersweetine and oxymatrine, were approved for hepatoprotective and immunomodulatory use in china more than 30 years ago. numerous studies have found that bitter ginseng bases and oxymatrine have a wide range of biological activities[33-34], such as antibacterial, antiviral, antioxidant, antiinflammatory, antitumor, and cardioprotective, hepatic, pulmonary, and vascular effects. among them, studies mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 5; september-october 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 5 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe on antitumor, antibacterial, antiviral, immunomodulatory, cytoprotective and antifibrotic effects have also been extended to the treatment of dentistry patients. according to chen ling et al.[35], rats were pre-divided into blank group, control group, and experimental group and intervened with oxymatrine, and then executed after 6 weeks to examine the alveolar bone loss, and the results showed that the alveolar bone resorption of rats after oxymatrine intervention was less than that of the control group. 4.6 red peony red peony has the effect of clearing heat and cooling blood, dispersing blood stasis and relieving pain, and its extract has good antibacterial and anti-inflammatory effects[36]. radix paeoniae contains paeonol, which inhibits rankl-induced activation of erk, p38 and nf-κb in macrophages to inhibit osteoclastogenesis and ovariectomy-induced osteoporosis. in addition, gong yi et al. preliminarily described that the main components, targets of action and related pathways of paeonia lactiflora have important research value in the prevention and treatment of cp[37]. 5. conclusions periodontal disease is defined as a multifactorial inflammatory disease characterized by destruction of the supporting tissues around the teeth (including periodontal ligaments, gums, and alveolar bone) and is a major cause of tooth loss if left untreated. mechanical plaque removal has been shown to be ineffective in adult patients, and further measures are needed to establish good oral hygiene. in the general population, maintaining good plaque control with conventional products is difficult. therefore, it is important to use adjunctive antiseptics to improve oral hygiene and further improve periodontal treatment response. the use of antiseptics is essential to assist periodontal treatment, especially when non-surgical periodontal treatment is inadequate. chlorhexidine is considered the gold standard for periodontal antiseptic treatment and is widely used as an adjunctive antimicrobial agent for root surface leveling[38]. however, patient compliance is not ideal due to its disgusting taste and the staining it causes in teeth. natural pharmaceutical products including mouthwashes, dental cleaners and gels have made advances in the past few years. the active ingredients in natural pharmaceutical oral products penetrate biofilms and prevent plaque buildup, thereby minimizing bacterial colonization of tooth surfaces. in addition, they have antimicrobial efficacy against caries and periodontal pathogens, while reducing the development of drug resistance due to their synergistic combination. natural drug extracts also inhibit osteoclast differentiation as well as the expression of pro-inflammatory cytokines, thus inhibiting bone resorption in periodontitis. however, herbal medicines also have many drawbacks such as slow and short duration of action, long treatment period, and poorly defined therapeutic mechanisms. there are fewer studies on the mechanisms by which herbal medicines regulate oral microorganisms and thus influence disease progression and treatment from a macroscopic perspective, and in-depth investigations of the downstream genes and products that influence them are still lacking. in addition, there are some microbial-related diseases in the oral cavity, such as oral cancer, oral mucosal disease, peri-implantitis, etc., but few studies have mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 5; september-october 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 6 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe been conducted to correlate herbal medicine with these diseases by regulating oral microecological balance. therefore, future directions can focus on herbal medicine to assist periodontitis prevention and treatment. references gross a j, paskett k t, cheever v j, et al. periodontitis: a global disease and the primary care provider's role [j]. postgrad med j, 2017, 93(1103): 560-565. nakayama m, ohara n. molecular mechanisms of porphyromonas gingivalis-host cell interaction on periodontal diseases [j]. jpn dent sci rev, 2017, 53(4): 134-140. rashrash m, schommer j c, brown l m. prevalence and predictors of herbal medicine use among adults in the united states [j]. j patient exp, 2017, 4(3): 108-113. laleman i, teughels w. novel natural product-based oral topical rinses and toothpastes to prevent periodontal diseases [j]. periodontol 2000, 2020, 84(1): 102-123. meng huanxin. periodontology [m] people's health press, 2020: 31-47. liaw a, miller c, nimmo a. comparing the periodontal tissue response to non-surgical scaling and root planing alone, adjunctive azithromycin, or adjunctive amoxicillin plus metronidazole in generalized chronic moderate-to-severe periodontitis: a preliminary randomized controlled trial [j]. aust dent j, 2019, 64(2): 145-152. borges i, faveri m, figueiredo l c, et al. different antibiotic protocols in the treatment of severe chronic periodontitis: a 1-year randomized trial [j]. j clin periodontol, 2017, 44(8): 822-832. mcgowan k, mcgowan t, ivanovski s. optimal dose and duration of amoxicillin-plusmetronidazole as an adjunct to non-surgical periodontal therapy: a systematic review and meta-analysis of randomized, placebo-controlled trials [j]. j clin periodontol, 2018, 45(1): 56-67. nibali l, koidou v p, hamborg t, et al. empirical or microbiologically guided systemic antimicrobials as adjuncts to non-surgical periodontal therapy? a systematic review [j]. j clin periodontol, 2019, 46(10): 999-1012. teughels w, feres m, oud v, et al. adjunctive effect of systemic antimicrobials in periodontitis therapy: a systematic review and meta-analysis [j]. j clin periodontol, 2020, 47 suppl 22: 257-281. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 5; september-october 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 7 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe matesanz-pérez p, garcía-gargallo m, figuero e, et al. a systematic review on the effects of local antimicrobials as adjuncts to subgingival debridement, compared with subgingival debridement alone, in the treatment of chronic periodontitis [j]. j clin periodontol, 2013, 40(3): 227-241. chackartchi t, hamzani y, shapira l, et al. effect of subgingival mechanical debridement and local delivery of chlorhexidine gluconate chip or minocycline hydrochloride microspheres in patients enrolled in supportive periodontal therapy: a retrospective analysis [j]. oral health prev dent, 2019, 17(2): 167171. rosa c, gomes j m l, moraes s l d, et al. use of chlorhexidine chips after scaling and root planning on periodontal disease: a systematic review and metaanalysis [j]. saudi dent j, 2021, 33(1): 1-10. ma l, diao x. effect of chlorhexidine chip as an adjunct in non-surgical management of periodontal pockets: a meta-analysis [j]. bmc oral health, 2020, 20(1): 262. myneni s r, brocavich k, h h w. biological strategies for the prevention of periodontal disease: probiotics and vaccines [j]. periodontol 2000, 2020, 84(1): 161-175. haque mm, yerex k, kelekis-cholakis a, et al. advances in novel therapeutic approaches for periodontal diseases [j]. bmc oral health. 2022, 22(1): 492. luo w, li h, ye f. clinical therapeutic effects of probiotics in combination with antibiotics on periodontitis: a protocol for systematic review and meta-analysis [j]. medicine (baltimore), 2021, 100(4): e23755. luo lj, shuang ry. overview and prospects of chinese medicine treatment for periodontal disease [j]. journal of endodontics and periodontology, 2003, 13(9): 534-537. chatzopoulos g s, karakostas p, kavakloglou s, et al. clinical effectiveness of herbal oral care products in periodontitis patients: a systematic review [j]. int j environ res public health, 2022, 19(16). kang yingying, xu fang, pu yiping, et al. determination of eight naphthoquinone components of xinjiang comfrey and optimization of its extraction process [j]. chinese journal of traditional chinese medicine, 2022, 37(08): 4720-4724. cheng min, tang jun, li shanshan. progress of pharmacological activity of naphthoquinone components of comfrey and its quantitative analysis method [j]. journal of pharmaceutical sciences, 2018, 53(12): 20262039. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 5; september-october 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 8 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe guo c, he j, song x, et al. pharmacological properties and derivatives of shikonin-a review in recent years [j]. pharmacol res, 2019, 149: 104463. li yj, tal y. study on the inhibition of lipopolysaccharide-induced macrophage inflammation by comfreyin through tlr4/nf-κb signaling pathway [j]. anhui medicine, 2017, 21(8): 1384-1387. [24] huang wr, zhang y, tang x. shikonin inhibits the proliferation of human lens epithelial cells by inducing apoptosis through ros and caspase-dependent pathway. molecules. 2014 jun 11; 19(6):77857797. chen y, zheng l, liu j, zhou z, cao x, lv x, chen f. shikonin inhibits prostate cancer cells metastasis by reducing matrix metalloproteinase-2/-9 expression via akt/mtor and ros/erk1/2 pathways. int immunopharmacol. 2014 aug;21(2):447-455. wang liping, lin jing, bo yujia, et al. effects of comfrey on proliferation, differentiation, mineralization and osteogenesis-related gene expression in mc3t3⁃e1 cells [j]. journal of practical medicine, 2022, 38(5): 583-588. brown i s. current advances in the use of lasers in periodontal therapy: a laser‐assisted new attachment procedure case series[j]. clinical advances in periodontics, 2013, 3(2). doi:10.1902/cap.2013.120087. chen nn, hou yp, tang ql, et al. study on the natural drug pseudostellaria pentaphylla for the prevention and treatment of oral diseases and related mechanisms [j]. dietary health, 2016, 3(4):2021. chen yf, fang d, wang lh. the therapeutic effect of pseudostellaria pentaphylla on periodontal diseases [j]. chinese journal of traditional chinese medicine, 2014, 32(5):1233-1235. tan s. b., xu j. s. experimental study on the inhibitory effect of the non-phenolic component of pentaphyllum album slow-release gel on chronic periodontitis in rats [j]. journal of kunming university of science and technology (natural science edition), 2015, 40(02):103-107. yang m, shrestha sk, soh y, heo sm. effects of aloe-emodin on alveolar bone in porphyromonas gingivalisinduced periodontitis rat model: a pilot study. j periodontal implant sci. 2022 oct;52(5):383393. yu qian, lin jing, zulikarjiang ahebaiti, zhao jin*, experimental study on the effect of yili black bee propolis on biofilm of major caries-causing bacteria in the oral cavity, west china journal of stomatology: 2015, 33(4): 343-346. bhat n, bapat s, asawa k, tak m, chaturvedi p, gupta vv, et al. the antiplaque efficacy of propolis-based herbal toothpaste: a crossover clinical study j nat sci biol med 2015;6(2):364-368 [34] wang h, tong mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 5; september-october 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 9 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe y, li w, et al. enhanced ultrasound-assisted enzymatic hydrolysis extraction of quinolizidine alkaloids from sophora alopecuroides l. seeds [j]. seeds [j]. j nat med, 2018, 72(2): 424432. luo k, chen l, chen yl et al. experimental study on the inhibition of alveolar bone resorption in rats with experimental periodontitis by oxidized bitter ginseng base [j]. journal of fujian medical university, 2010, 44(02):100-102. zhang jianjun, li wei, le na, wang yujie, zhou xue, zhang rui. efficacy of paeonia lactiflora and total monoterpenes of paeonia lactiflora and total phenols of paeonia lactiflora in clearing heat, cooling blood and dispersing stasis in rats with heat toxicity and blood stasis evidence[j]. journal of beijing university of traditional chinese medicine, 2020, 43(03):196-202. gong yi, wu zeyu, wang chen, zhao jin. study on the antibacterial effect of radix paeoniae alba and its mechanism for the prevention and treatment of chronic periodontitis [j]. dentistry, 2021, 41(05): 391397. thangavelu a, kaspar s s, kathirvelu r p, et al. chlorhexidine: an elixir for periodontics [j]. j pharm bioallied sci, 2020, 12(suppl 1): s57-s59. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.9, issue 1; january-february 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 7 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe uncharted territory: exploring medulloblastoma in the cerebellopontine angle of a toddler – a singular case study 1rafael m. santos and carla a. silva2 1department of neurosurgery, hospital regional do baixo amazonas dr. waldemar penna, santarém, pará, brazil 2department of neurosurgery, hospital regional do baixo amazonas dr. waldemar penna, santarém, pará, brazil doi: https://doi.org/10.5281/zenodo.10598161 abstract medulloblastomas (mb) are malignant embryonic neuroepithelial tumors of the cerebellum, accounting medulloblastomas, predominant childhood tumors, account for a substantial portion of central nervous system neoplasms in the first decade of life. originating from embryonic and undifferentiated neuroepithelial cells within the cerebellum, particularly the cerebellar vermis, these tumors are intricately linked to the external granular layers of the cerebellar hemispheres (millard and de braganca, 2016; valtz et al., 1991). this research aims to elucidate the unique manifestation of medulloblastoma in the cerebellopontine angle (cpa), an uncommon occurrence with sparse documentation in the literature, primarily observed in the adult population. the embryological association of medulloblastomas with the external granular layers of the cerebellum and germinal cell remnants in the posterior medullary velum provides a foundation for understanding their prevalence in pediatric cases (millard and de braganca, 2016; valtz et al., 1991). proper classification of these tumors stems from their origin in embryonic and undifferentiated neuroepithelial cells, accentuating their affiliation with the cerebellar vermis (rutka and hoffman, 1991; jakacki, 2005; gajjar et al., 2004). in contrast, medulloblastoma occurrences in the cerebellopontine angle are infrequent, with limited documented cases primarily observed in the adult demographic, constituting up to 75% of cases within this age group (noiphithak et al., 2016; faried et al., 2016). notably, adult medulloblastomas in the cpa display distinctive characteristics, predominantly lateral localization in the cerebellar hemispheres, axial positioning, cystic formations, and ill-defined margins, often extending to the fourth ventricular foramen (taylor et al., 2012; helseth et al., 1999; savardekar et al., 2012). mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.9, issue 1; january-february 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 8 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe this research endeavors to contribute to the limited body of knowledge on medulloblastomas in the cerebellopontine angle, providing insights into the unique features and challenges associated with this rare manifestation in the adult population. keywords: medulloblastomas, cerebellopontine angle, central nervous system tumors, pediatric neurooncology, adult neurosurgery introduction medulloblastomas are common childhood tumors, especially in the first decade of life, representing 25% of all tumors of the central nervous system in this age group. embryologically related with external granular layers of the cerebellar hemispheres, either with germinal cells remnants located at posterior medullary velum (millard and de braganca, 2016; valtz et al., 1991). the proper tumor classification is due to embryonic and undifferentiated neuroepithelial cells from the cerebellum, especially the cerebellar vermis (rutka and hoffman, 1991; jakacki, 2005; gajjar et al., 2004). in turn, medulloblastoma in cpa are uncommon, with rare reports in the literature, these mainly related to the adult population, representing up to 75% of the population group reaching the disease (noiphithak et al., 2016; faried et al., 2016). in adults, medulloblastomas is predominantly lateral located in the cerebellar hemispheres, in comparison with the axial position, with cystic formation and ill-defined margins, extending to the fourth ventricular foramen (taylor et al., 2012; helseth et al., 1999; savardekar et al., 2012). the diagnosis is made by neuroimaging exams and 2 med. case stud. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.9, issue 1; january-february 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 9 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe figure 1. t1-weighted coronal section of magnetic resonance imaging showing a lesion with sharp limits, located in the right cerebellopontine angle that displaces and deforms the brain stem and the right cerebellar hemisphere. confirmed by means of histopathology and immunohistochemistry techniques, presenting great difficulty in the neuroradiological differential diagnosis when compared with vestibular meningiomas and schwannomas. treatment consists of surgical resection, when possible, followed by chemotherapy, however an early diagnosis is necessary for a better prognosis (faried et al., 2016; spina et al., 2013; bhaskar et al., 2017). the present study aims to report a clinical case of medulloblastoma in the pontocerebellar angle and thus contribute to scientific knowledge on this topic. materials and methods report of a single case of a patient seen at the regional hospital of baixo amazonas dr. waldemar penna, santarém, pará. the data were collected through the analysis of the patient's medical record, having access to the data contained therein such as medical developments, laboratory tests, exams imaging and histopathological. case report clinical history a one-year-old male patient attended in a pediatric service with a history of facial weakness. after the initial analysis, he was referred to the oncology and neurosurgery services, being admitted for clinical followup. the mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.9, issue 1; january-february 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 10 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe patient evolved with progressive neurological disfunction, presenting glasgow 15 with right hemifacial paresis, followed by cyanosis, mydriatic pupil and associated dysphagia. imaging, myelogram, histopathological and immunohistochemical exams the initial approach involved the screening for neurological tumors and after the confirmation, was realized the tumor staging. cerebral magnetic resonance imaging (figures 1 and 2) was performed, showing a lesion located in the right cerebellar cistern, with displacement and deformation of the brain stem and the right cerebellar hemisphere. figure 3 shows a penetrating lesion in the internal auditory canal, with full canal filling and dilation of the internal auditory canal. magnetic resonance imaging of vertebral column showed no abnormality. the myelogram exam showed 37% of mature lymphocytes, 1% of monocytes and 6% of medium to large cells, with fine chromatin, grumpetch’s nuclear shadow, absent granules and high magalhães et al. 3 figure 2. t2-weighted coronal section of magnetic resonance imaging showing a hypertense lesion in the region of the right cerebellopontine angle with a mass effect on the brainstem. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.9, issue 1; january-february 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 11 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe figure 3. axial magnetic resonance imaging, t1-weighted hypertense homogenous extra-axial image. the lesion penetrates the internal ear canal, filling it completely and dilating the internal auditory canal. 4 med. case stud. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.9, issue 1; january-february 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 12 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe figure 4. (a) histopathological analysis increased parallel alignment of neoplastic nuclei in rows. (a) histopathological analysis increased parallel alignment of neoplastic nuclei in rows "or rhythmic palisades". there are also homer wright's pseudorosettes and fat cells. (b) immunohistochemistry analysis gfap positivity in tissue suggests malignant lesion. (c) immunohistochemistry analysis cd99 staining is predominantly noticed on cell membranes and here we see positivity in different sections of the tumor suggesting medulloblastoma. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.9, issue 1; january-february 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 13 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe nuclecytoplasmatic ratio. the histopathological result (figure 4a) showed tumor cells arranged in homer wright's pseudorosettes, morphologically classified as classic medulloblastoma. which are dense cellular neoplasms, consisting of small, oval cells with a high nucleus/cytoplasm ratio. immunohistochemistry (figure 4b and c) showed positivity for glial fibrillary acid protein (gfap) and cd99. in addition to positivity for synaptophysin, beta catenin, and ki67, genetically classified as wnt-activated medulloblastoma. using histopathology and immunohistochemistry information, the diagnosis of medulloblastoma was established, based on guidelines (pietsch and haberler, 2016). therapeutic conduct and outcome after diagnosis, the patient underwent tumor resection at a right cerebellar point angle, by retrosigmoid approach, without complications and no need of ventricular shunt technique. surgical procedure was subsequently accompanied by an oncological therapeutic plan based on three cycles of chemotherapy, with methotrexate, vincristine and cyclophosphamide. however, after 21 days of the surgical procedure, the patient progressed to a coma, followed by multiple organ failure related with neurogenic shock, until the diagnosis of brain death was confirmed. discussion mb is a highly malignant and aggressive neuroectodermal tumor of cerebellar origin, densely cellular and distinct from sarcomas and other gliomas. the current literature considers it as a common pediatric tumor of the posterior fossa representing 20-25% of all pediatric tumors, which develop in the cerebellar vermis and in the fourth ventricle. it can be found in the midline, in the cerebellar hemisphere or in the cpa. in adults and children, the most common location is the cerebellar hemisphere, with cpa being an extremely rare variant (spina et al., 2013; batista et al., 2017). the epidemiological profile of the tumor, considering the higher prevalence in the first decade of life, is explained by its embryonic characteristic. clusters of neuroepithelial cells from the roof of the fourth ventricle can migrate to make the composition of the outer granular layer of the cerebellum. migratory cells can remain resident until the first year of age, being related to the appearance of medulloblastomas in any part of the migratory path of these cells (rubinstein, 1972; zimmerman et al., 1978). the rare location in cpa makes mb an unusual differential diagnosis of tumors that affect the appropriate area, with the most frequent differentials in relation to mb: lymphomas, schwannoma, meningioma, primary cholesteatomas and epidermoid tumors. vestibular schwannomas and meningiomas are the two most frequent lesions and represent 90% of all tumors in cpa (batista et al., 2017) imaging findings have variable and non-specific characteristics, making it difficult to differentiate, giving preference to histopathological and immunohistochemical diagnosis. the appearance of medulloblastoma on magnetic resonance imaging usually manifests itself with hypo-intensity on t1-weighted images and heterogeneous hyperintensity on t2-weighted images and improves with magalhães et al. 5 mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.9, issue 1; january-february 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 14 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe conrasts (faried et al., 2016; bhaskar et al., 2017; batista et al., 2017; nyanaveelan et al., 2007). histopathologically, classic medulloblastoma contains small individual cells with scarce cytoplasm and hyperchromatic nuclei that are often elongated. the tumor may express neurosecretory granules or homer wright rosettes. the characteristic immunohistochemistry reveals positivity for synaptophysin with variable reactivity to gfap, β-catenin, membrane epithelial antigen and cytokeratin (pietsch and haberler, 2016). in our report, the results showed tumor reactivity to synaptophysin and gfap. synaptophysin is an integral membrane glycoprotein from presynaptic vesicles of neuronal and neuroendocrine cells that has been identified as a reliable marker for neuronal differentiation, which is commonly seen in medulloblastoma. gfap is an intermediate astroglial cytoskeletal protein that is commonly expressed in neural stem cells (noiphithak et al., 2016; faried et al., 2016; bhaskar et al., 2017). the preoperative clinical history showed an atypical symptom of right hemifacial weakness and absence of classical symptoms. the literature shows classic symptoms of mb as irritability, lethargy, nausea and vomiting, morning headaches, anorexia, behavioral changes and seizures. the finding is important, since demonstrates the atypical presentation of the clinical case reported (millard and de braganca, 2016). as for treatment, total removal with adjuvant radiotherapy is commonly performed as therapy, when age and other prerequisites permits. chemotherapy has also been combined in some cases, as the residual tumor is associated with worse progression. however, pant et al. (2016) states that aggressive brain tumor removal is not recommended, since a high rate of postoperative complications have been reported after tumor resection. thus, the outcome of mb treatment in the cpa is not well established due to limited reports, because despite the 60 to 70% increase in survival, attributed to improvements in surgical techniques and adjuvant therapies, more cases are still needed to confirm these discoveries (noiphithak et al., 2016; spina et al., 2013). conflict of interests the authors have not declared any conflict of interests. references batista kmp, eulate-beramendi sa, rico m, rodrigo v, batista yeb, reyes kya (2017). atypical bilateral cerebellopontine angle medulloblastoma: differential diagnosis, immunohistochemical features and radiological presentation. contemporary oncology (pozn) 21(3):249-253. bhaskar mk, jaiswal m, ojha bk, singh sk, chandra a, meel m, faheem m (2017). extra-axial cerebellopontine angle medulloblastoma in an infant. pediatric neurosurgery 52(2):122-126. faried a, pribadi ma, sumargo s, arifin mz, hernowo bs (2016). adult medulloblastoma: a rare case report and literature review. surgical neurology international 7(17 suppl):481-484. gajjar a, hernan r, kocak m, fuller c, lee y, mckinnon pj, wallace d, lau c, chintagumpala m, ashley dm, kellie sj, kun l, gilbertson r (2004). clinical, histopathologic, and molecular markers of prognosis: mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.9, issue 1; january-february 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 15 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe toward a new disease risk stratification system for medulloblastoma. journal of clinical oncology 22(6):984-993. helseth e, due-tonnessen b, wesenberg f, lote k, lundar t (1999). posterior fossa medulloblastoma in children and young adults (0-19 years): survival and performance. child’s nervous system 15(9):451455. jakacki ri (2005). treatment strategies for high-risk medulloblastoma and supratentorial primitive neuroectodermal tumours. review of the literature. journal of neurosurgery 102(1 suppl):44-52. millard ne, de braganca kc (2016). medulloblastoma. journal of child neurology 31(12):1341-1353. noiphithak r, yindeedej v, thamwongskul c (2016). cerebellopontine angle medulloblastoma with extensive nodularity in a child: case report and review of the literature. child’s nervous system 33(5):839842. nyanaveelan m, azmi a, saffari m, banu sk, suryati my, jeyaledchumy m (2007). cerebellopontine angle medulloblastoma. medical journal of malaysia 62(2):173-174. pant i, chatuverdi s, gautam vk, pandey p, kumari r (2016). extraaxial medulloblastoma in the cerebellopontine angle: report of a rare entity with review of literature. journal of pediatric neurosciences 11(4):331-334. pietsch t, haberler c (2016). update on the integrated histopathological and genetic classification of medulloblastoma – a pratical diagnostic guideline. clinical neuropathology 35(6):344-352. rubinstein lj (1972). tumors of the central nervous system. armed forces institute of pathology; sold by american registry of pathology. rutka jt, hoffman hj (1991). a critical review of medulloblastoma: from a difficult past to a promising future. neurosurgery quarterly 1(1):54-78. savardekar a, salunke p, ahuja ck, rane s, singla n (2012). unusual presentation in adult medulloblastomas: imaging features mimicking cerebellar dysplastic gangliocytoma (lhermitte-duclos disease). neurology india 60(5):555-557. spina a, boari n, gagliardi f, franzin a, terreni mr, mortini p (2013). review of cerebellopontine angle medulloblastoma. british journal of neurosurgery 27(3):316-320. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.9, issue 1; january-february 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 16 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe taylor md, northcott pa, korshunov a, remke m, choy, clifford s, eberhart cg, parsons dw, ruthkowski s, gajjar a, ellison dw, lichter p, gilbertson rj, pomeroy sl, kool m, pfister sm (2012) molecular subgroups of medulloblastoma: the current consensus. acta neuropathologica 123(4):465-472. valtz nl, hayes te, norregaard t, liu sm, mckay rd (1991) an embryonic origin for medulloblastoma. new biology 3(4):364-371. zimmerman ra, bilaniuk lt, pahlajani h (1978). spectrum of medulloblastomas demonstrated by computed tomography. radiology 126(1):137-141. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.9, issue 1; january-february 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 17 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe preserving potential: uterus resilience in the context of placenta percreta and uterine rupture – a case study 1mei x. wang and liang y. chen2 1,2department of obstetrics and gynaecology, fuxing hospital, capital medical university, beijing, china. doi: https://doi.org/10.5281/zenodo.10598189 abstract: adherent placenta disorders, encompassing conditions like placenta accreta, placenta increta, and placenta percreta, pose significant threats to maternal health during pregnancy. of these, placenta percreta represents a severe manifestation where chorionic villi invade the uterine serosa and affix to surrounding organs, presenting complex challenges in management. this review delves into the distinctive features of placenta percreta, emphasizing its gravity compared to other adherent placenta disorders. the placental villi play a pivotal role in facilitating nutrient exchange between the mother and fetus. abnormal attachment of fetal chorionic villi to the myometrium, instead of the decidua, leads to the development of placenta accreta, increta, or percreta. placenta percreta, the most severe variant, involves chorionic villi breaching the uterine serosa and establishing adherence to adjacent organs. this paper presents a compelling case of a woman with a preserved uterus following a history encompassing two occurrences of placenta percreta and three incidents of uterine rupture. the rarity and intricacy of such cases underscore the urgency for a nuanced understanding of placenta percreta, not only for immediate clinical management but also for long-term considerations. despite the gravity of placenta percreta, optimal management strategies remain contentious due to a dearth of comprehensive studies evaluating treatment modalities and long-term outcomes for affected individuals (clausen et al., 2014). this review aims to contribute to the evolving discourse on placenta percreta, elucidating the complexities of its presentation, management, and the need for sustained research efforts in this critical area of maternal-fetal medicine. keywords: placenta percreta, adherent placenta disorders, maternal health, uterine rupture, pregnancy complications. introduction adherent placenta disorders are potentially fatal for pregnant women. branching villi of the placenta are important for nutrient exchange between the mother and fetus. if villi from the fetal component (chorionic placenta) attach abnormally to the myometrium instead of the endometrium (decidua), pathologies known as placenta accreta, placenta increta, or placenta percreta can result. this review focuses on placenta percreta, which is more severe mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.9, issue 1; january-february 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 18 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe than the other conditions. in placenta percreta, chorionic villi breach the uterine serosa and adhere to the surrounding organs. this paper describes the case of a woman with an intact uterus after a history of two instances of placenta percreta and three instances of uterine rupture. techniques for optimal management of placenta percreta remain controversial due to a lack of studies on treatment and long-term outcomes of this condition (clausen et al., 2014). this review aimed to synthesize available diagnostic and treatment methods for placenta percreta. it highlights the importance of early detection in avoiding complications. informed consent 2 med. case stud. was obtained from the patient for publication of this report case report first hospitalisation the patient was a 35-year-old woman. she was initially admitted to the hospital because she required labour induction in september, 2008. her last menstruation period was in march, 2008. she had vaginal bleeding twice, and she had taken dydrogesterone during early pregnancy. the foetal ultrasonogram showed foetal heart structural abnormalities, a supraventricular septum defect, an atrial septal defect, and an endocardial pad defect at 25 weeks of gestation. she denied a history of diabetes, hypertension, allergies, or any other remarkable family history. she had four pregnancies: premature birth, 1; drug abortion, 1; artificial abortion, 1; and full-term baby, 1. an intrauterine injection of rivanol (100 mg) was administered to induce labour at 0930, and contractions began at 0000 on the next day. her water broke naturally at 0300, and a male baby (weight: 975 g, length: 36 cm) with no abnormal appearance was born at 0323. the placenta was not delivered spontaneously within 10 min, and vaginal bleeding continued. artificial stripping of the placenta was difficult because the placenta was attached closely to the uterine wall; thus, vaginal bleeding continued. the mother became pale and lost consciousness at 0445. her heart rate was 104 beats/min, and her blood pressure was 75-80/35-45 mmhg. the ultrasonogram obtained in the emergency ward showed free fluid in the abdominal cavity. results of the haemogram showed that the haemoglobin level, haematocrit level, and platelet (plt) count were 7.2 g/dl, 23.1%, and 110 000/µl, respectively. the other coagulation test results were also abnormal. after her vital signs stabilised, two intravenous lines were set, packed red blood cells were reserved for transfusion, and she was transferred to the operating room. an emergency laparotomy was performed with simultaneous on going resuscitation. intraoperative findings showed about 2500 ml of blood in the abdominal cavity and between the intestinal loops. the uterus was torn at the bottom left corner, the diameter of the rupture was about 2 cm, placental tissue was implanted in the uterine muscle near the serosal surface, part of the placental tissue was exposed, and active bleeding was present at the rupture site. intraoperatively, the placenta was peeled, the uterus was repaired, and b-lynch suturing was performed because of poor uterine contraction. additionally, 12 units of packed red blood cells, 4 units of fresh frozen plasma, 400 ml of normal frozen plasma, and 1 treatment volume of plts were transfused. she was transferred to the intensive care unit (icu) postoperatively. she received antibiotics and anticoagulation therapy. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.9, issue 1; january-february 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 19 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe postoperative diagnoses included placenta percreta, haemorrhagic shock, and uterine rupture. results of the postoperative placental pathologic examination showed specimens of the uterine wall muscle tissue in the placenta. the patient was discharged from the hospital in good condition 9 days after admission. second hospitalisation the patient was 39 years old, and she was admitted to the hospital a second time because of infertility in december, 2011. her menstrual volume decreased by 1/3 after labour induction without a change in her menstrual cycle. she had no pregnancy without contraception for 1 year. ultrasonography showed a left ovarian cyst measuring 28×15 mm, and it was considered a wrapped effusion. hysteroscopy showed that the uterine cavity was normal, and both tubal openings could be seen. using b-ultrasound guidance, we found that the muscle wall was the thinnest (0.15 cm) on the left side of the bottom of the uterus. a diagnosis of secondary infertility was made. laparoscopic pelvic adhesiolysis, uterine repair, and hysteroscopy were performed 5 days later. intraoperative findings showed that the left fallopian tube was distorted, and the left ovum and posterior lobe of the ipsilateral broad ligament had wrapped adhesions. additionally, the ampulla adhered closely to the left posterior wall near the left corner of the uterus, part of the intestine adhered closely to the left posterior wall of the uterus, and the left ovary was wrapped in the adhesive band. laparoscopically, meilan fluid was visible, the left oviduct was not smooth, and a significant amount of liquid overflowed from the left corner of the bottom of the uterus. hysteroscopy showed a fissure in the left corner of the uterus, a previous uterine rupture, and an old laceration with figure-of-8 suture stitching. the postoperative diagnoses included secondary infertility and uterine rupture (the old injury to the uterine muscle wall). she was discharged from the hospital in good condition 3 days later. third hospitalisation the patient was 40 years old, and she was admitted to the hospital a third time in july, 2013 because of her pregnancy with her second child. her last menstrual period was in november, 2012. her pregnancy was uneventful. the ultrasonogram showed that the foetus’ gestational age was 35 weeks and 4 days, the placenta was positioned posteriorly toward the bottom of the uterus, demarcation was unclear between the part of the placenta on the left side of the bottom of the uterus and myometrium, and the local area was about 40 mm, which was not obvious. the magnetic resonance imaging (mri) scan showed that the thin myometrium was about 2 mm at the left corner of the bottom of the uterus. diagnoses on admission were intrauterine pregnancy (35 weeks and 4 days), left occiput anterior (loa), scarring of the uterus, placenta percreta, and a poor pregnancy history. the uterus had become extremely weak because of a history of uterine rupture (two times). at 37 weeks, she was scheduled for an elective caesarean section with intestinal adhesion adhesiolysis and uterine repair. a male baby (weight: 3140 g, apgar score: 10, 10) was born. the placenta was removed without difficulty. intraoperative findings showed that the left fundus of the uterus was completely ruptured (diameter, about 3 cm), the tissue surrounding the meager area was about 7×7 cm, intestine was adhered around the uterus, double attachment could not be observed, oedema and congestion were present, and extensive surrounding tissue adhered mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.9, issue 1; january-february 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 20 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe to the uterus. uterine repair was performed after the adhesions were separated. total operative blood loss was 200 ml. postoperative diagnoses were gravida 3, parity 2, intrauterine pregnancy (37 weeks and 1 day), loa, scarring of the uterus, placenta percreta, uterine rupture, a poor pregnancy history, and pelvic adhesions. results of the postoperative pathologic examination showed implanted placenta tissue consistent with placenta percreta. the patient and her baby were discharged from the hospital in good condition 4 days later. her postoperative recovery was good, and she was followed up for 6 years. the patient remained healthy with regular menstruation. discussion morbidly adherent placentation (map), which includes placenta accreta, increta, and percreta, is a serious complication of pregnancy associated with perinatal massive haemorrhage, intensive care unit (icu) admission, and caesarean hysterectomy (vahanian et al., 2015). map occurs in approximately 1 in 500 to 1,000 pregnancies (vahanian et al., 2015). this rate has increased up to 10-fold in the past 20 years, and it is largely attributed to increasing rates of caesarean deliveries (eshkoli et al., 2013). the reported incidence in the united states increased from 0.08% in 1985 to 0.3% in 2005 (rao et al., 2012). the domestic incidence of map increased by 10 times within nearly 30 years, with the increasing rates of abortion, hysteroscopic operation, and caesarean section (lian and wang, 2013). the present patient had placenta percreta, which is more severe than the other classifications. in placenta percreta, chorionic villi breach the uterine serosa and adhere to the surrounding organs (solheim et al., 2011). the steadily increasing rate of placenta previa and caesarean section may result in an increased number of patients with abnormal placentation (solheim et al., 2011). additional zhao 3 risk factors for map include uterine operation, caesarean delivery, advanced maternal age (≥35 years), multiparity, and a history of endometrial ablation (belfort, 2010). the occurrence of placenta percreta will significantly affect the outcome of pregnancy, causing postpartum hemorrhaging, uterine perforation, and other serious complications; additionally, it can even endanger the lives of pregnant women and their foetuses. uterine rupture in pregnancy is rare, and it can often be life threatening and catastrophic. it is very difficult to manage placenta percreta and uterine rupture during vaginal delivery; thus, invasive treatment is needed to control for the occurrence of serious complications after various rescue measures are ineffective. severe complications of placenta percreta are significantly higher with vaginal delivery than with caesarean section. pregnancy with placenta percreta is associated with a high risk of uterine rupture. placenta percreta is rare, but three instances of uterine rupture with delivery of normal newborn infants, as seen in our patient, are very rare. the first instance of placenta percreta with uterine rupture was not a prenatal diagnosis, so the patient had more complications and was transferred to the icu. the second instance of placenta percreta was diagnosed before pregnancy; thus, prenatal preparation was adequate to prevent intraoperative bleeding and to ensure a good postoperative recovery and preservation of the uterus. traditionally, placenta percreta is treated by removing the uterus, as it is effective for reducing maternal mortality and stopping bleeding rapidly and completely. decisive hysterectomy should be performed in patients with mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.9, issue 1; january-february 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 21 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe serious intraoperative bleeding, shock, a coagulation dysfunction or blood shortage, a large area of placenta percreta, a thin uterine wall, and poor uterine contractions. kohn et al. (2016) reported the case of a pregnant woman in whom hysterectomy was performed because of placenta percreta and incomplete uterine rupture after endometrial ablation was performed at 18 weeks of pregnancy. however, removal of the uterus would cause the patient to lose fertility, resulting in physical and psychological damage, and some patients cannot accept this outcome. thus, conservative treatment should be considered if the patient’s condition is relatively stable. however, this depends on an accurate prenatal diagnosis, adequate pre-operative preparation, and a skilled surgical operation. the key to conservative treatment is effective haemostasis. if the area of placenta percreta is small, local resection and suturing may be appropriate during caesarean section (for example, wedge resection or excision and a partial figure-of-8 suture or ring suture). ligation of the uterine muscle can facilitate haemostasis. the b-lynch suture can also be used, and the uterus can be sutured at the anterior and posterior walls. in clinical practice, surgeons can combine several surgical procedures to stop bleeding. for pregnant women at high 4 med.case stud. risk for uterine rupture, such as scarring of the uterus and placenta percreta, it is necessary to provide detailed and prudent prenatal counselling, evaluate the relationship of the uterine muscle and placenta with ultrasonography regularly, and recommend caesarean section as soon as possible. if uterine rupture is suspected, a timely caesarean section to terminate the pregnancy may be necessary, or laparotomy can be performed to make a clear diagnosis in an attempt to keep the uterus. the treatment for placenta percreta should be selected according to the patient’s condition, blood loss, and rate of blood loss, taking into consideration the type and location of the placenta percreta, surgeon’s skills, rescue capacity of the medical institution, and the patient’s reproductive requirements. a comprehensive analysis must be conducted to make the right decision. a prenatal diagnosis and identification of abnormal placentation are vital for the following reasons: 1) to plan the date, place, and mode of delivery; 2) to ensure the availability of highly qualified specialists in the field of obstetrics and anaesthesia, and 3) to ensure the availability of a sufficient amount of blood and blood substitutes. if the mri scan or ultrasonogram findings are suggestive of placenta percreta pre-operatively or prenatally, sufficient preparations should be made, including adequate blood preparation, a detailed, reasonable surgical program, and treatment methods to control bleeding and avoid unnecessary hysterectomy (palacios-jaraquemada, 2013). conclusion patients with placenta percreta may not have any symptoms, and placenta percreta may not affect intrauterine foetal development; however, if it is found during delivery, it is more difficult to manage, especially in cases of natural childbirth. therefore, an early diagnosis is particularly important. additionally, an early diagnosis of uterine rupture can save a patient’s life. an adequate prenatal assessment, accurate diagnosis, and timely treatment are essential to reduce maternal and child mortality and complications. conflict of interests mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.9, issue 1; january-february 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 22 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe the author has not declared any conflict of interests. acknowledgments the author thanks editage (www.editage.cn) for the english language editing. the study was supported by the capital medical university foundation clinical research cooperation fund (17jl23). references clausen c, lönn l, langhoff-roos j (2014). management of placenta percreta: a review of published cases. acta obstetricia et gynecologica scandinavica. 93(2):138-143. eshkoli t, weintraub ay, sergienko r, sheiner e (2013). placenta accreta: risk factors, perinatal outcomes, and consequences for subsequent births. american journal of obstetrics and gynecology. 208(3):219.e1-7. kohn jr, popek e, diaz-arrastia cr, guan x, shamshirsaz aa, belfort ma, fox ka (2016). placenta percreta and incomplete uterine rupture after endometrial ablation and tubal occlusion. american journal of perinatology 6(4):e445-e450. lian y, wang x (2013). conservative treatment of morbidly adherent placentation. journal of practice and gynecology 29(8):565-568. palacios-jaraquemada jm (2013). caesarean section in cases of placenta praevia and accrete. best practice and research: clinical obstetrics and gynaecology 27(2):221-232. belfort ma (2010). publications committee, society for maternal-fetal medicine. placenta accreta. american journal of obstetrics and gynecology. 203(5):430-439. rao kp, belogolovkin v, yankowitz j, spinnato ja (2012). abnormal placentation: evidence-based diagnosis and management of placenta previa, placenta accreta, and vasa previa. journal of obstetrical and gynecological survey 67(8):503-519. solheim kn, esakoff tf, little se, cheng yw, sparks tn, caughey ab (2011). the effect of cesarean delivery rates on the future incidence of placenta previa, placenta accreta, and maternal mortality. journal of maternal-fetal and neonatal medicine 24(11):1341-1346. vahanian sa, lavery ja, ananth cv, vintzileos a (2015). placental implantation abnormalities and risk of preterm delivery: a systematic review and metaanalysis. american journal of obstetrics and gynecology 213(4 suppl):s78-s90. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 11 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe national investigation of adherence to acsm's pre-activity screening procedures in fitness facilities michael eickhoff, elizabeth a. jones and john d. smith abstract: pre-activity health screening procedures (phsp) are important for fitness professionals to minimize the risk of sudden cardiac death (scd) and acute myocardial infarction (ami) in new exercise participants. phsp can identify individuals who may be at increased risk for these events and allow for appropriate interventions to be taken. keywords: phsp, scd, ami, exercise, risk, screening 1. introduction it is well established in the literature that the morbidity and mortality rates due to chronic illnesses such as cardiovascular (cv) disease and diabetes in the u.s. are alarmingly high. numerous studies also exist to demonstrate that participation in regular physical activity can be effective in the prevention and control of many chronic illnessesand other medical conditions (“physical activity”, 2008). although the benefits of regular exercise outweigh the risks, the riskof untoward events, e.g., sudden cardiac death (scd) and acute myocardial infarction (ami) do exist (thompson, et al., 2007). it is important for fitness professionals to take precautions to minimize these risks in the design and delivery of exercise programs.these precautions include having new participants (individuals who, for the first time,join a fitness facility as a member or participate in a program offered by the facility)complete pre-activity health screening procedures (phsp) prior to initiating an exercise program, as required and/or recommended by several professional organizations including the american college of sports medicine (acsm).a major purpose of conducting phsp is to identify individuals who may be at increased risk (“at risk”) for scd or ami during exercise. the acsm has three publications that provide standards (requirements) and/or guidelines (recommendations) for fitness facilities to follow when developing and implementing various safety practices into the daily operations of a fitness facility including phsp. these are: (a) acsm’s guidelines for exercise testing and prescription(acsm’s getp)(pescatello, arena, riebe, & thompson,2014), (b) acsm’s health/fitness facility standards and guidelines(acsm’s standards) (tharrett& peterson, 2012), and (c) recommendations for cardiovascular screening, staffing, and emergency policies at health/fitness facilities, a joint position statement by the american heart association and acsm (aha/acsm joint ps) (balady et al. 1998). although the specific required and/or recommended practices for phsp vary among the three acsm publications, all of them describe two basic steps. the first is to havenew participants complete a screening device (a form that asks about medical conditions such as cv disease and/or cv risk factors) and then based on the data obtained; determine if the mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 12 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe individual is “at risk” for scd or ami. the second step is to refer an “at risk” individual to his/her medical care provider for a medical exam, exercise test, consultation, or clearance prior to initiating an exercise program. following these steps can increase the safety for new participants by mitigating the risk of scd or ami during exercise. both scd and ami events do occur in fitness facilities (abbott, 2013; eickhoffshemek, herbert, & connaughton, 2009). previous researchby mcinnis, hayakawa, and balady (1997) and herbert, et al.(2007) found that 17% and 27%, respectively, of the facilities investigatedin these studies had at least one cv medical emergency in the last five years. in the present study, 35% of the facilities had at least one cv medical emergency in the last five years(craig, 2014).unfortunately, when a scd or an ami occurs in a fitness facility, a negligence lawsuit often follows (abbott, 2013). several negligence claims are made against the facility in these lawsuits and include the failure to conduct preactivity health screening such as (a) the club failed to require prescreening of members to assess fitness and health prior to use of the facility (chai v. sport & fitness clubs of america, 1999) and (b) the club failed to properly screen the decedent’s health (l.a. fitness international, llc v. julianna tringali mayer, 2008). negligence claims against fitness facilities also include the failure to adhere to safety standards and guidelines published by professional organizations (eickhoff-shemek et al., 2009; voris&rabinoff, 2011). in negligence lawsuits, expert witnessesoften refer to standards/guidelines published by acsm and other professional organizations to educate the court as to the duty (or standard of care) the defendant (e.g., the facility)owed to the plaintiff, the injured party(voris&rabinoff, 2011). if the conduct of the defendant is consistent with the standard of care, it will be difficult for the plaintiff to prove a breach of duty, and thus can protect the facility from being found liable (eickhoff-shemek, et al., 2009). however, if the conduct is inconsistent with the standard of care, it will be easier for the plaintiff to prove a breach of duty which can lead to a ruling of negligence against the defendant. therefore, it is important that fitness facilitiesconduct phsp not only to enhance participant safetyby minimizing the risk of scd/ami but also help avoid costly negligence lawsuits for not adhering to the standard of care when a scd/ami occurs. six previous studies between 1997 and 2009 investigated phsp in fitness facilities:(1) eickhoff-shemek & deja, 2002a and eickhoff-shemek & deja, 2002b, (2) herbert et al., 2007, (3) mcinnis et al., 1997, (4) mcinnis et al., 2001, (5) morrey, finnie, hensrud, & warren, 2002, and (6) springer, eickhoff-shemek, &zuberbuehler, 2009a and springer, eickhoff-shemek &zuberbuehler, 2009b. these studies were limited in the number and types of variables investigated, e.g.,they primarily determined if facilities required new participants to complete a screening device and if they required medical clearance for “at risk” participants. the present study not only investigated these variables, but many other variables to provide acomprehensive analysis of phsp in fitness facilities.for example,one of the purposes of this study was to determine if the detailed screening criteria in the acsm’s getpwere used in the development and implementation of the facility’s phsp and if so, to what extent. although some changes have occurred, the screening proceduresin the current 9thedition of acsm’s getphave been virtually the same since its third edition published 30 years ago (blair, et al., 1986). however, noprevious studies have investigated if fitness facilities are following these recommended screening procedures. currently, mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 13 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe significant changes are being proposed with these screening procedures for the next edition (10th) of acsm’s getp to be published in 2017. a paper describing these changes and the rationale for them was recently publishedin acsm’s medicine & science in sports &exercise(riebe, et al., 2015). the present study is timely in that it provides additional evidence to support the proposed changes as described below in the discussion. acsm certified health fitness specialists (hfss) served as the population to investigate the many variables associated with phsp in fitness facilities in this study. note: acsm recently changed the title of this certification to certified exercise physiologist (“american college”, 2014) but the former title (hfs) will be used. fitness professionals, especially those certified as hfss should be familiar with screening procedures published by acsm, e.g., the acsm’s getp is the recommended resource to help prepare for the acsm hfs certification exam. given this orientation to the acsm’s getpand the likely exposure to other acsm publications, it was assumed that the fitness facilities where these hfss were employed would make genuine efforts to follow the acsm’s standards and guidelines regarding phsp. the major purposes of this study were todetermine if fitness facilities were adhering to acsm’s pre-activity screening procedures and to inquire about other facility practices related to screening. variables investigated related to facility practices included(a) the requirement ofnew participants to complete a screening deviceand to determine if differences existedamong fitness settings, (b) reasons for not conducting screening, (c) type of screening conducted (i.e., self-guided or professionally guided), (d) specific practices related to professionally-guided such asrequiring medical clearance, frequency of screening, participant refusal, and (e)for facilities utilizing the acsm’s getp, determine to what extent they are following the screening criteria. another purpose of this study was to obtain perceptions of acsm certified hfss related to phsp such as their level of familiarity with acsm’s professional standards/guidelines, knowledge/beliefs, and perceived challenges in carrying out phsp. 2.0 methods the following methods were developed utilizing the checklist for reporting results of internet surveys – cherries (eysenbach, 2004). a more detailed description of how the methods (and the reporting of results) met the applicable items in this checklist can be found elsewhere (craig, 2014). 2.1 instrument for obtaining data/irb approval.a web-based survey instrument was developed to obtain the data for this study and consisted of 54 questions with 32 questions addressing fitness facility practices related to phsp, 14 questions regarding perceptions of the participants (acsm certified hfss) related to phsp, seven demographic questions, and one open-ended question to inquire about the perceived challenges in carrying out phsp. the majority of questions were written as close-ended using multiple choice, multiple choice table, and 4-point scalar format response options. the survey was made available via survey gizmo(“survey”, 2014). irb approval was received on january 15, 2014 (prior to the pilot study) and again on august 11, 2014, prior to the survey being distributed. the survey began with the informed consent (ic) approved by the irb at the university of south florida. survey participants were then directed to a “notes” page with instructions and definitions of terms used throughout the survey. participants were informed of the voluntary nature of this study, a requirement of the irb. according to mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 14 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe dillman(2007),“respondents should never be forced to provide a substantive answer before moving to the next question”(p. 394). this was achieved by enabling a “soft requirement” feature for each question in the survey which allowed respondents to skip questions they voluntarily chose not to answer. the survey also was designed with logic and functionality features which customized the survey based on responses to previous questions (pressor, 2004). for example, for the question “does your facility require new participants to complete a preactivity screening device prior to their participation,” those who answered “yes” automatically continued with the next question and those who answered “no” or “don’t know” were automatically redirected toother follow-up questions based on their response. additional user-friendly features to enhance the efficiency in completing the survey included hyperlinks for the all the terms defined in the “notes” page and used throughout the questions in the survey. the definitions would appear by hovering over the hyperlink to quickly remind respondents of the definitions. 2.2 pre-pilot and pilot studies, and validation of survey instrument.to establish sound methodology and obtain valid data, both pre-pilot and pilot studies were conducted. the results of the pre-pilot study provided constructive feedback from experts, health/fitness professionals, and lay persons.this feedback was integrated into the methods of the study as well as the design of the instrument in preparation for the pilot study. the pilot study involved 21 acsm certified hfss in the tampa bay, fl area and was designed to (a) obtain feedback regarding the clarity and content of the questions in the survey instrument, (b) assess the effectiveness and functionality of the procedural aspects of the study, and (c) establish validity of the survey instrument. the feedback and data obtained were used to make many relevant changes and improvements in the survey instrument. the results of the pilot study established evidence of face and content validity of the survey instrument and demonstrated the effectiveness and ease of the web-based procedures (craig, 2014). 2.3 description/selection of population sample.the population sample for this study were all fitness professionals who possessed the acsm health fitness specialist (hfs) certification in the u.s. (n = 10,359). acsm certifications have been available since 1975 and currently are offered in three different categories: (a) health fitness, (b) clinical, and (c) specialty. the hfs certification has the most rigorous qualification requirements of the health fitness certifications including a bachelor’s degree in exercise science, exercise physiology, or kinesiology from a regionally accredited college or university (“american college”, 2014). professionals who possess the hfs certification are typically employed or self-employed in a variety of fitness settings such as commercial (for profit), hospital/clinical, corporate, community (nonprofit), university/college, and government. 2.4 data collection procedures.as recommended by dillman (2007),multiple contacts with study participants are essential for maximizing responses to surveys.therefore, four recruitment e-mails were sent out by the acsm certification office to the study participantsover a two week period, august 22 – september 8, 2014. the actual number of emails sent (n = 9,433) was lower than the total population due to deletion of pilot study participants, hfss who requested to not receive any e-mails from the acsm certification office, and those who had inaccurate e-mail addresses. to also help increase the number of responses to the survey, a financial incentive as suggested mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 15 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe by fowler (2009)was offered within each of the e-mails, i.e., participants were informed of an option to enter a drawing for a chance to win one of six $50 gift cards. 2.5 response results/data analysis.of those who received the recruitment emails, 1,246 (13%) responded to the survey. exclusion criteria removed hfss who were not currently working part-or full-time in a fitness facility, leaving 677 usable responses. special measures were taken to remove duplicate responses for any given facility which resulted in 656 usable responses for the facility-related questions. although the response rate was less than anticipated, the number (n = 656) and types (n = 6) of fitness facilities represented in this study were higher than any of the previous studies investigating phsp. the six types of facilities represented were: (a) commercial (31.7%), (b) hospital/clinical (22.5 %), (c) corporate (16.9%), (d) community (14.7%), (e) university/college (9.2%), and (f) government (5.0%). in addition, to help strengthen the external validity of the results, the percentages of respondents in the study population and those in the total population were similar across the 12 acsm geographical regions. other variables available to compare the study population and total population were sex and age. the percentages for these variables were also similar between the two populations.the sample of respondents also possessed strong credentials with 55%, 36% and 4% having a bachelor’s, master’s, or doctorate degree, respectively, and 60% having 5 or more years of professional experience and 41% having 10 or more years of professional experience. the data were analyzed using both quantitative, i.e., descriptive statistics, chi-square analyses (powell, 1982) and qualitative (grounded theory) analyses (glaser & strauss, 1967) for the one open-ended question. for the chi-square analyses, a bonferoni (keppel, 1991)adjustment was made resulting in the level of significance set at p < 0.006 to help decrease the likelihood of a type i error. 3.0 results part 1: fitness facility prac tices related to phsp (n=656) 3.1 practices -new participants. prior to completing a screening device, new participants are often informed of the inherent risks (minor, major, life threatening, and death) associated with physical activity through a written document such as an informed consent, waiver, or membership agreement. when asked if their facility formally notifies (through a written document) new participants of these risks, 605 (86%)of the respondents indicated yes. when asked if their facility required new participants to complete a pre-activity screening device, 443 (73%), 144 (24%), and 18 (3%) of the respondents indicated yes, no, and don’t know, respectively. among the 443 facilities that required new participants to complete a screening device, comparisons among six types of settings are presented in figure 1 with hospital settings significantly higher (p <0.006) than all other settings and corporate settings significantly higher (p <0.006) than community and commercial settings. of the 144facilities that did not require completion of a screening device, 118 respondents of these facilities provided the following reasons: (a) participants have responsibility for their own health and actions (36%), (b) screening takes up too much staff time (19%), (c) fitness facility/franchise policy (17%), and (d) screening is barrier to participation (10%), (e) there is no need or purpose (9%), and (f) legal counsel advice commercial(9%). these six reasons for not conducting screening originated from one of the previous studies by springer et al.(2009b).in this previous study, two of the top three reasons were the same as found in this study: (a) screening takes up too much mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 16 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe staff time and (b) participants have responsibility for their own health and actions. when these respondents were asked if they had made efforts to encourage management to conduct screening, 45% indicated yes, 45% indicated no, and 10% indicted they were the manager. of the 443 facilities that required new participants to complete a screening device, 423 respondents indicated the type of screening their facility provided. of these 423, 110 (26%) conducted self-guided screening (participants are provided a screening device that they complete and interpret on their own such as the par-q),182 (43%)conducted professionally guided screening (participants complete a screening device but the information is interpreted by a qualified professional to determine if an individual is “at risk”and involves follow-up steps such as requiring medical clearance for anyone classified as “at risk”), and 131 (31%) conducted both selfand professionally-guided screening. it is speculated that the facilities conducting both may have new participants who join to exercise on their own complete self-guided screening and those who enroll in individualized programs such personal training complete professionally-guided screening. 3.2 practices -professionally-guided screening. the respondents of the 313 facilities (182 + 131 as indicated above) that conducted professionally-guided screening were asked several follow-up questions on the survey to obtain further details regarding these practices. when asked which screening device they used, 310 respondents representing the 313 facilities answered with 163 (53%) indicated they used a ready-made tool such as the parq or a health risk appraisal and 123 (40%) indicated they used a “custom/in-house developed” device. when asked if they had pre-established criteria to identify “at risk” individuals, 301 responded with 248 (83%) indicated they did, and of these 248, a large majority (n=219, 88%) had a health/fitness professional interpret the criteria and make the determination if a participant was “at risk.” a large majority of these 248 facilities (n=216, 87%) also required “at risk” participants to obtain medical clearance and most of these (n=169, 78%) provided these participants with a medical clearance form for their medical care provider to complete and sign. with regard to how often participants complete their professionally-guided screening procedures, 301 respondents of 313 facilities represented answered this question and two other questions regarding: (a) the facility’s mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 17 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe policy/procedure for participants who refuse to complete their phsp, and (b) which publication was primarily used to develop/implement their phsp. see table 1 for these data. regarding having a policy to keep personal health information obtained on the screening device (a) private, (b) confidential, and (c) secure, a large percentage of these 301 facilities did so with 89%, 96%, and 85%, respectively. 3.3 practices -acsm’s getp criteria/process. of the 157 facilities that used acsm’s getpto develop/implement their professionally-guided phsp, 151 respondents of these facilities provided additional information regarding the inclusion of the getp criteria on their screening device as follows: (a) 96%, 91%, 87% included known cv, pulmonary and metabolic disease, respectively, (b) 88% included signs/symptoms with dizziness/syncope the highest (95%) and intermittent claudication the lowest (44%), and (c) 87% included cv risk factorswith smoking the highest (99%) and high-density lipoprotein the lowest (64%).see figure 2.it is likely that certain items such as intermittent claudication and high-density lipoprotein are not included on screening devices as often because the lay public may not understand what they mean. the acsm’s getp provides a logic model using these criteria to classify participants into low, moderate, and high risk categories to help determine which individuals should obtain medical clearance, i.e., all high risk and certain moderate risk (those who want to initiate a vigorous exercise program). however, only 62% of the respondents of these facilities indicated they conducted this risk classification process. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 18 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe part 2: perc eptions of acsm certified hfss related to phsp (n=677) 3.4 perceptions – familiarity with acsm’s published standards/guidelines. table 2 provides the data from the respondents when asked about their level of familiarity (and that of their facility’s top manager)with the three acsm publications. the respondents were more familiar with the acsm’s getp than with the other two acsm publications. for all three acsm publications, the respondent’s’ level of familiarity was higher than their perception of their top manager’s level of familiarity. a similar pattern of responses was found when respondents were asked about their perceived level of importance to adhere to published standards/guidelines and that of their top manager, e.g., 70% of the respondents felt it was “very important” whereas only 49% indicated “very important” when rating their top manager’s level of importance. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 19 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 3.5 perceptions -knowledge and belief regarding phsp. when asked about their level of confidence in conducting professionally-guided screening, the majority of respondents (70%) indicated “very confident” (see table 3). of the 547 respondents who answered that question, 493 (90%) indicated that their academic course work included preactivity health screening content. however, when asked about their level of adequacy regarding pre-activity screening information covered in their academic programs, only 52% indicated “more than adequate” and only 28% indicated “more than adequate” when asked specifically about the level of information covered regarding legal implications involved with phsp (see table 3). only 118 (22%) of the respondents were aware of any legal cases in which the failure to conduct phsp resulted in a negligent claim/lawsuit against a facility but 432 (79%) indicated there was an increased risk for a negligence claim/lawsuit against facilities that do not conduct phsp. regarding the respondents’ beliefs related to the various purposes and benefits regarding screening, > 70% of the respondents indicated “strongly agree” to each of the statements as shown in table 4. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 20 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe 3.6perceptions – challenges regarding phsp. from the open-ended question regarding perceived challenges in conducting phsp, 281 different responses were analyzed. using grounded theory principles, these data were coded and then categorized into three major themes: (a) member related issues (n=140, 50%), (b) administrative/procedural related issues (n=106, 38%), and (c) medical clearance related issues (n=35, 12%). the following statements are a representation of the type of comments provided by respondents for each of the major themes: mem ber related issues: o “some individuals do not want to go through the process of obtaining physician clearance prior to using the facility.” o “people do not understand the importance of it.” o “clients not understanding the questions.” o “some people are unsure of their health history/information” o “many people are not totally honest on their forms.” adm inistrative/proc edural related issues: o “lack of support from owners and managers who do not have an educational background in exercise science.” o “owners would not like it. it was discussed.” o “at my facility it does not seem to be as important as selling personal training and memberships.” o “part-time staff does not have knowledge or skills to properly discuss health history and risks.” o “time is the biggest problem.” • “no systems in place.” • medic al c learance related issues: o “clients resist seeing a physician for clearance.” o “some people do not come back/quit when i inform them that they need to get medical clearance.” o “dr. offices not responding to forms faxed regarding their patient’s risk of exercise and any restrictions.” mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 21 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe o “when requesting clearance, not all doctors consent because they state it is not up to them to clear the patient.” 4.0 discussion the discussion will highlight the significance of the findings from several perspectives. to assist with the interpretation of the data with regard to adherence to acsm’s pre-activity screening procedures, it was arbitrarily decided that percentages above 75% indicated high adherence or positive findings. most importantly, recommendations to increase adherence are provided throughout. 4.1 limitations. several limitations inherent in survey research include four sources of error: coverage, sampling, measurement, and nonresponsive (dillman, 2007). for example, a coverage error occurs when all members of the survey population do not have an equal chance of being included in the study sample. this was minimized by the acsm office emailing all acsm hfss in the u.s. inviting them to participate in the study. a sampling error occurs when only a subset of a population is surveyed and to address this limitation, this study included the entire population of certified acsm hfs in the u.s. a measurement error results from faulty question wording and poor questionnaire construction and was addressed in this study through well-designed and implemented pre-pilot and pilot studies. a nonresponse error occurs when a significant number of the population do not respond and have different characteristics from those who do respond. data describing characteristics of non-respondents were not available but certain characteristics (sex, age, and acsm geographical region) of the respondent sample and the total sample were similar. additional limitations in survey research include “response effects” and include the data being selfreported, the order of the questions may influence responses to subsequent questions, and missing data due to the voluntary nature which allowed respondents to skip questions (a preferred practice and requirement of the irb). 4.2 support for proposed changes with the acsm’s getp screening criteria/process. the proposed changes to be published in the next edition of the acsm’s getp addressing pre-participation screening criteria/process will simplify phsp for fitness facilities by (a) reducing the criteria needed on a screening device, (b) eliminating the process to classify individuals into of low, moderate, and high risk categories, and (c) decreasing the number of individuals who would need to obtain medical clearance (riebe, et al., 2015).the proposed changes also will be advantageous for many new participants who will no longer need to obtain medical clearance and thus remove this barrier prior to initiating a physical activity program. this study provides data to support these proposed changes. for example, of the facilities conducting professionally-guided screening, only 52% utilized the acsm’s getp to develop/implement their phsp. this low percentage may be due to the complexity of the screening criteria and the steps to carry out the process as evident by the comments of respondents especially with respect to medical clearance issues with members, managers, and physicians. the issue of medical clearance and the barriers/challenges it creates was a major rationale for the changes discussed in the acsm paper (riebe, et al., 2015).in addition, about ¼ (24%) of fitness facilities represented in this study were not conducting screening and of those conducting screening, over ¼ (26%) were conducting self-guided screening which does not meet acsm’s getp criteria/process.by simplifying the screening process, perhaps more facilities will consider adopting the mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 22 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe revised procedures because they will be more efficient for facility staff members to carry out than the current procedures and will address one of the major reasons for not conducting screening – it takes up too much staff time – as evident from the findings of this study and springer et al. (2009b). 4.3fitness facility practices.the percentage of fitness facilities that required new participants to complete a screening device was 73% in this study, which is the second highest when compared to the previous six studies in which these percentages were 10% (herbert et al., 2007),33%(springer et al., 2009a), 42%(mcinnis et al., 2001), 61% (mcinnis et al, 1997), 66% (eickhoff-shemek & deja, 2002a),and 87% (morrey et al., 2002).the lowest (10%) was a national study of university settings (campus recreation facilities) and the highest (87%) was a national study of corporate settings. as hypothesized, significantly more hospital/clinical and corporate settings required new participants to complete a screening device than other settings. these results are similar to two previous studies(eickhoff-shemek & deja, 2002b; springer et al., 2009b). hospital/clinical and corporate settings often have more resources (e.g., staff to participant ratios may be lower) and they also may provide fitness services for a smaller membership base than commercial, university/college, community, and government settings. also, hospital/clinical settings are accustomed to following standards (e.g., joint commission on the accreditation of health care organizations) and therefore are likely to follow other standards/guidelines such as those published by acsm. the facilities (24%) that do not have new participants complete a screening device are most common in commercial, community, university/college,and government settings. it is important to realize that the reasons provided for not conducting screening would not be considered viable defenses in a court of law for the failure to follow the standard of care (eickhoff-shemek, et al., 2009). however, there are positive findings from a legal perspective. a high percentage of facilities are formally notifying new participants of the inherent risks associated with physical activity. although this procedure is not included within in the screening procedures in the acsm publications, it is a recommendation found elsewhere in these publications and is often administered immediately prior to the screening process. in addition, a high percentage of facilities conducting professionally-guided screening have policies in place to keep health information gathered on a screening device private, confidential, and secure. notifying participants of the inherent risks in a document that is signed by the participant can strengthen the primary assumption of risk defense – a potentially effective defense in refuting negligence claims/lawsuits. keeping an individual’s health informationprivate, confidential, and secure would reflect compliance with certain federal and/or state privacy laws that might be applicable (eickhoff-shemek, et al., 2009). also indicative of positive findings among the facilities conducting professionallyguided screening is that a high percentage of them (> 83%) have health/fitness professionals interpret the data on the screening device to determine if a participant is “at risk” and then require medical clearance for “at risk” participants. having qualified professionals interpret the data on a screening device is a standard in acsm’s standards and a guideline in the aha/acsm joint ps and acsm’s getp. regarding frequency of screening, none of the acsm publications provide any specific guidance. however, in the acsm’s mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 23 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe standards (tharrett& peterson, 2012), it states that “pre-activity screening may be repeated at appropriate intervals” (p. 9). because one’s health status can change suddenly, it might be best to have participants inform a staff member when this occurs as 40% of the facilities represented in this study did.informing participants of this responsibility can be done by adding a signed statement on the screening device such as: if my health status changes at any time, i understand that i am responsible to inform the facility of any such changes. this could be done in addition to annual screening, e.g., when members renew their membership, as did some of the facilities represented in this study. over half (51%) of the facilities excluded participants who refused to complete their screening process. other facilities (38%) allowed these individualsto participate after they sign a refusal document. refusal procedures are described in both the acsm standardsand the aha/acsm joint ps.however, the decision to exclude participants may violate the americans with disabilities act (and other anti-discrimination laws) and therefore is essential to obtain legal advice before implementing such as policy(eickhoff-shemek et al., 2009). the refusal document signed by participants is considered a protective legal document and also needs legal review/approval. 4.4 perceptions of acsm certified hfss. the respondents’ familiarity with acsm’s publications was quite high with 95%, 73%, and 55% being “very familiar” or “familiar” with the acsm’s getp, acsm standards, and aha/acsm joint ps, respectively. however, when rating their manager’s levels of familiarity (very familiar and familiar) with these publications, the percentages were much lower -52%, 44%, and 36%. both quantitative data (e.g., 45% of the respondents who work in facilities that did not conduct screening have made an effort to encourage their managers to conduct screening) and qualitative data (e.g., comments made by respondents such as “lack of support from owners and managers who do not have an educational background in exercise science”) might reflect frustration among acsm certified professionals who want to implement phsp but do not have the support of their managers to do so. this is important because managers make decisions regarding the daily operations of a fitness facility and if they are unaware of professional safety standards/guidelines or do not think it is important to follow them, it can lead to poor decision making and compromise the safety of participants and subject the facility to legal liability. issues concerning managerial decision-making are evident from an experienced expert witness who stated that there has been little or no improvement since a study conducted by davis (1987)that showed many club managers had a ba degree in business but few had any formal education in exercise science (abbott, 2009). he also stated that “because managers are rarely well versed in this area of expertise, they are incapable of determining what is necessary to establish safe and effective fitness programming of their membership…of extreme concern is the current lack of adequate screening for new members...” (abbott, 2009, p. 99).in order for improvements to be made with regard to screening and other safety practices, it will be necessary to educate fitness facility managers about the acsm standards/guidelines and how to implement them (i.e., describing administrative steps that can make the process efficient) especially those in certain settings (government, university/college, community, and commercial) in which many (33%-60%) do nothave new participants complete a screening device. high percentages of the respondents “strongly agreed” with the benefits/purposes of screening as shown in table 4 and these beliefs likely came from their educational background. almost all (90%) of the respondents indicated mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 24 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe pre-activity screening was covered in their academic course work and most (70%) were “very confident” in conducting screening. however, adequacy of their course work especially related to legal implications associated with phsp was not perceived as high with only 28% indicating “more than adequate.” these data, along with only 22% of the respondents being were aware of negligent lawsuits for failing to conduct screening, indicate a need for education related to the legal issues associated with phsp. many of the challenges identified by the respondents in carrying out phsp also can be addressed through educational efforts directed toward members and medical providers. for example, comments related to member issues such as “people don’t understand the importance of it” can be addressed by informing participants “why” screening is done, as two respondents indicated “once the importance is expressed to them [new members], they were more than understanding” and “education quells the rebellion.”some of the challenges in obtaining medical clearance can be addressed by having the participant obtain the clearancedirectly from his/her medical provider that includes a cover letter addressed to the medical provider explaining why the clearance is needed 4.5educationalrecommendations. pre-activity screening involves the development and implementation of various steps as described in the acsm publications to enhance safety. it also involves addressing a variety of legal issues. although certainfindings in this study related to these steps and legal issueswere quite positive, there are areas for improvement that can be addressedthrough academic and/or continuing education programs for fitness professionals and managers. these educational efforts should focusonincreasing familiarity with and adherence to the acsm standards/guidelines -not just on “what” they are, but “how” to develop/implement them into a facility’s practices so they can be carried out properly and efficiently and with consideration of applicable laws, and “why” it is important from both safety and legal perspectives. perhaps acsm could develop such a program that could be offered in both academic and continuing education programs. 5.0 conclusions this was the first study to provide a comprehensive overview of pre-activity screening practices being conducted in fitness facilities across the u.s. and to identify various challenges experienced by acsm certified professionalswhen carrying out screening procedures. positive results indicating high adherence rates (>75%) to acsm’s screening procedures were: (a) facilities are informing new participants of the inherent risks associate with physical activity, (b) two out of the six settings (hospital/clinical and corporate) are requiring new participants to complete a screening device, (c) facilities that are conducting professionally-guided screening have health/fitness professionals interpret the data on the screening device to determine if an individual is “at risk” and then require “at risk” participants to obtain medical clearance, and (d), facilities that have adopted the acsm’s getp screening procedures are including a majority of the recommended screening criteria on the device.in order to improve adherence to acsm’s screening procedures, educational efforts are needed to (a) increase the number of facilities in certain settings (government, university/college, community and commercial) to have new participants complete a screening device, (b) decrease the number of facilities who are not conducting screening or are conducting self-guided screening, and (c) increase the number of facilities to adopt professionally-guided procedures such as those in acsm’s getp. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 25 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe acsm’s standards and guidelines are only effective in enhancing safety if fitness professionals and managers are implementing them into their daily operations. the findings from this study, reported by acsm’s own certified professionals, provide new insights into the realities and challenges related to implementing the acsm’s screening procedures.based on the findings, educational and other strategies were described that could improve adherence by focusing on ‘how” to implement them and “why” it is important to implement them.the findings in this study alsoprovided support for the proposed changes with the screening proceduresthat will be published in next edition of the acsm’s getp and will likely lead to increased adherence among facilities and remove the medical clearance barrier for many new participants. future research might involve surveying fitness facility managers to determine their familiarity with and adherence to acsm’s screening procedures and other safety standards and guidelines described in the acsm publications. references abbott a.a. (2009). fitness professionals: certified, qualified and justified. the exercise standards and malpractice reporter, 23(2), 17, 20-22. abbott, a.a. (2013). cardiac arrest litigations.acsm's health & fitness journal, 17(1), 31-34. american college of sports medicine. (2014). acsm certified exercise physiologist. retrieved may 11, 2014, from http://certification.acsm.org/acsm-certified-exercise-physiologist. balady, g. j., chaitman, b., driscoll, d., foster, c., froelicher, e., gordon, n., ..bazzarre, t. (1998). recommendations for cardiovascular screening, staffing, and emergency policies at health/fitness facilities.circulation, 97(22), 2283-2293. blair, s.n., gibbons, l.w., painter, p., pate, r.r., taylor, b., & will, j. (1986).acsm’sguidelines for exercise testing and prescription. (3rded.). philadelphia, pa: lea &febiger. chai v.sport& fitness clubs of america, inc. (1999).in: failure to defibrillate results in new litigation. the exercise standards and malpractice reporter, 13(4), 55-56. craig, a.c. (2014). a national investigation of pre-activity health screening procedures in fitness facilities: perspectives from american college of sports medicine certified health fitness specialists [dissertation]. tampa, fl: university of south florida. davis, k.a. (1987). sport management in the private sector.american journal of health education, 58(5), 8185. dillman, d. a. (2007).mail and internet surveys: the tailored design method (2nd ed.). hoboken, n.j.: wiley. eickhoff-shemek, j. m., & deja, k. (2002a). are health/fitness facilities complying with acsm standards? part 1 of 2.acsm's health & fitness journal, 6(2), 16-21. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 26 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe eickhoff-shemek, j. m., & deja, k. (2002b). are health/fitness facilities complying with acsm standards? part 2.acsm's health & fitness journal, 6(3), 19-24. eickhoff-shemek, j. m., herbert, d. l., & connaughton, d. (2009).risk management for health/fitness professionals: legal issues and strategies. philadelphia: wolters kluwerhealth/lippincott williams & wilkins. eysenbach g. (2004). improving the quality of web surveys: the checklist for reporting results of internet esurveys (cherries).journal of medical internet research,6(3), e34. fowler, f. j. (2009).survey research methods (4th ed.). thousand oaks: sage publications. glaser, b. g., & strauss, a. l. (1967).the discovery of grounded theory; strategies for qualitative research. chicago,: aldine pub. co. herbert, w. g., herbert, d. l., mcinnis, k. j., ribisl, p. m., franklin, b. a., callahan, m.,& hood, a. w. (2007). cardiovascular emergency preparedness in recreation facilities at major us universities: college fitness center emergency readiness. prevcardiol, 10(3), 128133. keppel, g. (1991). design and analysis: a researcher's handbook. englewood cliffs, n.j.: prentice hall. l.a. fitness international, llc v. julianna tringali mayer, no. 980 so.2d. 550 (fla. app. lexis 5893 2008). mcinnis k.h., herbert w., herbert d., herbert j., ribisl p., franklin b. low compliance with national standards for cardiovascular emergency preparedness at health clubs. chest.2001; 120(1): 283-288. mcinnis, k. h., hayakawa, s., &balady, g. j. (1997). cardiovascular screening and emergency procedures at health clubs and fitness centers.american journal of cardiology, 80(3), 380383. morrey, m. a., finnie, s. b., hensrud, d. d., & warren, b. a. (2002).screening, staffing, and emergency preparedness at worksite wellness facilities.[evaluation studies].med sci sports exerc, 34(2), 239-244. pescatello, l. s., arena, r., riebe, d., thompson, p. d., american college of sports medicine., wolters kluwer health., & lippincott williams & wilkins. (eds.). (2014). acsm's guidelines for exercise testing and prescription (9th ed.). philadelphia: wolters kluwer health/lippincott williams & wilkins. physical activity guidelines advisory committee report. (2008, july 17, 2013). odphp publication retrieved no u0036, from http://www.health.gov/paguidelines/report/pdf/committeereport.pdf mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.7, issue 6; november-december 2022; 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 27 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe powell, f. c. (1982). statistical tables for the social, biological, and physical sciences. cambridge; new york: cambridge university press. pressor, s. (2004).methods for testing and evaluating survey questionnaires. hoboken, nj: john wiley & sons. riebe, d., franklin, b.a., thompson, p.d., garber, c.e., whitfield, g.p., magal, m., &pescatello, l.s. (2015).updating the american college of sports medicine’s recommendations for the exercsie preparticipation health screening process.medicine & science in sports& exercise, 47(11), 2473-2479. springer, j. b., eickhoff-shemek, j. m., &zuberbuehler, e. j. (2009a). an investigation of pre-activity cardiovascular screening procedures in health/fitness facilities--part i: is adherence with national standards decreasing? [comparative study].prevcardiol, 12(3), 155-162. doi: 10.1111/j.1751-7141.2009.00026.x springer, j. b., eickhoff-shemek, j. m., &zuberbuehler, e. j. (2009b). an investigation of pre-activity cardiovascular screening procedures in health/fitness facilities--part ii: rationale for low adherence with national standards. prevcardiol, 12(4), 176-183. doi: 10.1111/j.1751-7141.2009.00029.x survey gizmo. (2014). retrieved march 5, from http://www.surveygizmo.com/survey software-features/pagejumping/ tharrett, s. j., & peterson, j. a. (2012).acsm's health/fitness facility standards and guidelines(4th ed.). champaign, il: human kinetics. thompson, p.d., franklin, b.a., balady, g.j., blair, s.n., corrado, d., estes, m.,…costa, f. (2007). exercise and acute cardiovascular events: placing the risks into perspective. medicine & science in sports & exercise, 39(5), 886-897. voris, h.c., &rabinoff, m. when is a standard of care not a standard of care? the exercise standards and malpractice reporter. 2011: 25(2): 20-1. mailto:topacademicjournals@gmail.com 050815-cr095.docx american journal of medical and physical education vol.8, issue 5; september-october 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 10 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe harnessing curcumin's therapeutic potential in cancer treatment" 1dr. xin li and 2dr. wei zhang 1shaanxi university of chinese medicine, xianyang, shaanxi, 712000, china 2nanzheng district people's hospital, hanzhong, shaanxi, 723100, china abstract: curcumin, a bioactive compound derived from various zingiberaceae plants, has garnered increasing attention for its potential in cancer therapy. this review explores the multifaceted role of curcumin in cancer treatment, encompassing its anti-tumor effects, impact on apoptosis induction, regulation of signaling pathways, anti-angiogenic properties, and enhanced chemosensitivity. beyond its medicinal applications, curcuminoids are also utilized as food pigments, making curcumin a versatile and cost-effective option with fewer adverse reactions compared to conventional western medicine. keywords: curcumin, cancer therapy, anti-tumor effects, apoptosis, signaling pathways, angiogenesis, chemosensitivity, traditional chinese medicine, tumor microenvironment. introduction curcumincuma longa is a curcumincuma genus of zingiberaceae. it grows widely in southwest of china[1]. the earliest recorded medicine of curcumincuma longa in our country's tang bencao (materia medica of the tang dynasty) was warm in nature, bitter and spicy in taste, and returned to the spleen and liver meridians. it was said that "the main heart knot accumulation, cystic disease, qi breaking blood, in addition to wind and heat, eliminate carbunction and swelling" [2]. curcumin is an active compound extracted from the dried rhizome of zingiberaceae plants such as curcumincuma longa, zedoary turmeric, and curcumincuma vulgare [3]. the molecular formula of curcumin was c21h20o6 and the molecular weight was 368.4 g/mol. the 2d and 3d structures of curcumin were downloaded from pubchem website. see figure 1. kuttan r et al. [4] first proposed that curcumin could be used in anti-tumor therapy in 1985. more and more studies have confirmed that curcumin plays an anti-tumor role by inducing tumor cell apoptosis, regulating tumor cell growth signal transduction pathway, inhibiting tumor angiogenesis and increasing the sensitivity of tumor cells to chemotherapy [5-7]. in addition to medicinal use, curcuminoids are also used as food pigments and are one of the main ingredients of curcuminry [8]. compared with western medicine, it is cheap and safe, and has fewer adverse reactions. it has broad prospects in the treatment and prevention of tumor diseases [9]. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 5; september-october 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 11 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe figure 1: 2d structure of the curcumin compound and 3d structure of the curcumin compound according to the latest global cancer data in 2020 released by the international agency for research on cancer (iarc) of the world health organization, the number of new cancer cases and cancer deaths in china ranks first in the world [10]. tumor refers to the uncontrolled growth or even infinite abnormal proliferation of local tissues in the body under different carcinogenic conditions, which is the local manifestation of systemic diseases. traditional chinese medicine (tcm) is one of the important means of tumor treatment in china. its main advantage lies in improving the internal environment of the body, especially in remodeling the tumor-related microenvironment [11]. traditional chinese medicine experts put forward that "when the positive qi is insufficient, the evil qi is behind", indicating that the basic pathogenesis of malignant tumors is a continuous struggle between "positive deficiency" and "evil poison" [12]. tcm improves the body's immune function and inhibits the proliferation and migration of cancer cells, thereby reducing the growth, metastasis and recurcuminrence of tumor cells and preventing the occurcuminrence of tumors [13]. through a large number of literature studies, it has been confirmed that curcumin is particularly effective in the treatment of tumors, which is summarized as follows. 1. curcumin and nasopharyngeal carcinoma nasopharyngeal carcinoma (npc) is a malignant epithelial tumor originating from the nasopharynx, most of which is geographically located in southeast asia, while china is one of the countries with the highest incidence and mortality. lin et al. [14] confirmed that curcumin can significantly inhibit the growth of human poorly differentiated nasopharyngeal carcinoma cell line cne-1, and s phase arrest prevents cells from entering the next proliferation cycle. by affecting the distribution of cell cycle, it affects the metabolism and function of cells, so as to achieve the purpose of inhibiting cell proliferation. wang et al. [15] found that the high expression of pi3k and akt phosphorylation levels in cne-2z cells were effectively inhibited after curcumin intervention, suggesting that inhibition of endogenous pi3k/akt pathway is one of the mechanisms of curcumin anti-tumor. tiam1 is a gene related to tumor invasion and metastasis. it can specifically activate the gtpase activity of rho protein family, and its downstream effector is rac1, an important member of rho protein family. "cellular endocytosis and membrane transport, cell migration, adhesion, invasion, apoptosis, and tumorigenesis." chen et mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 5; september-october 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 12 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe al. [16] confirmed that tiam1 was highly expressed in nasopharyngeal carcinoma tissues by immunohistochemistry, and the expression of tiam1 protein was determined by treating nasopharyngeal carcinoma cells with different concentrations of curcumin. the results suggested that with the increase of curcumin concentration, the expression of tiam1 in nasopharyngeal carcinoma 5-8f cells decreased. the migration and invasion of cells were inhibited, further indicating that curcumin may inhibit the invasion of npc by inhibiting the expression of invasion related gene tiam1. 2. curcumin and lung cancer lung cancer is the second most common cancer in the world with a high mortality rate. the incidence of lung cancer is closely related to the maturity of the tobacco epidemic [10]. jin et al. [17] found that curcumin treatment of human lung adenocarcinoma cell line a549 could inhibit cell proliferation, induce cell apoptosis and increase caspase-3 activity. further studies showed that curcumin inhibited the proliferation and induced apoptosis of human non-small cell lung cancer cells by up-regulating mir-1925p and inhibiting pi3k/akt signaling pathway. chen et al. [18] found that after the treatment of a549 cells with curcumin, the inhibition of cell viability increased and the proportion of apoptotic cells increased gradually with the increase of the concentration, and the inhibition of lung cancer cells was achieved by reducing the akt signaling pathway in lung cancer cells. xu et al. [19] found that neutrophil elastase plays an important role in regulating lung tumor proliferation in the inflammatory microenvironment of a549 cells. curcumin can inhibit tumor proliferation induced by neutrophil elastase. curcumin can also inhibit the growth of cancer cells by up-regulating the expression levels of p53 and p21 genes in a549 cells, down-regulating the expression levels of pc-na and if4e genes, and initiating the p53/p21/pcna/ if4e signaling pathway [20-21]. li et al. [22] found that when a549 cells were treated with different concentrations of curcumin for 24 h, the expression level of mmp-9 was significantly decreased and the level of timp-1 was significantly increased with the increase of concentration. further studies showed that curcumin inhibited the expression of phosphorylated erk1/2 (p44/42) in a concentration-dependent manner. however, the expression of non-phosphorylated erk1 did not change significantly, indicating that curcumin promoted the apoptosis of a549 cells by inhibiting the phosphorylation of erk1/2 signaling pathway. 3. curcumin and gastric cancer gastric cancer is a highly malignant tumor, ranking fifth in morbidity and fourth in mortality in the world [10]. early endoscopic radical resection can curcumine more than 90% of gastric cancer, but chemotherapy and radiotherapy are not effective for advanced gastric cancer. it has been reported that curcumin can inhibit the proliferation of gastric cancer cells by inducing apoptosis. in vitro, curcumin can induce apoptosis of gastric cancer cells by promoting the disintegration of mmp, and mmp plays an important role in initiating the mitochondria-dependent apoptosis pathway [23]. kruppel-like factor 4(klf4) is a transcription factor that plays an important role in cell development and progression. curcumin combined with klf4 could block the cell cycle of bgc-823 cells in g1 phase. western blot showed that the expression levels of p-pi3k and cyclind1 were increased, and the expression of p-erk was decreased. these results indicated that the combination of curcumin and klf4 could inhibit the proliferation of human bgc-823 cells by regulating pi3k/akt and erk/mapk mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 5; september-october 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 13 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe pathways [24]. curcumin can inhibit the proliferation and induce apoptosis of gastric cancer cells by inducing cell cycle arrest in g2/ m phase, down-regulating the expression of glycolytic enzymes and effectively inhibiting the mir21 /pten/akt molecular pathway [25]. curcumin induces apoptosis of gastric cancer cells in vitro and in vivo in conjunction with chemotherapy drugs such as 5-fluorouracil and oxaliplatin through bcl/baxcaspase8, 9caspase3 pathway [26]. yang et al. [27] conducted a clinical study on 56 patients with advanced gastric cancer, and the results showed that curcumin adjuvant chemotherapy drugs could improve the therapeutic effect of patients with advanced gastric cancer, reduce the adverse reactions of chemotherapy, and improve the tolerance of patients compared with the chemotherapy group. 4. curcumin and liver cancer liver cancer ranks fifth in the global incidence and is the third leading cause of cancer death. in china, the infection rate of hepatitis b virus is the most important risk factor, and reducing the exposure to alcohol and aflatoxin can reduce the incidence [10]. the expression of mirna-29 and mirna-30 family members is elevated in normal liver and breast cancer liver metastasis models, and multiple members of each mirna family directly target and inhibit the insulin-like growth factor-1 (igf-1) /igf-1 receptor (igf-1r) signaling axis, which is associated with reduced cancer progression and metastasis [28]. chen caiping et al. [29] found that the inhibition rate of hepatocellular carcinoma hepg2 cells was the best after 72 hours of culture, and curcumin may regulate the biological process of hepatocellular carcinoma cells by increasing the expression of mirna-29 and reducing the expression of vascular endothelial growth factor (vegf). mirna-21-5 promotes the growth, migration and invasion of hepatocellular carcinoma (hcc) cells by targeting downstream target genes, such as faslg, suppressor of cytokine signaling 6(socs6) and kruppel-like transcription factor 5(klf5) [30]. studies have shown that curcumin can down-regulate the expression of mirna-21, up-regulate the expression of timp3, and inhibit the transforming growth factor β1(tgf-β1)/recombinant smad family member 3(smad3) signaling pathway, thereby inhibiting the proliferation of hepg2 and hcc lm3 cells [31]. in addition, curcumin can also reduce the expression of mirna-21-5p and increase sox6 expression to inhibit the proliferation, migration and invasion of hcc cells [32]. 5. curcumin and colorectal cancer the incidence of colorectal cancer is the third in the world, and the mortality rate is the second due to its insidious early stage, easy recurcuminrence and metastasis in the late stage [10]. fang li [33] et al. found that curcumin could inhibit the expression of cyclin d1 in human colon cancer ht-29 cells in a dose and time-dependent manner. in addition, curcumin inhibited the activation of activator protein-1 (ap-1) in colon cancer cells, resulting in the overexpression of mir-21 gene binding to the mir-21 promoter. under the regulation of mir-21, colon cancer cell cycle was arrested in g2/m phase. thereby inhibiting the abnormal and rapid proliferation of tumor cells .in the study of curcumin-induced apoptosis of tumor cells, curcumin can effectively disturb the balance of mitochondrial membrane potential, enhance the inhibition of bcl-xl protein, and regulate cell apoptosis [34]. luo qiang [35] treated human colon cancer sw620 cells cultured in vitro with different concentrations of curcumin for 24 h, and found that the proliferation ability of tumor cells was significantly mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 5; september-october 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 14 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe inhibited in a dose-dependent manner. at the same time, sw620 cells were regulated by bcl-2 signaling pathway and underwent apoptosis. curcumin was applied to colon cancer sw480 cells cultured in vitro. rt-qp cr and western blot experiments showed that curcumin could regulate the apoptosis of colon cancer sw480 cells by recruiting fas death receptor and activating downstream signals of death receptor pathway [36]. zhang et al. [37] found that curcumin significantly inhibited the proliferation of colon cancer sw620 cells and upregulated the expression of nkd2 in colorectal cancer cells and xenografts, leading to the downregulation of key markers in wnt signaling. in addition, curcumin inhibited the progression of epithelialmesenchymal transition (etm) through the overexpression of e-cadherin and the down-regulation of vimentin. 6. curcumin and gynecologic tumors 6.1. ovarian cancer ovarian cancer is a common malignant tumor in the female reproductive system with high mortality and poor prognosis. seo et al. [38] found that an abnormal increase in the expression level of muscle/endoplasmic reticulum calcium atpase (serca), which regulates ca (2+) homeostasis, was observed in ovarian cancer. curcumin induced apoptosis of ovarian cancer cells in a concentration and time-dependent manner, and the solute ca (2+) flux in ovarian cancer cells was significant (15μm). it was further confirmed that inhibition of serca activity by curcumin could disrupt ca (2+) homeostasis, thereby promoting apoptosis of ovarian cancer cells. liu et al. [39] found that curcumin significantly reduced cell viability and induced apoptotic cell death in human ovarian cancer cell lines sk-ov-3 and a2780, and induced protective autophagy in human ovarian cancer cells by inhibiting the akt/mtor/p70s6k pathway. weir et al. [40] found that curcumin can inhibit the proliferation of cisplatin-resistant (cr) and sensitive (cs) human ovarian cancer cells, activate caspase-2 and parp degradation to enhance p53 phosphorylation and apoptosis, thereby inducing g (3) /m phase cell cycle arrest in cr cells. 6.2. cervical cancer cervical cancer is the fourth most commonly diagnosed cancer and the fourth leading cause of cancer death in women [10]. cervical cancer and human papillomavirus (hpv) infection have a great correlation. curcumin can significantly down-regulate the expression of hpv e6 mrna in hela cells of cervical cancer, so as to play an anti-hpv effect, and promote the generation of reactive oxygen species (ros) and damage dna [41]. by inhibiting the activity of pi3k/akt/mtor, curcumin can induce autophagy and inhibit the proliferation of cervical cancer siha cells, up-regulate the expression of tumor suppressor genes p53, p21 and p27, and secrete ifn-γ [42]. 7. curcumin and esophageal cancer the incidence of esophageal cancer ranks the seventh in the world, and the overall mortality ranks the sixth [10]. china is a high-incidence area of esophageal cancer, and pickled vegetable consumption, smoking, alcohol consumption, low intake of fruits and vegetables are all its risk factors [43]. li et al [44]. found that curcumin inhibited the proliferation of esophageal cancer ec109 cells by up-regulating the expression of pten, gsk3β and caspase 3 and inhibiting the pi3k/akt signaling pathway. lin et al. [45] found that curcumin inhibited the mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 5; september-october 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 15 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe formation of rac1-pi3k-akt signaling complex related to lipid rafts in ec cells, and inhibited the invasion of ec cells induced by stromal cell-derived factor-1α (sdf-1α) through the localization of lipid rafts on the cell surface and the enhancement of matrix metalloproteinase-2 (mmp-2) promoter activity. chen et al. [46] confirmed that after 48 hours of intervention with different concentrations of curcumin, the cell cycle of esophageal cancer eca109 cells changed significantly, the proportion of cells in g0/g1 phase decreased significantly, and the proportion of cells in g2/m phase increased significantly. these results indicated that curcumin could induce g2/m phase arrest, inhibit the proliferation and induce apoptosis of eca-109 cells. 8. curcumin and other tumors zhao et al. [47] found that curcumin inhibited the growth of mouse prostate cancer xenografts in vivo and promoted the apoptosis of prostate lncap cells by inhibiting jnk pathway in vitro. liu et al. [48] confirmed that curcumin treatment of prostate cancer cell lines du44 and 133rv145 inhibited the proliferation and invasion of cancer cells in vitro, as well as cell cycle arrest. gong et al. [49] found that the viability of human renal cell adenocarcinoma achn cells was inhibited and the number of apoptosis increased after curcumin treatment. the results in c57bl / 6 nude mice verified that the tumor size, weight and volume were also significantly inhibited after curcumin treatment, and confirmed that the expression of akt/mtor protein in the treatment group was significantly reduced, while autophagyrelated proteins were significantly increased. these results indicate that curcumin plays a role in antirenal cell carcinoma through akt/mtor pathway. zhou et al. [50] found that curcumin had stronger cytotoxic activity on acute myeloid leukemia (aml) cells, and flavin inhibited the phosphorylation of akt, pras70, 6e-bp1, p27s2k, raf-5 and p1 in aml cell lines (ml-4 and oci-aml1) in a dosedependent manner. regulation of cell cycle d21 leads to cell cycle arrest and apoptosis in ml-5 and oci-aml79 cells. hu et al. [51] found that curcumin showed anti-proliferation and colony formation inhibitory activities in the treatment of human breast cancer mcf-7 and mda-mb-231 cell lines, and it also inhibited the migration of mda-mb-231 cells. in addition, curcumin downregulated the mrna expression of vimentin, fibroniconin and β-catenin, and upregulated the mrna expression level of ecadherin, indicating that the inhibitory effect of curcumin on breast cancer cells was closely related to epithelial-mesenchymal transition (emt). shi et al. [52] found that curcumin can inhibit the cell proliferation of bladder cancer cells t24 and 5637, and reduce the migration and invasion ability of t24 and 5637 cells by regulating the expression of β-catenin and reversing emt. bharti et al. [53] found that the transcription factor nuclear factor-kappab (nf-kappab) plays a central role in cell survival and proliferation of human multiple myeloma (mm), and that curcumin could down-regulate the expression of nfkappab-regulated gene products, including ikappabalpha, bcl-2, and bcl-2. bcl-x (l) and cyclin d1. this resulted in the arrest of the g (1) /s phase of the mm cell cycle and effectively inhibited the proliferation of mm cells. thus, it provides a molecular basis for the use of curcumin in the treatment of mm patients. 9. conclusion and outlook in summary, more and more studies have shown that the anti-tumor activity of curcumin involves the regulation of a variety of cell signaling pathways, and acts on a variety of molecular targets, including transcription factors, cytokines, growth factors and their receptors, enzymes, inflammatory factors, and genes regulating cell mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 5; september-october 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 16 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe proliferation and apoptosis. the above research results let us see the benefits of curcumin in the treatment of animal and human tumors, but it has not yet entered the clinical antiexperiment. it is still necessary to develop curcumin and its derivatives and new dosage forms to improve its absorption and metabolic characteristics, in order to find a more appropriate dose or dosage form, give precise anti-tumor treatment for specific tumors, and improve the efficacy. it has become a clinically effective tumor treatment drug. references kocaadam b, şanlier n. curcumin, an active component of turmeric (curcuma longa), and its effects on health [j]. crit rev food sci nutr, 2017, 57(13): 2889-95. cui yuhan, an xiao, wang haifeng, et al. study on chemical components of curcumincuma longa [j]. chinese herbal medicine, 2016, 47(7): 1074-1078. kunnumakkara ab, bordoloi d, padmavathi g, et al. curcumin, the golden nutraceutical: multitargeting for multiple chronic diseases[j]. br j pharmacol, 2017, 174( 11) : 1325-1348. kuttan r, kuttan g. inhibituon of lung metasis in mice induced by bi6f10 melanoma calls polyphenolic compounds [j]. cancer lett, 1985, 29:197. xiao xuyang, wang xiaodong. research progress on the anti-tumor mechanism of curcumin [j]. journal of jinzhou medical college, 2006, 27 (1): 56-58. duan jinqi, zhang linxi. research progress of anti-tumor mechanism of curcumin [j]. jiangsu medicine, 2011, 27 (15): 1824-1826. aggarwal b b, sung b. pharmacological basis for the role of curcumin in chronic diseases: an age old spice with moderntargets [j]. trends pharmacol sci, 2009, 30(2): 85 -94. osorio-tobón j f, carvalho p i, barbero g f, et al. fast analysis of curcuminoids from turmeric (curcumincuma longa l. ) by high-performance liquid chromatography using a fused-core column [j]. food chem, 2016, 200: 167-74. cui minghua, fu erhua, lin zhenhua, park yong-shi. research progress of anti-tumor pharmacological effects of curcumin [j]. chinese journal of clinical pharmacology, 2021, 37(02):186188+196. sung h, ferlay j, siegel r l, et al. global cancer statistics2020: globocan estimates of incidence and mortalityworldwide for 36 cancers in 185 countries [j]. ca cancerj clin, 2021, 71(3): 209-249. [11] tian tongde, yue liyun, tian tongliang, et al. relationship between tumor inflammatory microenvironment mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 5; september-october 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 17 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe and immunity and intervention strategy of traditional chinese medicine [j]. chinese journal of traditional chinese medicine, 2017, 58(3):209-213. xu ming, lu jiahui. pathogenesis and treatment of malignant tumor from phlegm, blood stasis and poison [j]. international journal of traditional chinese medicine and chinese materia medica, 2016, 38(11): 10281029. ling changquan, yue xiaoqiang, ling chen. threeadvantages of using traditional chinese medicine to preventand treat tumor [j]. journal of integrative medicine, 2014, 12(4):331-335. lin yuanxiong. effect of curcumin on the proliferation and cell cycle of nasopharyngeal carcinoma cne-1 cells [j]. journal of qiqihar medical college, 2010, 31(12):1855-1856. wang guiqiu. the effect of curcumin on the apoptosis of human nasopharyngeal carcinoma cell line cne-2z and its mechanism [j]. journal of practical medicine & clinic, 2013, 16(12):1126-1129. [16] chen j. effects of curcumin on proliferation and invasion of nasopharyngeal carcinoma by regulating tiam1 protein expression [j]. journal of central south medical science, 2019, 47(5):483507. jin h, qiao f, wang y, et al. curcumin inhibits cell proliferation andinduces apoptosis of human non small cell lung cancer cells throughthe upregulation of mir 192 5p and suppression of pi3k / akt sig-naling pathway[j]. oncology reports, 2015, 34(5): 2782 2789. chen shi, li dechuan, liu hua. apoptosis of human lung cancer cells induced by curcumin and its mechanism [j]. journal of wuhan university: medical edition, 2012, 33 (4) : 507-510. xu y, zhang j, han j, et al. curcumin inhibits tumor proliferation in-duced by neutrophil elastase through the upregulation of α1 antitryp-sin in lung cancer[j]. molecular oncology, 2012, 6( 4) : 405 417. jiang j, cao y d, mo na, et al. curcumin inhibits a549 cell proliferation through p53 /p21 /pcna/ei f4e signaling pathway [j]. journal of the third military medical university, 2012, 34 (1) : 49-53. he qiuxia, hou hailong, yuan yanqiang, et al. effects of curcumin on proliferation and apoptosis of lung adenocarcinoma a549 cells [j]. chin j traditional chinese medicine, 2010, 28 (10) : 2130-2132. [22] li ziguang, wang enju, liu zhaoyang, et al. the role of erk1/2 in the inhibitory effect of curcumin on the proliferation of lung cancer a549 cells [j]. journal of bengbu medical college, 2011, 36 (3) : 231-234. liu x, sun k, song a, et al. curcumin inhibits prolif-eration of gastric cancer cells by impairing atpsensitivepotassium channel opening [j]. world j surg oncol, 2014, 12: 389. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 5; september-october 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 18 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe ji j, wang h s, gao y y, et al. synergistic anti-tumoreffect of klf4 and curcumin in human gastric carcinomacell line[j]. asian pac j cancer prev, 2014, 15( 18) :7747-7752. chen x, chen x, zhang x, et al. curcuminoid b63 in-duces ros-mediated paraptosis-like cell death by targeting trxr1 in gastric cells[j]. redox biol, 2019, 21: 101061. zhou x, wang w, li p, et al. curcumin enhances theeffects of 5-fluorouracil and oxaliplatin in inducing gastric cancer cell apoptosis both in vitro and in vivo[j]. oncol res, 2016, 23( 1-2) : 29-34. [27] yang weili, yang rongping, luo yongsheng, et al. clinical analysis of curcumin combined with folfox regimen in the treatment of advanced gastric cancer [j]. journal of inner mongolia medical university, 2019, 12 (1): 96-99. shastri a a, saleh a, savage j e, et al. dietary alterations modulate the microrna 29/30 andigf1/akt signaling axis in breast cancer livermetastasis[j]. nutr metab(lond), 2020, 3(17):23-043. chen c p, xu q, zhao h f. intervention effect of curcumin on the expression of mir-29 and vegf in hepatocellular carcinoma cells [j]. zhejiang journal of integrated traditional chinese and western medicine, 2020, 30 (10) : 785-790, 869. chen s, yang c, sun c, et al. mir-21-5psuppressed the sensitivity of hepatocellular carcinomacells to cisplatin by targeting faslg[j]. dna cellbiol, 2019, 38(8):865-873. li j, wei h, liu y, et al. curcumin inhibitshepatocellular carcinoma via regulating mir-21/timp3 axis[j]. evid based complement alternatmed, 2020, 7(17):2892-917. zhou c, hu c, wang b, et al. curcuminsuppresses cell proliferation, migration, and invasionthrough modulating mir-21-5p/sox6 axis inhepatocellular carcinoma [j]. cancer biother radiopharm, 2020, 8(4):37-34. . fang l, zhou j, xie h, et al. effects of curcumin on cell proliferation, cell cycle distribution and cyclind1 gene expression in human colon cancer ht-29 cells [j]. chongqing med, 2016, 45(32): 44794481. mudduluru g, george-william jn, muppala s, et al. curcumin regulates mir-21expression and inhibits invasion and metastasis in colorectal cancer[j]. bioscience reports, 2011, 31(3): 185-197 [35] tuorkey m. curcumin a potent cancer preventive agent: mechanisms of cancer cellkilling[j]. interventional medicine and applied science, 2014, 6(4): 139-146. luo qiang, sun li, zhang zhang, et al. effect of curcumin on apoptosis of human colon cancer sw620 cells [j]. chinese journal of gerology, 2011, 31(16): 3108-3109. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 5; september-october 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 19 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe zhang z, chen h, xu c, et al. curcumin inhibits tumor epithelial‑mesenchymal transition by downregulating the wnt signaling pathway and upregulating nkd2 expression in colon cancer cells [j]. oncol rep, 2016, 35(5): 2615-23. seo j a, kim b, dhanasekaran d n, et al. curcumin induces apoptosis by inhibiting sarco/endoplasmic reticulum ca2+ atpase activity in ovarian cancer cells [j]. cancer lett, 2016, 371 (1): 30-7. liu l d, pang y x, zhao x r, et al. curcumin induces apoptotic cell death and protective autophagy by inhibiting akt/mtor/p70s6k pathway in human ovarian cancer cells [j]. arch gynecol obstet, 2019, 299(6): 1627-39. weir n m, selvendiran k, kutala v k, et al. curcumin induces g2/m arrest and apoptosis in cisplatin-resistant human ovarian cancer cells by modulating akt and p38 mapk [j]. cancer biol ther, 2007, 6(2): 178-84. kumar d, basu s, parija l, et al. curcumin and ellagic acid synergistically induce ros generation, dna damage, p53 accumulation and apoptosis in hela cervical carcinoma cells. biomed pharmacother, 2016, 8(1):31-37. fan shizhen, chen xuna, yu bohai, et al. curcumin promotes autophagy in siha cells by inhibiting pi3k/akt/mtor. chin j lab diagnostics, 2017, 5 (21): 897-900. yang s, lin s, li n, et al. burden, trends, and risk factors of esophageal cancer in china from 1990 to 2017: an up-to-date overview and comparison with those in japan and south korea [j]. j hematol oncol, 2020, 13(1): 14-6. li x j, luo q, sun l, et al. effects of curcumin on proliferation and pten/pi3k/akt signaling pathway of esophageal cancer ec109 cells [j]. chin j applied physiology, 2015, 31(05): 465-8. lin m l, lu y c, chen h y, et al. suppressing the formation of lipid raft-associated rac1/pi3k/akt signaling complexes by curcumin inhibits sdf-1α-induced invasion of human esophageal carcinoma cells [j]. mol carcinog, 2014, 53(5): 360-79. chen jianhua. the effect of curcumin on the proliferation and wnt signaling pathway of esophageal cancer cell line eca-109 [d]; hebei medical university, 2015. zhao w, zhou x, qi g, et al. curcumin suppressed the prostate cancer by inhibiting jnk pathways via epigenetic regulation [j]. j biochem mol toxicol, 2018, 32(5): e22049. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 5; september-october 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 20 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe liu t, chi h, chen j, et al. curcumin suppresses proliferation and in vitro invasion of human prostate cancer stem cells by cerna effect of mir-145 and lncrna-ror [j]. gene, 2017, 63(1): 29-38. [49] gong x, jiang l, li w, et al. curcumin induces apoptosis and autophagy inhuman renal cell carcinoma cells via akt/mtor suppression [j]. bioengineered, 2021, 12(1): 5017-27. zhou h, ning y, zeng g, et al. curcumin promotes cell cycle arrest and apoptosis of acute myeloid leukemia cells by inactivating akt [j]. oncol rep, 2021, 45(4). 79-62. hu c, li m, guo t, et al. anti-metastasis activity of curcumin against breast cancer via the inhibition of stem cell-like properties and emt [j]. phytomedicine, 2019, 58(12): 1527-40. shi j, wang y, jia z, et al. curcumin inhibits bladder cancer progression via regulation of β-catenin expression [j]. tumour biol, 2017, 39(7): 1770-2548. bharti a c, donato n, singh s, et al. curcumin (diferuloylmethane) down-regulates the constitutive activation of nuclear factor-kappa b and ikappabalpha kinase in human multiple myeloma cells, leading to suppression of proliferation and induction of apoptosis [j]. blood, 2003, 101(3): 1053-62. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.9, issue 3; may-june 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 1 | american journal of medical and physical education | https://topjournals.org/index.php/ajmpe cyberloafing behaviour in workplace: probing its effects on organizations’ productivity as evidenced from literature 1dr. blessing chinwe ovwromoh (ph.d.) and 2assoc. prof. abraham oriji (ph.d.; dls.) 1department of adult & non-formal education, faculty of education, university of portharcourt, nigeria. 2department of curriculum studies & educational technology, faculty of education, university of portharcourt, portharcourt, nigeria. doi: https://doi.org/ 10.5281/zenodo.11519626 abstract: technological advancements of the 21st century dictate how things are done. these technologies have also come with lots of benefits and negativities, especially in the workplace. the word cyberloafing is one of the technological terms that is gaining ground in recent times, particularly in the industry. the dawn of the internet in the present century is like an elephant viewed by different persons from all sides that is prone to several interpretations. due to several activities performed on the internet, several technological terms have emerged. one such term is referred to as “cyberloafing”. it has been identified as one of the most common ways employees waste their precious time at workplaces, doing unrelated activities as opposed to their assigned jobs by their employers. however, syed, singh, thangaraju & yok (2020) opined that there is an existing hullabaloo among researchers about the impact of cyberloafing on employees' job performance. some argue that cyberloafing distracts employees from effective job performance, while others argue that cyberloafing is very helpful as it adds quality to employees' work. hence, the focus of this paper is to review past literature to understand the impact of cyberloafing. firstly, to conceptualize the term “cyberloafing” and explain it to the understanding of a neophyte in the field. it will address the problems of cyberloafing (technological distractions) in any related workplace. the paper will further examine the immediate causes, how cyberloafing impacts an organization's productivity, and how to adopt appropriate counter-measures to help reduce the incidents in any type of organization in modern times. keywords: cyberloafing, employees' productivity, social media, workplace deviance, security technology, and work performance. introduction thanks to the dawn of the internet that makes almost everything available online, which we surf at the click of the computer mice and the keyboards when we want to socialize, finding new things, booking travels, etc. this has given rise to increased cyberloafing in the 21st century, which we perceive and practice in our day-to-day work (rehan, 2023). internet addiction, the urge to post everything on social media, and google searches for minor things have also led to an increase in cyberloafing, and this incident has become more widespread and now very difficult to monitor what employees’ do while working from home. mailto:topacademicjournals@gmail.com https://www.researchgate.net/profile/sumera-syed?_sg%5b0%5d=48kxzx7iey0t6wptihfiaai_fejbpqav1ydgjj1xrejqj6nduq636xvx45-nxfoepxwyni4.6msl6derq5mz0v-30mlvgqjmu5chd2oa3ibdo8gfm1jyk-mtloieth3bqxryjdlalw1vb6b4r9tehx6h8_n-ca&_sg%5b1%5d=9ll7cehktc2qnphyphwah-vo7bcgm069uk8x3ma0cs621itblgolbtmjutawo4jrtxzl1c0.y5a8u-hewpdtihk2zb8ategkgyl5b7i9wdyoaitg4vbtowexr3ixlbdzbe0cdc86bd7jeuvhpmbawjff9ykesq https://www.researchgate.net/profile/harcharanjit-singh?_sg%5b0%5d=48kxzx7iey0t6wptihfiaai_fejbpqav1ydgjj1xrejqj6nduq636xvx45-nxfoepxwyni4.6msl6derq5mz0v-30mlvgqjmu5chd2oa3ibdo8gfm1jyk-mtloieth3bqxryjdlalw1vb6b4r9tehx6h8_n-ca&_sg%5b1%5d=9ll7cehktc2qnphyphwah-vo7bcgm069uk8x3ma0cs621itblgolbtmjutawo4jrtxzl1c0.y5a8u-hewpdtihk2zb8ategkgyl5b7i9wdyoaitg4vbtowexr3ixlbdzbe0cdc86bd7jeuvhpmbawjff9ykesq https://www.researchgate.net/profile/savithry-thangaraju?_sg%5b0%5d=48kxzx7iey0t6wptihfiaai_fejbpqav1ydgjj1xrejqj6nduq636xvx45-nxfoepxwyni4.6msl6derq5mz0v-30mlvgqjmu5chd2oa3ibdo8gfm1jyk-mtloieth3bqxryjdlalw1vb6b4r9tehx6h8_n-ca&_sg%5b1%5d=9ll7cehktc2qnphyphwah-vo7bcgm069uk8x3ma0cs621itblgolbtmjutawo4jrtxzl1c0.y5a8u-hewpdtihk2zb8ategkgyl5b7i9wdyoaitg4vbtowexr3ixlbdzbe0cdc86bd7jeuvhpmbawjff9ykesq https://www.researchgate.net/scientific-contributions/koh-yok-2183719837?_sg%5b0%5d=48kxzx7iey0t6wptihfiaai_fejbpqav1ydgjj1xrejqj6nduq636xvx45-nxfoepxwyni4.6msl6derq5mz0v-30mlvgqjmu5chd2oa3ibdo8gfm1jyk-mtloieth3bqxryjdlalw1vb6b4r9tehx6h8_n-ca&_sg%5b1%5d=9ll7cehktc2qnphyphwah-vo7bcgm069uk8x3ma0cs621itblgolbtmjutawo4jrtxzl1c0.y5a8u-hewpdtihk2zb8ategkgyl5b7i9wdyoaitg4vbtowexr3ixlbdzbe0cdc86bd7jeuvhpmbawjff9ykesq american journal of medical and physical education vol.9, issue 3; may-june 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 2 | american journal of medical and physical education | https://topjournals.org/index.php/ajmpe gul (2020) revealed that in the 21st century there's a distraction at our fingertips like nothing ever experienced by previous generations. the scholar also asked a question thus: “how many of us could honestly say that we spend every moment of our working hours industriously involved in some work-related activity? this question becomes relevant because, we usually have brief chats with friends and relatives, quick phone calls to fix one appointment or the other, or engage on social media activities. we often engage in online activities, such as, texting messages, shopping, reading news, talking to friends & relatives, checking our bank accounts, watching television or videos, pornographic pictures/videos, and the rest at the click of the mouse and a tap at the keyboard, and with our eyes glued to the mobile deice screens (gul, 2020). according to the scholar, to the less keen observer, we might even appear to be beavering (working) away at some professional tasks. it seems that hundreds of millions of us are regularly giving in to this irresistible temptation, gul (2020) affirmed. these, according to the scholar, we all take this kind of liberty from time to time, and usually without consequences. the 21st century has been demarcated as a different world from all others because many things are perceived and done differently. the dawn of the internet has given birth to several digital terms, such as cyberloafing, cyberslacking, cybersecurity, cybercrime, cyberbullying, virtual learning, virtual workmanship, and the rest of the cybers’ and virtuals’. similarly, all types of digital devices have been produced to conform with the digital age. additionally, every aspects of human activities have become digitalized, which makes us glue our eyes to all forms of digital devices, such as computers, mobile phones, and digital screens to cope with the digital world. li q, xia b, zhang h, wang w and wang x (2022) assert that with the gradual penetration of network media into various fields of peoples’ lives, the relationship between network behavior and the sense of meaning of life is bound to be closer and closer. our interest in this this paper is on the term, “cyberloafing”. researchers have developed widespread interest on cyberloafing because it is said to have cost businesses worldwide billions of naira annually. the researchers believe that cyberloafing is a problematic behavior of network use (kim and byrn, 2011), and it has become a prevailing topic in the field of psychological research. khansa, barkhi, ray & davis (2018) opined that academic literature has demonstrated both the prevalence and severity of cyberloafing at workplaces. hence, udemy (2018) revealed the adverse effects of employees’ cyberloafing in work-related places by reporting that 62% of employees wasted about 60 minutes of worktime, per day, through personal phone use alone. conner (2015) also asserts that employees’ cyberloafing have hit an alarming critical stage. therefore, the interest of this paper is to explain to readers the meaning of cyberloafing, its effects in workplaces, the causes and suggestions that will reduce the incidents. the authors believe that this paper will add to the existing literature on this topic and will as well be of immense benefits to the most organizations’ that intends to achieve maximally. review of related literature concept of cyberloafing the term cyberloafing, according to gul (2020) first emerged during the mid-90s among a proliferation of words created by productive use of the prefix “cyber” to describe things relating to computers or the internet, (i.e., cybercafé, cyberspace, etc.). loaf mean to loiter or malinger. when organization’s internet facilities, or other mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.9, issue 3; may-june 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 3 | american journal of medical and physical education | https://topjournals.org/index.php/ajmpe resources are used for entertainment or engage in any other personal gains, it is referred to as cyberloafing behavior; though this behaviour could not be termed criminal, but violates organizational regulation (kenton, 2023). cyberloafing has become more prevalent in recent times with the presence of internet-connected computers and devices becoming a necessity for the normal functioning of most businesses today (kenton, 2023). the scholar further expressed that as most businesses require the internet for communications and transactions, it will be difficult to tell when someone is cyberloafing instead of carrying out the official tasks they are being paid for. in most cases, the employees prefer surfing the net instead of performing the official job assigned to them. an employee, as kenton (2023) observed, may use their official time to scroll through social networking sites, such as the facebook, twitter, and instagram, or simply browse news and content on sites unrelated to their work. others include online gambling, playing games, checking email, and browsing pornographic sites. controlling cyberloafing usage of these it devices and the above internet related sites becomes very difficult since many companies use social networking sites for marketing channels and also requires employees to be up-to-date on trends and news, classifying these activities as either work or cyberloafing becomes very challenging (kenton, 2023). there is no unique or one size fits all definition of cyberloafing, which is generally referred to as non-workrelated internet use in organizations. however, there are variety of approaches and definitions for non-workrelated internet use in organizations. different approaches by professionals in the filed have resulted in a broad and inconsistent use of terminology, definitions, and labels, as observed by weatherbee (2010). countless concepts and terms have been used to describe the phenomenon. the following terms or concepts have been used thus: internet dependency internet deviance, on-line loafing, problematic internet use, cyberslacking, non-work related computing, cyberloafing, cyberbludging, personal web usage at work, internet abuse, internet addiction and internet addiction disorder (kim & bryne, 2011) as cited in ozler, e. e. & polat, g. (2012). rehan (2023) described “cyberloafing” simple as when an employee is using the internet connection at the workplace for reasons other than work. according to kenton (2023), it is an update of the term "goldbricking", which referred to employees who tried to look busy while doing less work than they were truly capable of. cyberloafing has been defined by lord (2023) as employees becoming distracted by technology in the workplace, usually due to personal, non-work-related internet usage. making personal use of the internet during working hours is now a commonplace activity, and it's known as cyberloafing. cyberloafing occurs when an employee uses the organization’s it facilities (network/internet) to engage in personal tasks or entertainment (kenton, 2023). kawamoto (2020) conceptualized it as when employees use their work time to engage in non-work-related internet activities from checking social media and personal email to web browsing and more. pindek, krajcevska & spector (2018) defined cyberloafing as when employees engage in technologicallymediated malingering behaviours instead of work-related behaviors. cyberloafing occurs when employees use technology to loaf instead of work (giordano & mercado, 2023). cyberloafing was originally used to describe the phenomenon that employees use the network tools provided by the organization to browse non-work-related mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.9, issue 3; may-june 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 4 | american journal of medical and physical education | https://topjournals.org/index.php/ajmpe websites, sending and receiving personal e-mails, which has an impact on job performance during working hours (li, xia, zhang, wang & wang, 2022). furthermore, kawamoto (2022) defined cyberloafing as term to describe employees who use work time to engage in non-work-related activities on the internet, such as web browsing, using social media, or checking and responding to personal email. in an organization or company, as observed by lord (2023), some employees that use computers and smartphones could use company’s time and equipment for personal online shopping, playing games, accessing inappropriate videos, or using social media websites to communicate with friends. this they do by sending text messages to friends and relatives, checking personal emails, and visiting social media sites at the expense of their official jobs. finally, coker, 2011 and ugrin & pearson, 2013 have simply defined cyberloafing as the unauthorized use of the internet for non-work or personal activities during work time. in totality, there are common observations noticed in all the definitions above. they are as follows: 1. technology is involved (internet/network or mobile phones) 2. an employee (a person) 3. work-related (in organization or company) 4. time (mismanagement) 5. behaviours (malingering) 6. performance (the record of outcomes produced by a specified job function or activity during a specified time period, which is associated with quantity of output, quality of output, timeliness of output, presence/ attendance on the job, and efficiency of the work completed and effectiveness of work accomplished (mathis & jackson, 2009). determinant for cyberloafing in workplaces while cyberloafing is seen by many as a bad thing or habit (kawamoto, 2020) in which employees use company’s it infrastructures and time for frivolous or perky activities, there are still valid concerns about cyberloafing in workplaces. there is more understanding that an employee may need personal breaks throughout the day that can be facilitated through mindless browsing or carrying out specific personal tasks while still on the company network (kenton, 2023). according to kawamoto (2020), mason, a ph.d. candidate at aston university, researching on the use of cyberloafing as a coping mechanism reported that loneliness and workplace ostracism (isolation) can prompt some employees to turn to social media to offset the lack of interaction with co-workers and others. the candidate further stressed that the employees concerned may find the emotional support they need to power through the rest of the day via social media. cyberloafing is said to address burnout in workplaces. according to a study titled “unraveling cyberloafing paradox: towards a targeted approach for managing cyberloafing”, it has been revealed that some workers may turn to cyberloafing to relieve stress on the job by browsing the internet as a coping mechanism (kawamoto, 2020) an obvious example of this is when the employees do this by spending most of their official time browsing the internet via their phones, emailing friends and relatives, and looking at social media when they are supposed mailto:topacademicjournals@gmail.com https://builtin.com/authors/dawn-kawamoto https://www.aston.ac.uk/ https://builtin.com/people-management/burnout-symptoms https://aisel.aisnet.org/cgi/viewcontent.cgi?article=1353&context=amcis2022 https://aisel.aisnet.org/cgi/viewcontent.cgi?article=1353&context=amcis2022 https://builtin.com/career-development/burnout-and-balance-advice-column https://builtin.com/people-management/mental-health-stigma american journal of medical and physical education vol.9, issue 3; may-june 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 5 | american journal of medical and physical education | https://topjournals.org/index.php/ajmpe to be working on a report (kawamoto, 2020). in summary, kawamoto (2020) and rehan (2023) have listed the following as some of major causes of cyberloafing in workplaces thus: 1. stress/burnout: there is an axiom which says, “work no play makes jack a dull boy”. when employees are burnout, they tend to have rest. employees are using cyberloafing as a release valve for their stress, whether it’s from feeling burned out or because of workplace aggression from others, mason said. some employees find their rest on the internet, hence, they cyber-loaf. it can provide a mental distraction that can help employees jump back into work once their cyberloafing break is over. it can momentarily offset workplace boredom, allowing employees to take a mental break from their tasks and return refreshed. 2. loneliness and workplace ostracism (“exclusion from society or group”). the scholars noted that employees seek refuge on the internet and social media sites when they feel excluded and lonely at work from their team members or peers. 3. non-challenging or not too difficult tasks have also given rise to cyberloafing. it has been affirmed that if employees are given tasks or role that are not challenging enough for them, there is a possibility that they will push away the tasks to complete for a later time and end up spending half of the work hours on non-work-related internet activities. 4. call it competitive or difficult tasks, these tasks need lots of mental input to perform. it has been proven that the employees taking short bouts of breaks has shown an increase in the productivity levels after reducing burnout or stress. 5. employer policies that allowing workers to bring their own electronic devices, such as smartphones, tablets or even laptops, into the workplace can also contribute to cyberloafing. 6. employees who lack adequate resources at work, such as an ergonomic office chair, may jump on the internet to learn of alternative resources they could use, like browsing for one. that internet activity, however, is considered a form of cyberloafing since it is not directly involved with the task at hand and is considered developing new non-work-related skills or abilities while on the job. 7. boredom is yet another reason for cyberloafing. frequently, employees experience tediousness for performing the same task over and over again. performing the same mundane activities at work can cause employee to look up to doing anything apart from work to keep them occupied. rehan (2023) stated that naturally, diverting focus to something entertaining is a natural response to boredom. 8. internet addiction is yet another reason for the rise of the cyberloafing. this act has been described as one of the biggest downside of the internet. many people are today addicted to it because of the vast possibilities. social media put lots of peer pressure on some employees, and to keep up with this, many of them tend to embrace the ‘reel’ life to gain satisfaction with others. 9. desire to find resources that make work and life better 10. upskilling is one of the causes of cyberloafing. there is no gainsaying that a sizeable number of employees now are enrolled in online lectures that are offered by top companies, such as, linkedin, udemy, coursera, and the rest; hence, there is room for cyberloafing among employees. mailto:topacademicjournals@gmail.com https://www.sciencedirect.com/science/article/abs/pii/s0747563218302048#:~:text=cyberloafing%20as%20boredom%20coping,interesting%20(albeit%20personal)%20components. https://geekflare.com/recommends/coursera/ american journal of medical and physical education vol.9, issue 3; may-june 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 6 | american journal of medical and physical education | https://topjournals.org/index.php/ajmpe 11. cyberloafing can occur when employees work overtime without compensation, when asked to do excessive amounts of work, or are exposed to conflicting demands, and when they perceived unfair treatment by their employer (e.g., unfair work outcomes, policies, or interpersonal interactions). (http://psychology.iresearchnet.com/industrial-organizational-psychology/organizational-behavior/cyberloafingat-work/) 12. cyberloafing occurs when an employee has exhausted a certain task given to him (rerhan, 2023) 13. with the hope of getting almost everything online has given rise to surf the net, be it socializing, finding new information, booking your travel, etc, thereby giving rise to cyberloafing consequences of cyberloafing on organizations’ productivity there is no doubt that the outbreak of the covid-19 virus had made rapid shift in people's work routines, and organizations and employees have as well been forced to change from working in offices to working at homes due to workplace lockdowns and social distancing requirements (zhong, 2022). in view of the above, more people become exposed to the internet and other electronic devices; employees would often read related news on websites via their smart phone and other electronic devices (kim, zhang, foo, alvarez-risco, del-aguila-arcentales, & yáñez (2021). hence, more non-work-related internet use in work time, especially working from homes might impact employees' work (syrek, kühnel, vahle-hinz, & de bloom, 2018), and the consequences of this shift, where managers or administrators have no close watch for employees have received increasing attention by scholars and professional in the field (derks, bakker & gorgievski, 2021; holland & bardoel, 2016; sonnentag, reinecke, mata & vorderer, 2018; wu, mei, liu, & ugrin, 2020a; 2020b). kenton (2023) reminded us that when cyberloafing was at its initial stage, many employers began to fear about the negative of its impact on productivity, since less time is spent working and generating revenue for the company. cyberloafing (technological distractions in the workplace) can negatively impact an organization's productivity. olajide, abdu & abdul-qadir (2018) opined other negative implications as noticed by the scholar are inefficient use of network resources, increased risks of legal liabilities due to, or as a result of illegal downloading of software applications, and unlawful misconducts and network security breaches. there is no doubt that an employee might inadvertently download some illegal software or unknown attachments from harmful websites (virus infected sites), which most times can lead to security breaches, risking the company’s data or information. cyberloafing results in waste of time and resources (gökçearslan, mumcu, haşlaman & çevik, 2016), and it seriously affects an organization's productivity and loss of revenue (lord, 2023). boxall & macky, 2014) affirmed that internet misuse can reduce employee productivity, that is, if an employee spends more time engaging on inappropriate activities on social media sites at the expense of their jobs, it means that the employer ultimately pays the employee to avoid work (lord, 2023). therefore, cyberslacking lead to financial loss to the organization (askew, buckner, taing, bauer & coovert (2014). for instance, saraç and çiftçioğlu (2014) revealed that web mailto:topacademicjournals@gmail.com http://psychology.iresearchnet.com/industrial-organizational-psychology/organiza%20tional-behavior/cyberloafing-at-work/ http://psychology.iresearchnet.com/industrial-organizational-psychology/organiza%20tional-behavior/cyberloafing-at-work/ https://www.sciencedirect.com/science/article/pii/s0747563221003058#bib104 https://www.sciencedirect.com/science/article/pii/s0747563221003058#bib104 https://www.sciencedirect.com/science/article/pii/s0747563221003058#bib22 https://www.sciencedirect.com/science/article/pii/s0747563221003058#bib41 https://www.sciencedirect.com/science/article/pii/s0747563221003058#bib88 https://www.sciencedirect.com/science/article/pii/s0747563221003058#bib88 https://www.sciencedirect.com/science/article/pii/s0747563221003058#bib102 https://www.sciencedirect.com/science/article/pii/s0747563221003058#bib103 https://www.investopedia.com/terms/p/productivity.asp https://www.sciencedirect.com/science/article/pii/s0747563221003058#bib10 american journal of medical and physical education vol.9, issue 3; may-june 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 7 | american journal of medical and physical education | https://topjournals.org/index.php/ajmpe surfing costs u.s. employers more than $50 billion each year in lost productivity. in the same manner, abbasi (2018) also revealed that productivity loss occurs in organizations that experience high levels of personal internet use by employees on company time, which includes employees using smartphones to surf without needing the firm’s internet connection kenton (2023) observed that cyberloafing or cyberslacking can lower employee productivity and create vulnerabilities in a company's it infrastructure depending on what the employee is doing on the sites they visit. the scholar further noticed that an employee switching between personal and professional tasks may take longer to focus back on their work. furthermore, since the employees are surfing with company resources, many companies or organizations are afraid of their technological devices or infrastructures on the ground that the employees usually do not know the security level of the sites they visit; hence, the network systems may become vulnerable to malware and other intrusions (kenton, 2023). if this happens, then, the company will definitely incur much financial lose. there is no doubt that when employees are monitored and they use the time they would have used for unrelated job activities that productivity improves. but this monitoring of employees also has its own downsides. it has been proved that the stress employees feel when being monitored can hurt their work performance (georner, 2019) one of the consequences of cyberloafing is that it makes the administration or management of the company or organization to be more expensive, because much money is spent hiring or purchasing monitoring surveillance computer programs. another pitfall of the cyberloafing is that for the management to purchase monitoring surveillance computer programs, means that the management does no trust the employees. therefore, there may be no effective cordial relationship between the employers and the employees. there is no doubt that when employees use the company’s internet facilities for personal use, there is the possibility of bandwidth loss by the company. in addition, it may be very difficult as well for any manager to differentiate between work-time and personal time for internet-based tasks. for instance, employees may be requested to reply or respond to company’s e-mails, but instead, they will use the same time to check their personal emails. furthermore, a lot of time is wasted when employees use the company’s time for personal activities. this has been affirmed by karaoğlan yılmaz, yılmaz, öztürk, sezer, and karademir (2015); they confirmed that using smartphone technology during work time for personal purposes affects work productivity and wastes work time. piscotty, martindell & karim (2016) opined that the cyberloafing phenomenon has penetrated into the health care sector with respect to nurses using smartphones for personal purposes, thereby causing patient care interruptions, contributing to possible errors, and violating the health insurance portability and accountability act, especially when they answered personal calls during a work shift. positive effects of cyberloafing mailto:topacademicjournals@gmail.com https://www.investopedia.com/terms/a/adware.asp american journal of medical and physical education vol.9, issue 3; may-june 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 8 | american journal of medical and physical education | https://topjournals.org/index.php/ajmpe zhong, chen, yan & luo (2021) hypothesized that cyberloafing has both negative and positive effects on employees' innovation performance. in the same manner, kim & christensen, 2017; wu et al., 2020a affirmed that cyberloafing is a mixed blessing because it leads not only to resource depletion but also resource recovery. research shows that cyberloafing helps employees that stay long working hours on a particular task by providing them an enjoyable break, thereby helping to overcome monotony in task and changes psychological mood and reduces stress. this is in tune with findings of oravec (2002) and eastin, glynn and griffiths (2007) that indicate that cyberloafing activities helps in overcoming monotony in tasks, changes psychological mood and reduces stress. therefore, if employees utilized their leisure time at work like break time in loafing, this may not have much impact on the task performance of the employees (olajide, abdu, & abdul-qadir, 2018). zhong (2022) revealed that cyberloafing can yield unexpected benefits because it helps employees recover or supplement resources through temporary detachment from work. the scholar emphasized that by offering microbreaks, cyberloafing allows employees to cope with work stress; for instance (job burnout (aghaz, & sheikh, 2016); workplace ostracism (koay, 2018); workplace boredom (pindek et al., 2018); work aggression (andel, kessler, pindek, kleinman, & spector, 2019), enhance work engagement (syrek, kühnel, vahle-hinz, & de bloom, 2018). and improve mental health (wu, mei, liu & wang, 2020a). coker (2011) and paulsen (2013) affirmed that some researchers are in agreement that cyberloafing acts as a break for employees’ brains from busy workday routines and may increase employee productivity. cyberloafing counter-measures in workplaces recent studies have shown that technology distracts many employees in workplaces. most of us scroll on social media or respond to personal emails during working hours without knowing that we are practicing “cyberloafing”. this is highly experienced in several companies or corporations. firstly, if a paid employee is distracted by technology in the workplace for several hours a week or month, this reduces the employee’s productivity for the organization/company. hence, there is a need for companies, organizations, or parastatals to take adequate measures to checkmate this act, which most times are committed on hourly bases in various workplaces. lord (2023), however, conceptualized cyberslacking/cyberloafing countermeasures as specific tools and policies that deter employees from wasting organization time, equipment, or other resources due to technological distractions. it is usually very difficult to checkmate someone on the internet, also takes lots of money to apply adequate counter measures to such an act, especially in a situation where the employees need to use company computers and internet access to perform their assigned tasks, such as interacting with customers through social media sites, and accessing vendor websites to purchase supplies for the business. kenton (2023) revealed that some companies have gone to great lengths to eliminate cyberloafing because of the perceived high costs associated with it. now, how do organizations effectively manage cyberloafing? many researchers are of the view that cyberloafing reduces productivity within the workplace and should therefore, be discouraged or eliminated (mason, 2022). nonetheless, lord (2023) suggested that in organizations in which cyberslacking involves web browsing on company’s computers, firewalls (web security systems), and mailto:topacademicjournals@gmail.com https://www.sciencedirect.com/science/article/pii/s0747563221003058#bib51 https://www.sciencedirect.com/science/article/pii/s0747563221003058#bib102 https://www.sciencedirect.com/science/article/pii/s0747563221003058#bib52 https://www.sciencedirect.com/science/article/pii/s0747563221003058#bib77 https://www.sciencedirect.com/science/article/pii/s0747563221003058#bib6 https://www.sciencedirect.com/science/article/pii/s0747563221003058#bib6 https://www.sciencedirect.com/science/article/pii/s0747563221003058#bib102 american journal of medical and physical education vol.9, issue 3; may-june 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 9 | american journal of medical and physical education | https://topjournals.org/index.php/ajmpe website monitoring could be installed to monitor what employees do during worktime. alternately, the scholar further stressed that a blocking software could also be installed on each employee’s computer to prevent the practice of cyberloafing. again, on extreme cases, an employee may not be allowed to use mobile technologies during worktimes in order not to be distracted for efficient work performance. these measures will enable companies to monitor the web browsing habits of their employees in the workplace via special software that provides statistics about which websites are accessed at work, who accessed them and for what length of time. additionally, some organizations may use software tools which blocks access to a list of unapproved websites in the workplace. (because content on the internet changes so rapidly, the list of blocked websites should be regularly reviewed and updated). as an additional measurer, the employee is expected to put additional work hours to compensate for the time wasted during the official working periods, which is the cause of reduction of employees productively. the measure will enable workers to concentrate on their work, once they know that they will definitely compensate for hours lost for cyberloafing. another measure is to terminate the contract of the employees once ascertained that they are involved in cyberloafing during official work hours. again, the salary of the employee could also be deducted for the period the employee cyber-loafed. some companies address cyberloafing through robust monitoring and enforcement. as views continue to evolve on our personal and professional relationship with the internet, many companies have instead sought to emphasize responsible and reasonable internet usage (kenton, 2023). in respect of the countermeasures, kenton (2023) suggests purchasing software or subscribing to platforms that allow all the internet traffic to be tracked and restrict access to sites that are not deemed valid for work. again, the scholar stressed that more advanced employee tracking software can actively log screenshots of activity on company owned devices at regular intervals in addition to reporting keyboard and mouse activities. many firms, according to kenton, (2023) have instead tried to foster a culture of reasonable and responsible internet usage while at work; a modern internet usage policy or code of conduct will allow for personal use as long as it does not put the network in danger, does not affect the employee's overall performance, and does not as well involve inappropriate content. in a nutshell, kawamoto (2020) and other professionals in the field have outlined major countermeasures to minimize the incidence of cyberloafing in workplaces. they are: 1. set expectations on when non-work-related internet activities are allowed, and on which devices. as kawamoto (2020) and goerner (2019) p u t i t , b y making explicitly policies, organizations will prohibit personal use of the internet on company time and property. hence, employees need precise guidance to know what they can and cannot do during work hours. 2. employers may allow employees to take “group” social media breaks for 30 minutes or so to interact online and check their personal e-mail once or twice a day (goerner, 2019) t o reduce their emotional or physical discomforts. this method will allow employees to focus on their jobs, knowing that there is time for everything, and any deviation will attract query or punishment. mailto:topacademicjournals@gmail.com https://www.investopedia.com/terms/s/software-as-a-service-saas.asp https://www.practicalparadigms.com/blog-content?author=5abaca3f7e59921837c3eb3e https://www.practicalparadigms.com/blog-content?author=5abaca3f7e59921837c3eb3e american journal of medical and physical education vol.9, issue 3; may-june 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 10 | american journal of medical and physical education | https://topjournals.org/index.php/ajmpe 3. organizations may clearly prohibit the employees from visiting some social websites during working hours; or cyberloafing could be reduce with explicit or realistic policy prohibiting personal use of the internet on company time and property (g o e r n e r , 2 019 . 4. identify triggers for employees who might be engaging in non-work-related internet activities to reduce emotional or physical issues. 5. have open conversations with employees to understand why they may be resorting to cyberloafing. 6. managers need to understand why someone might go to their phone or use the internet during a time they should be productive at work. hence, there is need for open communication between employers and employees to understand why they are doing what they are not supposed to do during worktime. 7. the organizations’ rewards mechanism serves to encourage employees to do better and be responsible during working hours and by continuing to receive their managers’ praise; this is the view of al abbasi (2018) because employees. 8. in addition to kawamoto (2020), kawamoto (2020) goerner, 2019; olajide et al (2018) suggested that organizations can use internet surveillance programs and put in place explicit policies and sanctions tailored to control internet usage in the workplace. this monitoring strategy will either restrict employees’ online access or monitor their activities. according to goerner (2019), a keylogger can record every keystroke, website, email, password, and application run on a computer. this is done with believe they’re managing risk, making sure employees don’t share private data or mistreat customers. also, “softactivity monitor” program gives manager/administrators easy-to-read data on what employees do online, both at work and whenever they’re using company-owned devices (goerner, 2019). 9. olajide et al (2018) further suggests that managers may also benefit if they hire employees that are less prone to engage in cyberloafing behaviours since several human behavioural traits have been identified to contribute to cyberloafing behaviours. 10. it is necessary that organizations consider hiring staff with high levels of conscientiousness since blanchard reported that higher levels of conscientiousness can limit cyberloafing behaviours (olajide et al, 2018). 11. companies could address cyberslacking through robust monitoring and enforcement (kenton, 2023). 12. organizational norms and policies should be used to discourage cyberloafing (kenton, 2023). 13. organizations or companies could have a policy that restrains employees from having their phones with them while on the job? after all players or sportspersons do away their cell phones during practice. 14. to reduce the effects of cyberloafing in an organization, the management of organizations or companies should provide meaningful work, make sure that employees’ jobs are engaging and as well interesting, because the individuals who find that their work matters, engaging and interesting are usually more diligent and productive (georner, 2019). 15. researchers have also suggested that self-control as one of the measures to reduce the incidence of cyberloafing in workplaces. they revealed that employees with weak self-control easily engage in cyberloafing, particularly when the opportunity comes to do so, whereas individuals with strong self-control tend not to practice cyberloafing, even if given the opportunity (inzlicht & schmeichel, 2012; wagner, barnes, lim & ferris (2012). 16. next to self-control is self-regulation, which, according to inzlicht & schmeichel (2012) refers to the individual thoughts and feelings that lead people to practice something over time. past studies revealed that failure in self-regulation leads individuals to increase their use of social media and be at risk for addictions, such as mailto:topacademicjournals@gmail.com https://www.practicalparadigms.com/blog-content?author=5abaca3f7e59921837c3eb3e https://www.practicalparadigms.com/blog-content?author=5abaca3f7e59921837c3eb3e https://www.practicalparadigms.com/blog-content?author=5abaca3f7e59921837c3eb3e https://www.practicalparadigms.com/blog-content?author=5abaca3f7e59921837c3eb3e american journal of medical and physical education vol.9, issue 3; may-june 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 11 | american journal of medical and physical education | https://topjournals.org/index.php/ajmpe smartphone addiction (jeong, kim, yum, & hwang, 2016). cheng, li, zhai & smyth (2014) opined that once an employee self-regulates itself, that there i possibility of staying on task. 17. added to the above is the issue of the work environment. it has been agreed by scholars (karimi, gilbreath, kim & grawitch, 2014) that an open-office design, and the supervisor’s proximity to the employees may represent a threat to continuing undesirable behavior, such as cyberloafing within the organization, which makes them feel exposed to their supervisors. 1. added to self-control and self-regulation is “self-esteem”, which, according to cheng et al (2014) includes self-acceptance, self-liking, and self-respect. gökçearslan, mumcu, haşlaman & çevik (2016) is of the opinion that an employee with a positive self-concept, strong self-control and self-regulation, and high levels of esteem perform their jobs more effectively because they have a positive view and strong motivation, thereby reduces the prevalence of cyberloafing in workplace. conclusion the use of new technologies has led to an unprecedented massive and rapid shift in people’s work routines, as many people use these technologies to while away valuable time “cyberloafing”, instead of concentrating on the task they are supposed to perform (zhong, chen, yan & lou, 2020) this paper really reviewed pertinent literatures on “cyberloafing”, as practiced in today’s world. the papers revised show that cyberloafing is a dangerous phenomenon that has come to stay, and must be fought by all means to enhance productivity in workplaces. al abbasi, 2018; li, xia, zhang, wang & wang, 2022; kenton, 2023; kawamoto, 2020; goerner, 2019; and olajide et al, 2018 have suggested appropriate hardware (camera) and/or software (computer or mobile tracking) as forms of monitoring technology measures to supervise and restrict employees’ internet use and provide them with corresponding guidance. this is in line with the ideas or suggestions of li et al (2022) on college students. smartphone addiction has come to stay, and will continue to cause many serious problems in all aspects of human activities, therefor, employers should adopt the rewards mechanism, which encourages employees to do better and be responsible during work hours so that they comply with organization policy and work hard to achieve this goal (al abbasi, 2018). references abbasi, h. a. (2018). organizational information security: strategies to minimize workplace cyberloafing for increased productivity. dissertation submitted in partial fulfillment of the requirements for the degree of doctor of philosophy management, walden university. aghaz, a., & sheikh, a. (2016). cyberloafing and job burnout: an investigation in the knowledge-intensive sector. computers in human behavior, 62, 51-60. https://doi.org/10.1016/j.chb.2016.03.069 al abbasi, h. (2018). organizational information security: strategies to minimize workplace cyberloafing for increased productivity. dissertation submitted in partial fulfillment of the requirements for the degree of doctor of philosophy, management faculty, walden university. retrieved from https://scholarworks.waldenu.edu/dissertations mailto:topacademicjournals@gmail.com https://www.practicalparadigms.com/blog-content?author=5abaca3f7e59921837c3eb3e https://scholarworks.waldenu.edu/dissertations american journal of medical and physical education vol.9, issue 3; may-june 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 12 | american journal of medical and physical education | https://topjournals.org/index.php/ajmpe andel, s. a., kessler, s. r., pindek, s., kleinman, g., & spector, p. e. (2019). is cyberloafing more complex than we originally thought? cyberloafing as a coping response to workplace aggression exposure. computers in human behavior, 101, 124-130. https://doi.org/10.1016/j.chb.2019.07.013 askew, e., buckner, j. e., taing, m. u., ilie, a., bauer, j. a., & coovert, m. d. (2014). explaining cyberloafing: the role of the theory of planned behavior. computers in human behavior, 36, 510-519. https://doi.org/10.1016/j.chb.2014.04.006 coker, b. l. s. (2011). freedom to surf: the positive effects of workplace internet leisure browsing. new technology, work & employment, 26(3), 238-247. https://doi.org/10.1111/j.1468-005x.2011.00272.x coker, b. l. s. (2013). workplace internet leisure browsing. human performance, 26(2), 114-125. https://doi.org/10.1080/08959285.2013.765878 cutino, c. m., & nees, m. a. (2016). restricting mobile phone access during homework increases attainment of study goals. mob media commun., 5, 63-79. https://doi.org/10.1177/2050157916664558 cyberloafing at work. (n.d.). retrieved from http://psychology.iresearchnet.com/industrial-organizationalpsychology/organizational-behavior/cyberloafing-at-work/ derks, d., bakker, a. b., & gorgievski, m. (2021). private smartphone use during worktime: a diary study on the unexplored costs of integrating the work and family domains. computers in human behavior, 114, 106530. https://doi.org/10.1016/j.chb.2020.106530 goerner, c. (2019). stop the cyberloafing! retrieved from https://www.practicalparadigms.com/blogcontent/2019/4/22/stop-the-cyberloafing giordano, c., & mercado, b. k. (2023). cyberloafing: investigating the importance and implications of new and known predictors. collabra: psychology, 9(1), 57391. https://doi.org/10.1525/collabra.57391 gul, m. (2020). introduction to cyber loafing a new variable -. retrieved from https://www.studocu.com/row/document/riphah-international-university/mba-hrm/introduction-to-cyberloafing-a-new-variable/22321230 holland, p., & bardoel, a. (2016). the impact of technology on work in the twenty-first century: exploring the smart and dark side. international journal of human resource management, 27(21), 2579-2581. https://doi.org/10.1080/09585192.2016.1238126 mailto:topacademicjournals@gmail.com https://doi.org/10.1525/collabra.57391 https://www.studocu.com/row/document/riphah-international-university/mba-hrm/introduction-to-cyber-loafing-a-new-variable/22321230 https://www.studocu.com/row/document/riphah-international-university/mba-hrm/introduction-to-cyber-loafing-a-new-variable/22321230 american journal of medical and physical education vol.9, issue 3; may-june 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 13 | american journal of medical and physical education | https://topjournals.org/index.php/ajmpe karaoğlan yılmaz, f. g., yılmaz, r., öztürk, h. t., sezer, b., & karademir, t. (2015). cyberloafing as a barrier to the successful integration of information and communication technologies into teaching and learning environments. computers in human behavior, 45, 290-298. https://doi.org/10.1016/j.chb.2014.12.023 kawamoto, d. (2022). cyberloafing: what is it and how to prevent it. retrieved from https://builtin.com/blog/cyberloafing-what-it-and-how-prevent-it kenton, w. (2023). cyberslacking. retrieved from https://www.researchgate.net/publication/359478808_cyberslacking_in_the_workplace_antecedents_a nd_effects_on_job_performance khansa, l., barkhi, r., ray, s., & davis, z. (2018). cyberloafing in the workplace: mitigation tactics and their impact on individuals’ behavior. information technology and management, 19(4), 197–215. kim, s., & christensen, a. l. (2017). the dark and bright sides of personal use of technology at work: a job demands–resources model. human resource development review, 16(4), 425–447. kim, s. j., & byrne, s. (2011). conceptualizing personal web usage in work contexts: a preliminary framework. comput hum behav., 27, 2271–83. https://doi.org/10.1016/j.chb.2011.07.006 koay, k. y. (2018). workplace ostracism and cyberloafing: a moderated–mediation model. internet research, 28(4), 1122-1141. https://doi.org/10.1108/intr-07-2017-0268 li, q., xia, b., zhang, h., wang, x., & wang, x. (2022). college students’ cyberloafing and the sense of meaning of life: the mediating role of state anxiety and the moderating role of psychological flexibility. front. public health, 10, 905699. https://doi.org/10.3389/fpubh.2022.905699 lord, i. (2023). cyberslacking: definition & impact on workplace productivity. retrieved from https://study.com/academy/lesson/cyberslacking-definition-impact-on-workplace-productivity.html mason, n. (2022). using social cyberloafing to cope with workplace ostracism. nature reviews psychology. https://doi.org/10.1038/s44159-022-00108 olajide, o., abdu, m., & abdul-qadir, a. b. (2018). effect of cyberloafing on employee performance among deposit money banks in kaduna metropolis. online journal of arts, management and social sciences (ojamss), 3(1), 27–37. mailto:topacademicjournals@gmail.com https://builtin.com/blog/cyberloafing-what-it-and-how-prevent-it https://www.researchgate.net/publication/359478808_cyberslacking_in_the_workplace_antecedents_and_effects_on_job_performance https://www.researchgate.net/publication/359478808_cyberslacking_in_the_workplace_antecedents_and_effects_on_job_performance https://doi.org/10.1038/s44159-022-00108 american journal of medical and physical education vol.9, issue 3; may-june 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 14 | american journal of medical and physical education | https://topjournals.org/index.php/ajmpe ozler, e. e., & polat, g. (2012). cyberloafing phenomenon in organizations: determinants and impacts. international journal of ebusiness and egovernment studies, 4(2), 1–15. pindek, s., krajcevska, a., & spector, p. e. (2018). cyberloafing as a coping mechanism: dealing with workplace boredom. computers in human behavior, 86, 147–152. rehan, a. (2023). how to prevent cyberloafing at workplace [+5 tools]. retrieved may 4, 2023, from https://geekflare.com/prevent-cyberloafing-tools/ saraç, & çiftçioğlu. (2014). what do human resources managers think about employee’s internet usage. anadolu university journal of social sciences, 14(2), 1–12. https://doi.org/10.18037/ausbd.51987 sonnentag, s., reinecke, l., mata, j., & vorderer, p. (2018). feeling interrupted—being responsive: how online messages relate to affect at work. journal of organizational behavior, 39(3), 369–383. https://doi.org/10.1002/job.2239 syed, s., singh, h., thangaraju, s., & yok. k. (2020). the impact of cyberloafing on employees' job performance: a review of literature. https://www.coursehero.com/file/125613697/workplaceaggression-and-cyberloafing-pdf/ syrek, c. j., kühnel, j., vahle-hinz, t., & de bloom, j. (2018). share, like, twitter, and connect: ecological momentary assessment to examine the relationship between non-work social media use at work and work engagement. work & stress, 32(3), 209–227. https://doi.org/10.1080/02678373.2017.1367736 ugrin, j. c., & pearson, j. m. (2013). the effects of sanctions and stigmas on cyberloafing. computers in human behavior, 29, 812–820. https://doi.org/10.1016/j.chb.2012.11.005 weatherbee, t. g. (2010). counterproductive use of technology at work: information and communications technologies and cyberdeviancy. human resource management review, 20, 35–44. wisconsin school of business. (2015). how to reduce ‘cyberloafing’ in the workplace. retrieved october 16, 2023, from https://business.wisc.edu/news/how-to-reduce-cyberloafing-in-the-workplace/ wu, j. n., mei, j. n., liu, l., & ugrin, j. c. (2020a). the bright and dark sides of social cyberloafing: effects on employee mental health in china. journal of business research, 112, 56–64. https://doi.org/10.1016/j.jbusres.2020.02.043 mailto:topacademicjournals@gmail.com https://geekflare.com/prevent-cyberloafing-tools/ https://business.wisc.edu/news/how-to-reduce-cyberloafing-in-the-workplace/ american journal of medical and physical education vol.9, issue 3; may-june 2024; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 15 | american journal of medical and physical education | https://topjournals.org/index.php/ajmpe wu, j. n., mei, j. n., liu, l., & wang, f. (2020b). curvilinear performance effects of social cyberloafing out of class: the mediating role as a recovery experience. information technology & people, 34(2), 581–598. https://doi.org/10.1108/itp-03-2019-0105 yan, y., kim, s., zhang, s. x., foo, a., alvarez-risco, m. d., del-aguila-arcentales, s., & yáñez, j. a. (2021). hospitality workers' covid-19 risk perception and depression: a contingent model based on transactional theory of stress model. international journal of hospitality management, 95, 102935. https://doi.org/10.1016/j.ijhm.2021.102935 zhong, j., chen, y., yan, j., & lou, j. (2020). the mix blessings on cyberloafing on innovative performance during covid 19 pandemic. computers in human behaviour, 126, 106982. zhong, j., chen, y., yan, j., & luo, j. (2022). the mixed blessing of cyberloafing on innovation performance during the covid-19 pandemic. computers in human behavior, 126, 106982. https://doi.org/10.1016/j.chb.2021 mailto:topacademicjournals@gmail.com https://doi.org/10.1016/j.chb.2021 american journal of medical and physical education vol.8, issue 2; march-april 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 1 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe "understanding the influence of perceived benefits on sport participation" 1dr. sarah johnson, and 2prof. michael anderson, 1department of sport management, auckland university of technology, new zealand. 2department of sports psychology, florida state university, usa abstract: sport has the potential to promote social good, but understanding how it accomplishes this remains a challenge. this study seeks to shed light on the perceived benefits of sport participation, examining how these benefits are perceived by individuals and their impact on participation in sports. physiological, psychological, and sociological benefits are all associated with engaging in sports, yet little is known about the relative importance of each benefit in influencing participation behaviors. this knowledge gap may contribute to the growing issue of physical inactivity and poor health in society. to address this gap, we employ an alternate conceptualization of the theory of planned behavior (tpb) to explore the underlying psychological processes associated with sport participation. by delving into how individuals perceive the benefits of sports and their influence on participation, we aim to provide insights that can inform sport management practices and enhance the contribution of sports to social well-being. keywords: sport participation, social good, benefits, psychological processes, theory of planned behavior (tpb). introduction sport management researchers have been challenged to advance our understanding of how sport can promote social good (chalip, 2006; zeigler, 2007). one way to contribute to an enhanced understanding of how sport can promote social good is to examine the benefits of sport participation available to both individuals and society as a whole. specifically, sport administrators should strive to understand how benefits are perceived by participants, and how perceptionsfit into the larger psychological process that drives participation in sport. physiological (warburton, nicol,andbredin, 2006), psychological (deciand ryan, 1985; haggerandchatzisarantis, 2005) and sociological (coalter, 2007) benefits are all believed to be attainable through sport participation. the respective salience of each benefit in the minds of both sport and non-sport participants remains unknown however, despite the fact that itmay explain some differences in sport participation behaviors (koivula, 1999). academicians have not yet successfully developed and empirically tested an effective model explaining the psychological process that underlies sport participation. a collective lack of focus and inability to model sport participation effectively may be responsible for troubling trends related to physical inactivity and illhealth that have recently emerged in society. the objective of this research is to contribute to an enhanced understanding of the underlying psychological processes associated with sport participation. this is mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 2; march-april 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 2 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe accomplished by exploring the phenomenon within an alternate conceptualization of the theory of planned behavior (tpb; ajzen, 1991). the current research includes a modified version (naylor and kim, 2010) of kang’s(2004) societal quality instrument designed to measure the importance that sport participants place on physical, sociological, and psychological benefits. the researchreported here builds on the naylor and kim study by testing how the importance of these benefits fit into the larger psychological process that leads to sport participation. developing an understanding of the psychological processes that lead to sport-related behavior will allow sport marketers to more effectively develop and implement relevant messages that will resonate with consumers (ko, park,andclaussen, 2008).examining a set of relationships beginning with attitudes and incorporating behavioral intention is also a traditional framework for marketing research (bagozzi, 1981). the research is significant because of inactivity (sapkota et al., 2006), which is directly related to ill-health in the form of obesity (kelly et al., 2008). from this we can conclude that the physiological benefits available through sport are not currently being taken advantage of to the extent that would benefit both individuals and society. therefore, an examination of the way in which benefits are perceived, and how that perception fits into a larger psychological process is important (koivula, 1999). the research is also significant because to date, marketing efforts designed to increase sport participation have been criticized (lera-lopez andrapun-garate, 2005). the research has the potential to inform marketing practices designed to increase sport participation. the research is significant because it addresses calls for inquiry in this area and has recently received increasing attention from the broader sport community including sport management scholars (chalip, 2006; zeigler, 2007), sport psychology scholars (niggandestabrooks, 2003),government (sapkota et al., 2006)and nongovernmental agencies (world health organization, 2004). literature review participant sport sport is a pervasive and valued social institution around the world. it is intertwined with economic activity, character building, patriotism and personal health (coakley, 2003). for the purpose of the current research, participant sport is defined as the performance of activities which inherently require moderately intense physical exertion, and are perceived by the individual as relatively freely chosen, and either beneficial or enjoyable (beaton and funk, 2008). although contemporary sport participation rates for subsets of the population have been described as sporadic and difficult to quantify (balaskaand kouthouris, 2014; barber and havitz, 2001; lera-lopez andrapun-garate, 2005, 2007), some general trends have emerged. humphreys and ruseski (2009) report that just over 50% of the u.s. population participates in sport regularly, based on data available from the national sporting goods association. sport participation declines as young people move from primary school to middle school, and then eventually high school (pharr and lough, 2014). among adults, the percentage of sport participants in the u.s. falls drastically from early life stages to 18.2% (ham et al., 2009). understanding why this takes place should be of interest to scholars and practitioners. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 2; march-april 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 3 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe it has been speculated that the recent overall decline in sport participation may be due to multiple factors (johnston, delva,and o’malley, 2007). it is commonly accepted that modern conveniences backed by large advertising budgets have facilitated sedentary lifestyles in north america (barber and havitz, 2001; putnam, 1995). it is very difficult for administrators promoting participant-based sport to compete with the complexity and pervasiveness of messages supporting mainstream commercial goods and services, many of which facilitate inactivity (mowenand baker, 2009). increasing participation in sport has become an important priority of governments and government-related organizations such as the centre for disease control (cdc) in the united states, an organization that regards the issue as a matter of public health (graham and graham, 2008). owners of participant-based sport businesses are also interested based on the potential to increase profits (vail, 2007). sport marketers who develop and sell equipment and apparel would also benefit from increased sport participation. sport scholars have recently made sport participation a priority based on the benefits potentially available (coalter, 2007; wicker, breuer, and pawlowski, 2009). representatives of the sport management academy have also specifically called for inquiry related to sport participation (scheerder ,vanreusel and taks, 2005; zeigler, 2007). all in all, there is a wide spectrum of those interested in growing participant based sport for a variety of reasons. benefits of participant sport benefits from sport participation can be categorized broadly as physiological, psychological and sociological (united nations, 2003). potential physiological benefits attainable through physical activity such as sport participation are significant (humphreys, mcleod and ruseski, 2013) and include, but are not limited to, a reduced risk of cardiovascular disease, cancer, arthritis, type-2 diabetes and obesity (world health organization, 2004). physical inactivity is more prevalent than any other modifiable risk factor for the above-mentioned health problems (warburton et al., 2006). research has shown that if money were to be invested into increased levels of physical activity in communities, health care costs would drastically decrease (colditz, 1999). psychological benefits of physical activity are numerous and have also been thoroughly examined over the years (chatzisarantisandhagger, 2007). in general, psychological benefits are believed to be related to three innate needs, autonomy, competence and relatedness (haggerandchatzisarantis, 2005). all three can be experienced through sport. it has also been argued that psychological benefits may be generated through hedonic enjoyment, an emotion that reflects pleasure as opposed to displeasure and satisfaction with life (deciand ryan, 1985). landers (1997) argued that involvement in physical activity can provide relief from symptoms of depression and anxiety as well as improve mood and self-esteem. evidence from one study demonstrates that psychological benefits associated with physical activity were highest among everyone over age forty and women of all ages (stephens, 1988). a variety of sociological benefits are also attributable to sport participation (cabane, 2014). sport participation can build social capital (coalter, 2007), which is linked to positive social networks in communities. social capital is a by-product of social interactions (putnam, 1995), such as those found in sport. sport participation has been linked to lowered delinquent behavior among adolescents (milleret al., 1998), another sociological benefit. pate et al., (2000) found that both male and female sport participants enrolled in high schools were less likely to report the use of cigarettes and other illicit drugs which might be considered both sociological and physiological benefits. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 2; march-april 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 4 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe it stands to reason that if individuals consider these benefitsto be important, it would drive involvement in sport participation. however, it remains largely unknown what impact one’sperception of the importance of these benefits has on the underlying psychological process that leads to sport participation. a better understanding of the role of benefits perceptions would be very useful to those charged with marketing participant-based sport. marketing of participant sport there have been calls in the sport literature for an increasing focus on participation in the context of the larger academic field of consumer behavior, with particular emphasis on how people become involved in sport and what makes them committed (bodet, 2012; shank, 2009; taksandscheerder, 2006). this involves looking beyond demographic variables in isolation (i.e., age, gender, income) which are generally not as useful to marketers as more powerful psychographic indicators (ko, park and claussen, 2008). attitudes, motivational structures and other relevant psychological processes must be examined to give sport marketers the best opportunity to develop effective messages that will resonate with consumers. marketing plans in sport participation settings “should be based on extensive marketing research related to a variety of aspects of sport participation and consumer behavior” (alexandrisand carroll, 1999, p. 329). for example, if sport marketers are aware of benefits sought, they can tailor programs and potentially satisfy participants (gray-lee andgranzin, 1997). despite calls for research examining the marketing of sport participation, few scholars have examined sport participation from a consumer behavior perspective (notable exceptions includebalaskaand kouthouris, 2014; latimer et al., 2008; naylor and kim, 2010; taksandscheerder, 2006). this lack of research is particularly noteworthy, given that traditional marketing strategies used by sport administrators have not generally been successful in stemming declining sport participation rates (graham and graham, 2008; lera-lopez andrapungarate, 2005; vail, 2007). increasing inactivity in north america, combined with the fact that there are significant benefits available from sport participation,suggests that marketing strategies need to be improved. effective consumer behavior based research is required to guide future efforts to market sport participation. ineffective marketing efforts may be at fault for declining involvement in participant sport, perhaps because sport administrators took for granted the fact that people wanted to participate in sport. now because people perhaps have more alternate ways to spend discretionary time and money than ever before, sport administrators will have to market participation opportunities based on a fundamental understanding of the underlying psychology of sport participants. theoretical framework a single, universally-accepted theoretical framework to shape research activities related to sport participation does not exist (beaton andfunk, 2008). the majority of theory in this area has been shaped in the field of health (e.g., susserandsusser, 1996) and sport psychology (e.g., spence and lee, 2003) with little contribution from sport and recreation social scientists, and almost no contribution from sport marketing scholars. a theoretical framework is essential in the domain of sport participation because it is a complex behavior determined by many factors and is not easily linked to demographic correlates (funk, mahoney,and havitz, 2003). mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 2; march-april 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 5 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe psychographic variables (i.e. measures of attitudes, values and beliefs) are vital to build a full understanding of participant sport because they can be used by marketers to effectively communicate the availability and benefits of goods and services (ko, et al., 2008; shank, 2009). a useful conceptual framework in sport participation settings should also provide functional meaning to practitioners (beaton, funk, and alexandris, 2009). one framework to consider is the theory of planned behaviour (tpb) (ajzen, 1991). theory of planned behavior the tpb is a model of social cognition designed to predict and explain human behavior in specific contexts (ajzen, 1991). the tpb is based on the notion that behavior is explained by the valence of behavioral, normative, and control beliefs. these three belief systems – attitudes, subjective norms and perceived behavioral control – are determinants of first intentions and then behaviors. attitude refers to the degree that an individual “has a favorable or unfavorable evaluation or appraisal of the behavior in question” (ajzen, 1991, p. 188). the tpb integrates specific attitudes toward the target behavior, because general attitudes tend to be poor predictors of behavior in specific situations (ajzen, 1991). the attitude component of the tpb is further broken down into affective and instrumental attitudes. the second of the tpb determinants is subjective norms. subjective norms “summarize an individual’s perceptions of social influence such as beliefs that significant others want them to participate in the target behavior” (hagger et al., 2007, p. 2). subjective norms are also conceptualized as a perception and refer to social pressure that an individual feels to either perform or not perform a behavior (ajzen, 1991). in the context of sport participation, this construct captures the pressure than an individual feels from others around them to participate in sport. the third determinant, perceived behavioral control (pbc) is similar to bandura’s (1977) notion of self-efficacy, a person’s belief that they are able to take action to deal with certain situations. two endogenous components are featured in the tpb. the intention construct, together with its three determinants, captures strength of motivation associated with a given behavior (ajzen, 1991). intention is believed to be the most proximal determinant of the target behavior. within the tpb, the relationship between the determinant constructs (pbc, subjective norms and attitude) and behavior is completely mediated by behavioral intention. sport participation is the focal point of the research and the target behavior. the most important outcome of the decision making process associated with participantbased sport from a marketing perspective is the participation decision itself (shank, 2009). in tpb frameworks, behavior is typically operationalized using self-report measures of past behavior (e.g., hagger et al., 2007) asking respondents to identify the number of times they have participated over a given period. one example of how this construct has been operationalized comes from hagger et al., (2007) who asked survey respondents how many times they had participated within the last five weeks. a model has been derived to shape the current research project (figure 1) based on the tpb. while the instrumental attitude component has been measured as a unidimensional construct (ajzen and fishbein, 1980, rhodes and courneya, 2004) within tpb frameworks, it is measured here using a multi-dimensional scale incorporating the notion of benefit importance as related to each of the three benefits of active sport participation that have been identified. it has been found in previous research that many identify highly with the benefit from recreational sport participation (spivey and hritz, 2013). it is theorized that this alternate conceptualization is a mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 2; march-april 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 6 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe useful addition to the traditional tpb framework in the context of sport participation. in fact, instrumental value is believed to lead to persistent behavior (ryan anddeci, 2007). if individuals value the benefits available, they may adhere to sport participation, which is essential to accrue those benefits. exploring attitude in sport contexts is particularly important because they have been previously linked to adherence and behavioral patterns (tomik, olex-zarychta and mynarksi, 2012). figure 1: reconceptualized tpb model of participant sport the tpb provides a thoroughly tested and accepted framework to examine physically active behavior (hagger, chatzisarantis, and biddle, 2002). in addition, the tpb incorporates psychological antecedents as well as a manifest behavioral variable, both of which are of interest from a marketing perspective. the appropriateness of the tpb in the context of sport participation has been widely lauded (e.g., chun, yusof, soon and abdullah, 2014; hagger, et al., 2007).reconceptualizing the instrumental component to incorporate an assessment of potential benefits is important because this construct may be linked to behavioral persistence (ryan anddeci, (2007), a desirable outcome which may facilitate benefit attainment. method participantsand procedure participants representing a variety of age groups and a relatively equal combination of men and women werepurposefully sampled using aquota scheme. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 2; march-april 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 7 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe data collection was conducted by 68 research assistants(graduate students) in a variety of communities across the southeastern united states.adult sport participants (n = 691) were given a questionnaire to complete; the data collected were utilized to test the behavioral model. questionnaire demographic variables including age, gender, marital status and ethnicity were included in the instrument.the items used to measure the multi-dimensional instrumental attitude construct were adapted from the work of naylor and kim (2010) and kang (2004). twelve items were selected to measure three dimensions of instrumental attitude. respondents indicated their level of agreement with statements based on a 7-pt scale. respondents were asked to respond to three affective attitude items on a continuum anchored by pairs of bipolar adjectives. the three pairs utilized in the research are taken from the work of rhodes et al. (2006), and include unenjoyable/enjoyable, unpleasant/pleasant, and boring/exciting. in order to measure the subjective norms construct, three items were utilized.hagger et al., (2007) used two items (listed first in table 3) to measure the construct in their research. a third item was developed specifically for this research, essentially to ensure that the construct was measured effectively and thoroughly. the hagger et al. study is also the source for three items used to measure perceived behavioral control. for both constructs, respondents indicated the extent to which they agree with each item on a 7point scale anchored by disagree and agree.a single continuous level variable is employed in the current research to measure sport participation intentions. respondents were asked to report the number of times they intended to participate in sport over the upcoming year. finally, respondents were asked to report their average weekly sport participation over the past year. analysis confirmatory factor analysis (cfa) was conducted using mplus statistical software to examine the quality of the questionnaire items and the structure of the constructs of interest. cfa was appropriate because the nature of the research met three criteria as set forth by thompson (2004). going into the analysis, there were specific expectations about the number of factors, which variables reflected given factors and that the factors would be correlated. one of the most common means of assessing fit associated with cfa models is an examination of the significance of the chi-square statistic. other fit indices should also be examined (weston and gore, 2006). two incremental fit indices, the tucker-lewis index (tli) and comparative fit index (cfi) have been recommended (mcdonald and ho, 2002) and two absolute fit indices, the standardized root mean square residual (srmr) and root mean square error of approximation (rmsea) statistics are also used in the current research. hu and bentler (1989) have recommended a combinatorial approach in the assessment of the magnitude of fit indices rather than evaluating model fit using any of the fit indices in isolation. assessing the reliability of measures used in the current research is through the use of the construct reliability statistic (hair et al., 2010). the construct reliability statistic measures the degree to which two or more indicators share in their measurement of a construct (hair et al., 2010). if the value of the coefficient exceeds .70, a scale can be considered reliable. it is also important to provide evidence of validity, in order to show that research mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 2; march-april 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 8 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe instruments are performing effectively. there are two main types of construct validity, and statistical evidence was generated for both. in order to assess convergent validity, average variance extracted (ave) scores werecalculated (hair et al, 2010). if a construct has an ave score above .5, it is an indication that the variance associated with that construct is greater than the variance associated with error and an argument can then be made that the scale has convergent validity. the second major type of construct validity is discriminant validity, which refers to a construct differing from other constructs that it theoretically ought to. in order to provide evidence of discriminant validity, latent construct correlations can be examined. correlations among constructs that are meant to measure different concepts should be low (hair et al., 2010), although related concepts can be expected to correlate to some degree. structural equation modeling (sem) is a confirmatory technique used to test theory (tabachnickandfidell, 2007). if the measurement model is deemed a good fit to the data, then structural relations amongst the latent variables can be estimated and tested for model fit, using similar assessments as employed for the measurement model. it has been suggested that samples of over 200 are generally acceptable for sem (weston and gore, 2006). the sample used for both the initial cfa procedure (n = 200) andthe estimation of the full structural model (n = 491) are appropriate based on this benchmark. results table1displays statistics related to several demographic and behavioral variables. the final sample included more males than females, but the mean (35.21) and standard deviation (13.60) for the age variable indicate that a range of ages participated in the research. the majority of the sample self-reported as white/caucasian (67.7%). the sample can be considered quite active sport participants as on average, respondents reported more than three weekly intention and behavioral participant sport episodes. in addition, the respondents collectively attributed a relatively high level of importance to the benefits attainable through sport participation (i.e., between 5-6 on a 7 point scale; table 2). table 1: demographic and behavioral characteristics of sport participants sport participants n % gender male 371 53.70 female 320 46.30 mean standard deviation age (years) 35.21 13.60 sport participation episodes per week 3.04 3.75 sport participation intentions (weekly episodes) 3.08 4.50 table 2: means and standard deviations for instrumental attitude items item* instrumental attitude variables mean standard deviation mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 2; march-april 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 9 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe phys1 it is important that participating in sport improves physical health. 5.73 1.47 phys2 sport promoting a participant's physical wellbeing is important. 5.72 1.44 phys3 sport fostering physical health within society is important. 5.50 1.48 phys4 it is important that participants experience physical benefits through sport. 5.61 1.45 soc1 it is important that sport builds friendships among participants. 5.47 1.54 soc2 it is important that sport cultivates friendships within communities. 5.31 1.55 soc3 sport participants sharing a sense of camaraderie is important. 5.42 1.50 soc4 it is important that sport fosters a sense of togetherness. 5.40 1.49 psych1 it is important that sport provides psychological benefits to participants. 5.40 1.51 psych2 sport promoting a participant's psychological well-being is important. 5.45 1.47 psych3 participants enhancing their psychological health through sport is important. 5.49 1.48 psych4 sport helping participants achieve better mental health is important. 5.46 1.45 *phys – physiological, soc – sociological, psych – psychological confirmatory factor analyses a random subset (n=200) of respondents was generated in order to explore the scale psychometrics ofthe tpb constructs. multivariate normality of data is an important assumption associated structural equation modeling procedures. as such, mardia’s coefficient, a measure of multivariate kurtosis, was calculated using lisrel 8.80 statistical software. the test was statistically significant (x2= 2866.97, p<.01) and accordingly, the mlm estimator was used on subsequent analyses. the chi-square test of model fit (x2= 299.86, df = 174, p<.01) was significant indicating poor fit of the data to the proposed data, but as noted, this is not an uncommon result for unsaturated models and relatively large data sets. the srmr (.05) and rmsea (.06) combinatorial thresholds as suggested by hu and bentler (1988) was reached indicating good model fit, while the cfi (.94) and tli (.93) values were very close. psychometric statistics for the constructs and variables are depicted in table 3. factor loadings, ave and construct reliability statistics were mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 2; march-april 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 10 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe almost exclusively indications of the scales’ quality based on the thresholds identified previously. although correlations among the instrumental attitude constructs were quite high (.83 .93) this may be a result of the factors represent associated concepts. nevertheless, this finding is discussed further in a subsequent section. table 3: scale psychometrics for tpb constructs and variables item factor loading ave construct reliability phys1 0.770 0.60 0.85 phys2 0.772 phys3 0.793 phys4 0.749 soc1 0.859 0.73 0.92 soc2 0.875 soc3 0.813 soc4 0.865 psych1 0.848 0.72 0.91 psych2 0.854 psych3 0.829 psych4 0.854 aff1 0.804 0.66 0.86 aff2 0.819 aff3 0.824 pbc1 0.812 0.46 0.70 pbc2 0.679 pbc3 0.445 sns1 0.841 0.59 0.81 sns2 0.619 sns3 0.832 structural model the next stage of the data analysis involved an estimation of a full structural model of the tpb variables (figure 2) using the data from the second subset of participants (n = 491), and the measurement structure examined with the first participant subset (n = 200). mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 2; march-april 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 11 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe figure 2: full structural model of participant sport the chi-square statistic was significant (x2 = 475.35, df = 220, p< .01) but other fit indices including cfi (.95), tli (.95), srmr (.04), rmsea (.05)suggested good model fit when interpreted in combination as per hu and bentler (1989). the attitude construct was supported by the affective and reconceptualized instrumental attitude latent constructs. these relationships were not tested in the initial assessment of measurement structure. as was evident from the cfa, the instrumental attitude construct itself was well-supported by the three importance sub-scales that lie underneath it. in all cases, paths between first and second order factors were significant and reasonably large. in contrast the path coefficients from attitude (β =.216, p <.01), sns (β = -.142, p = .26) and pbc (β =.056, p = .52)to intention and from intention to participation (β = .374, p = .01), serve to explain only a small portion of the variance for the two endogenous components of the model (r2 intention = .03, r2 participation= .14). of note is the fact that the paths from attitude to intention and from intention to participation are significant while the paths from subjective norms and pbc to intention are not significant. discussion instrumentation this project represents a scale development exercise for the newly conceptualized instrumental attitude factors and an initial test of the construct within a behavioral model. the performance of the first-order instrumental attitude factors was promising based on factor loadings, good ave values and adequate construct reliability mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 2; march-april 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 12 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe statistics. however, the three latent factors that underlie the instrumental attitude construct were relatively highly correlated with one another. the correlations among the physiological, sociological and psychological factors can be taken as evidence that the three factors were perhaps actually measuring one construct, instrumental attitude, and that slicing the construct more thinly was not appropriate. the lack of differentiation among the instrumental attitude sub-scales may not be a reflection that the multidimensional conceptualization of instrumental attitude didn’t work, but rather that the respondents indicated relatively equal importance in all three forms of benefit attainable through sport. in making this case, one would weigh the body of evidence supporting the benefit factors’ face validity as more compelling than the lack of statistical discriminant validity associated with the factors. another possible explanation for the lack of discriminant validity for the instrumental attitude factors is described as acquiescence, which is a tendency to agree with attitude statements regardless of content (winkler, kanouse, and ware, 1982). the psychometrics from the first administration of the instrumental attitude variables (naylor and kim, 2010) were a stronger indication of the multi-dimensional conceptualization of instrumental attitude than those calculated in the current project. specifically, the physiological, sociological and psychological factors discriminated from each other in the naylor and kim study, which can be interpreted to mean that respondents were able to differentiate conceptually among the categories of benefit. the correlations among the physiological, sociological and psychological factors in the study ranged from .62 to .69. no rationale is immediately apparent as to why the instrumental attitude factors discriminated from one another in the naylor and kim study but not in the current project. the data collection procedure was similar, although there were less items used to measure the instrumental attitude factors. best performing items from the naylor and kim study(i.e., those that had high factor loadings and limited cross-loadings on alternate factors) were utilized in the current project. despite relatively minor psychometric nuances, the current project contributes to the ongoing development of a scale to measure instrumental attitude towards sport participation. based on the sound theoretical foundation from which the instrument has been developed as well as the importance of understanding the underlying psychology of sport participation, it is advisable to continue to improve and test the instrument. psychometric statistics for the affective attitude and subjective norms factors provided evidence that the items performed well. the factor loadings were sufficiently high and ave and construct reliability scores were acceptable. this was not unexpected as both constructs are theoretically and empirically well established within the tpb (hagger, chatzisarantis, and biddle, 2002). overall, the pbc construct did not perform as well.one of the items used to measure this construct had a low factor loading (.445) which can be interpreted to mean thatthe indicator had less than half of its variance accounted for by the latent variable. a review of the wording of the poorly performing individual item (pbc3) did not reveal any particular reason why the item did not work well. the pbc items were taken directly from the work of hagger et al., (2007) and had been shown to perform well previously. structural model of participant sport mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 2; march-april 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 13 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe one of the main purposes of the current project was to empirically examine a behavioral model including instrumental attitude in the context of participant sport. with a measurement model shown to fit the data reasonably well, the next step was therefore to estimate a full model including paths among the latent tpb constructs. the hypothesized higher order relationships within the attitude construct (i.e., from affective attitude and instrumental attitude) were well supported by the data. in addition, the path from the attitude construct to intentions was positive and significant although the magnitude of the coefficient was quite small. the subjective norms construct did not significantly drive the intention to participate in sport as had been hypothesized. the path was negative and insignificant. there is a substantial body of research that supports the existence of a meaningful path between these two constructs, a portion of which is reviewed by hagger, chatzisarantis, and biddle(2002). the fact that the path was not significant suggests that in this context with this sample of sport participants, subjective norms do not play an important role in an individual’s intention to participate in sport. this may be reflective of a more individualistic culture in the southeastern united states in which the influence of others is not as important in sport participation decisions as it may be in other parts of the united states or the world. alternatively, results in this study may provide evidence that social influence on an individual’s decision to participate in sport is not as important as compared to behaviors in other domains of physical activity and perhaps other non-sport behaviors as well. this might be explained by the nature of sport itself, which is a voluntary, free-time activity. social influence may be more important in behaviors related to parenting, employment or civic responsibilities than it is in one’s decision to participate in sport. the intention construct was measured with just a single variable which may have limited its effectiveness in this explanatory model, and thus the statistical impact of the two constructs which were hypothesized to drive it. likewise, data did not support the pbc construct as a significant driver of intention among the sport participants as had been hypothesized. taken together the current project represents good evidence of the potential role that the re-conceptualized attitude factors may play in the psychological process that drives participation in sport. specifically, the factor appears to be linked to the intent to participate in sport and subsequently the participation behavior itself. the path from participation intentions to participation was positive and significant. attitude and behavioral intention are two of potentially many factors that impact sport participation so the expectation of these constructs generating significant variance for endogenous constructs in a research project like this is probably unrealistic. as a result, r-square values for the two endogenous variables employed in the current research were quite low (r2 intention= .03, r2 participation= .14).nevertheless, the two significant positive paths within the structural model provide evidence supporting the re-conceptualized instrumental attitude factor developed and tested in this research. managerial implications and implications for future research perhaps most significantly in terms of managerial implications, evidence has been found in the current research to support the notion that people across an array of demographics value the importance of the benefits attainable through participation in sport. this suggests that sport managers should highlight the benefits available in promotional efforts. further, the construct has been statistically linked to both the intention to participate in sport and participation itself – desirable outcomes for sport managers across the industry. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 2; march-april 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 14 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe considering the work that has now been done in the development of a scale to measure instrumental attitude towards the benefit available through participant sport, ongoing research is essential. although a multidimensional conceptualization of instrumental attitude makes sense theoretically and has been thoroughly justified based on prior academic inquiry but in reality, it is still not clear whether individuals really conceptualize the categories of benefit as is put forth here. in other words, benefits attainable through participant based sport may be a singular, uncomplicated notion that cannot be broken down into component parts. a qualitative exercise in which sport and non-sport participants provide an in depth perspective on the way in which they conceptualize the benefits attainable through participant sport is warranted to ensure their appropriateness. this exercise would provide evidence of whether differences do in fact exist regarding the categories of benefit importance that have been theorized. another option would be to revert back to the increased number of items used to measure the physiological, sociological and psychological importance factors in the pilot study and initiate further psychometric exercise to identify good items. although strong evidence was not found supporting the hypothesized model in its entirety,exploring the relationships among tpb variables remains an important direction for future research. the hypothesized structure of the attitude construct in this research was supported by the data. overall the implication of the current project for future research is that the reconceptualized factor has potential, but its items need ongoing refinement. in addition, the construct should continue to be modeled in conjunction with outcome variables of interest, perhaps beyond a self-report of past participation frequency. duration of participation would be one outcome variable of interest. the goal of this line of research ought to be the examination of psychological constructs in ways that maximize the variance explained on the key outcome variable – sport participation. another intriguing area of potential research would be to examine the level of physical activeness associated with particular sports compared with others and how that may be linked to the importance that an individual places on the physical benefits attainable from their involvement. if it is discovered that some individuals play sport purely for the physiological benefit, than that would have clear marketing implications (i.e., promotional images and messages could reflect the potential for an individual to attain these benefits). likewise, the importance of sport infrastructure (hallman, wicker, breuer and schonherr, 2012) for various benefit inducing sports and other constraints must be considered as an understanding of participant sport moves forward. although the sample in the current study features a relatively representative racial profilefor the united states, the underlying psychology of sport participants within specific racial groups (e.g., african americans or other groups around the world) remains of interest and could be examined specifically in future research. in fact, establishing instrumental attitude factorial invariance across racial groups would be useful given recent interest from scholars in race-related sport management research (e.g., armstrong, 2011). limitations one of the most significant limitations of the data collection is the fact that it was cross sectional. a longitudinal design may have provided a superior means to examine the relationships among the target variables – specifically intention and participation. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 2; march-april 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 15 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe the tpb framework incorporates the relationship between intention and behavior, which take place at separate moments in time. therefore, a cross sectional data collection is not ideal. in fact, the behavior construct in this project was measured as a self-report of past behavior. this methodological nuance, although relatively common in cross-sectional research studies, does represent counter intuition. self-reporting can be fraught with recall inaccuracies and other biases. another weakness of the data collection is the convenience sampling procedure that was employed. steps were taken during the data collection to create a diverse sample in terms of age, gender and weekly sport participation but the fact that a truly random sample was not generated does limit the conclusions that can be drawn somewhat. there are ongoing definitional issues associated with exactly meant by the notion of “sport” in sport management research circles. lera-lopez and rapungarate (2011) lamented the lack of a single, universally accepted definition of sport available to researchers. inevitably, and despite an attempt on the instrumentation itself to clarify what was meant, respondents would have different views of what exactly comprises sport and what doesn’t. unique interpretations of what comprises “sport” in the mind of each respondent impact not only frequency and intention measures but also items representing the other constructs.despite these limitations, the research represents an important step forward in developing our understanding of the underlying psychology of participant sport. references ajzen, i. (1991). the theory of planned behavior. organizational behavior and human decision processes, 50, 179-211. ajzen, i., &fishbein, m. (1980). understanding attitudes and predicting behavior. prentice hall, englewood cliffs, nj. alexandris, k., & carroll, b. (1999). constraints on recreational sport participation in adults in greece: implications for providing and managing sport services. journal of sport management, 13, 317-332. armstrong, k. l. (2011). “lifting the veils and illuminating the shadows”: further the explorations of race and ethnicity in sport management.journal of sport management,25, 95-106. bagozzi, r. p. (1981). attitudes, intentions and behavior: a test of some key hypotheses.journal of personality and social psychology,41, 607-627. balaska, p. &kouthouris, c. (2014). promoting sport participation in greece: issues and challenges. international journal of sport management, recreation & tourism, 13, 63-84. bandura, a. (1977). self efficacy: toward a unifying theory of behavioral change. psychological review,84, 191-215. barber, n., & havitz, m. e. (2001). canadian participation rates in ten sport and fitness activities.journal of sport management,15, 51-76. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 2; march-april 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 16 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe beaton, a. a., & funk, d. c. (2008). an evaluation of theoretical frameworks for studying physically active leisure. leisure sciences, 30, 53-70. beaton, a. a., funk, d. c., &alexandris, k. (2009). operationalizing a theory of participation in physically active leisure. journal of leisure research,44, 177-203. bodet, g. (2012). loyalty in sport participation services: an examination of the mediating role of psychological commitment. journal of sport management, 26, 30-42. hallman, k., wicker, p., breuer, c., &schonherr, l. (2012). understanding the importance of sport infrastructure for participation in different sports – findings form multi-level modeling. european sport management quarterly, 12(5), 525-544. cabane, c. (2014). unemployment duration and sport participation. international journal of sport finance, 9, 261-280. chalip, l. (2006). toward a distinctive sport management discipline.journal of sport management, 20, 1-21. chatzisarantis, n. l. d., &hagger, m. s. (2007). the moral worth of sport reconsidered: contributions of recreational sport and competitive sport to life aspirations and wellbeing. journal of sports sciences, 25, .1047-1056. chun, c. c., yusof, a., soon, c. c., abdullah, m. c. (2014). application of theory of planned behaviour to predict recreational sports activities participation of students in malaysia. journal of physical education and sport, 14(2), 172-177. coakley, j. (2003). sport in society: issues and controversies.mcgraw hill, boston, ma. coalter, f. (2007). a wider social role for sport. routledge, new york. colditz, g. a. (1999). economic costs of inactivity. medicine and science in sports and exercise, 31, 663-667. deci, e. i., &ryan, r. m. (1985). intrinsic motivations and self-determination in human behavior. plenum, new york. funk, d. c., mahoney, d. f., & havitz, m. e. (2003). sport consumer behavior: assessment and direction. sport marketing quarterly, 2, 200-205. graham, d. j., & graham, j. f. (2008). improving media campaigns promoting physical activity: the underutilized role of gender.international journal of nonprofit and voluntary sector marketing, 13, 205213. gray-lee, j. w., &granzin, k. l. (1997). understanding participation in exercise and sport: an extended application of personal investment theory. journal of sport behavior, 20, (1), 37-53. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 2; march-april 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 17 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe hagger, m. s., &chatzisarantis, n. l. d. (2005). the social psychology of exercise and sport. open university, milton keynes. hagger, m. s., chatzisarantis, n. l. d., barkoukis, v., wang, j. c. k., hein, v., pihu, m., soos, i., &karsai, i. (2007). cross-cultural generalizability of the theory of planned behavior among young people in a physical activity context. journal of sport and exercise psychology,29, 1-19. hagger, m. s., chatzisarantis, n. l. d., & biddle, s. h. (2002). a meta-analytic review of the theories of reasoned action and planned behavior in physical activity: predictive validity and the contribution of additional variables. journal of sport and exercise psychology, 24, 3-32. hair, j.f., black, w.c., babin, b.j., & anderson, r. e. (2010). multivariate data analysis. (7th ed.). prenticehall, upper saddle river, nj. ham, s. a., kruger, j., & tudor-locke, c. (2009). participation by us adults in sports, exercise, and recreational physical activities. journal of physical activity and health,6, 614. hu, l. &bentler, p. m. (1999). cutoff criteria for fit indices in covariance structure analysis: conventional criteria versus new alternatives. structural equation modeling, 6, 1-55. humphreys, b. r., mcleod, l., &ruseski, j. e. (2013). physical activity and health outcomes: evidence from canada. health economics, 23(1), 33-54. humphreys, b. r., &ruseski, j. e. (2009). ‘estimates of the dimensions of the sports market in the u.s.international journal of sport finance, 4, 94-113. johnston, l. d., delva, j., & o’malley, p. m. (2007). sports participation and physical education in american secondary schools: current levels and racial/ethnic and sociodemographic disparities. american journal of preventive medicine, 33, s195-s208. kang, g. d. (2004). soc*qual: the development of a scale to measure a societal marketing dimension. unpublished doctoral dissertation. university of illinois, urbana. kelly, b., chapman, k., king, l., hardy, l., & farrell, l. (2008). double standards for community sports: promoting active lifestyles but unhealthy diets.health promotion journal of australia, 19,226-228. kline, r. b. (2005). principles and practice of structural equation modeling. guildford publications inc., new york. ko, j. k., park, h., &claussen, c. l. (2008). action sports participation: consumer motivation. international journal of sports marketing and sponsorship, 1, 111-124. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 2; march-april 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 18 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe koivula, n. (1999). sport participation: differences in motivation and actual participation due to gender typing. journal of sport behavior, 22(3), 360-380. landers, d. m. (1997). the influence of exercise on mental health. president’s council on physical fitness and sports, 2, 1-8. lera-lopez, f., &rapun-garate, m. (2005). sports participation versus consumer expenditure on sport: different determinants and strategies in sports management. european sport management quarterly, 5(2), 167186. lera-lopez, f., &rapun-garate, m. (2011). determinants of sports participation and attendance: differences and similarities. international journal of sports marketing and sponsorship, 1, 167-190. mcdonald, r. p. & ho, m-h. r. (2002). principles and practice in reporting structural equation analyses. psychological bulletin, 7(1), 64-82. miller, k. e., sabo, d. f., farrell, m. p., barnes, g. m., & melnick, m. j. (1998). athletic participation and sexual behavior in adolescents: the different worlds of boys and girls. journal of health and social behavior, 39, 108-123. mowen, a. j., & baker, b. l. (2009). park, recreation, fitness sector recommendations for a more physically active america: a white paper for the united states national physical activity plan. journal of physical activity and health, 6, 236-244. naylor, m. e.,& kim, y. k. (2010). social and individual benefits of sports participation.international journal of human movement science, 4, .63-83. nigg, c. r., &estabrooks, p. a. (2003). future directions of physical activity participation research: discussions from the konza workgroup on physical activity participation. psychology of sport and exercise, 4, 3-5. pate, r. r., trost, s. g., levin, s., &dowda, m. (2000). sports participation and healthrelated behaviors among u.s. youth. archives of pediatrics and adolescent medicine, 154, 904-911. pharr, j., & lough, n. (2014). considering sport participation as a source for physical activity among adolescents. journal of physical activity and health, 11, 930-941. putnam, r. d. (1995). bowling alone: america’s declining social capital. journal of democracy, 6(1), 65-78 rhodes, r. e., blanchard, c. m., matheson, d. h., & coble, j. (2006). disentangling motivation, intention and planning in the physical activity domain. psychology of sport and exercise, 7, 15-27. rhodes, r. e., &courneya, k. s. (2004). differentiating motivation and control in the theory of planned behavior. psychology, health and medicine,9(2), 205-215. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 2; march-april 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 19 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe ryan, r. m., &deci, e. l. (2007). active human nature: self-determination theory and the promotion and maintenance of sport, exercise and health. in m. s. haggerandn. l. d. chatzisarantis (eds.) intrinsic motivation and self determination in exercise and sport (1-19). human kinetics, champaign, il. sapkota, s., bowles, h. r, ham, s.a., & kohl, h. w. (2006). adult participation in recommended levels of physical activity: united states, 2001 and 2003. journal of the american medical association, 295, 2729. scheerder, j., vanreusel, b., &taks, m. (2005). leisure-time sport among physical education students. a time trend analysis of sport participation styles. european sport management quarterly, 5, 415-441. shank, m. d. (2009). sports marketing: a strategic perspective. prentice hall, upper saddle river, nj. spence, j. c., and lee, r. e. (2003). toward a comprehensive model of physical activity. psychology of sport and exercise, 4, 7-24. spivey, l. m., &hritz, n. m. (2013). a longitudinal study of recreational sport participation and constraints. recreational sports journal, 37, 14-28. stephens, t. (1988). physical activity and mental health in the united states and canada: evidence from four population surveys. preventive medicine, 17, 35-47. susser, m., &susser e. (1996). choosing a future for epidemiology: ii. from black box to chines boxes and eco-epidemiology. american journal of public health, 86(5), 674-677. tabachnick, b. g., &fidell, l. s. (2007). using multivariate statistics.allyn and bacon, needham heights, ma. taks, m., &scheerder, j. (2006). youth sports participation styles and market segmentation profiles: evidence and applications. european sport management quarterly,6, 85-121. thompson, b. (2004). exploratory and confirmatory factor analysis. american psychological association, washington, dc. tomik, r., olex-zarychta, d., &mynarksi, w. (2012). social values of spot participation and their significance for youth attitudes towards physical education and sport. studies in physical culture and tourism, 19(2), 99-104. united nations inter-agency task force on sport for development and peace. (2003). sport as a tool for development and peace: towards achieving the united nations millennium development goals. retrieved july 8, 2010 from http://www.un.org/sport2005/resources/task_force.pdf. mailto:topacademicjournals@gmail.com american journal of medical and physical education vol.8, issue 2; march-april 2023; issn: 2994-0524 impact factor: 6.14 1252 columbia rd nw, washington dc, united states https://topjournals.org/index.php/ajmpe; mail: topacademicjournals@gmail.com 20 | a m e r i c a n j o u r n a l o f m e d i c a l a n d p h y s i c a l e d u c a t i o n | https://topjournals.org/index.php/ajmpe vail, s. e. (2007). community development and sport participation. journal of sport management, 21, 571-596. warburton, d. e. r., nicol, c. w., &bredin, s. s. d. (2006). health benefits of physical activity: the evidence. canadian medical association journal,174(6), 801-809. weston, r. & gore, p. a. (2006). a brief guide to structural equation modeling. the counseling psychologist,34(5), 719-751. wicker, p., breuer, c., &pawlowski, t. (2009). ‘promoting sport for all to age-specific groups: the impact of sport infrastructure.’european sport management quarterly,9, 103-118. winkler, j. d., kanouse, d. e., & ware, j. e., jr. (1982). controlling for acquiescence response set in scale development. journal of applied psychology, 67, 555-561. world health organization (2004). global strategy on diet, physical activity; and health. retrieved april 15th, 2010 from the world health organization website: http://who.int/diet/phsicalactivity/strategy/eb11344/en/index.html zeigler, e.f. (2007). ‘sport management must show social concern as it develops tenable theory. journal of sport management,21,297-318. mailto:topacademicjournals@gmail.com 