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Abstract
We sought to identify concepts that may facilitate National Collegiate Athletic Association efforts to assist member institutions in addressing the mental health needs of student-athletes of colour. A two-step process was followed to generate and refine concepts, guided by Delphi methodology. First, a scoping review was conducted, including original peer-reviewed research articles that quantified or qualitatively described determinant(s) of racial or ethnic differences in athlete mental health or mental healthcare. Next, a multiday virtual meeting was facilitated to review the results of the scoping review, discuss lived experiences and generate potential concepts. Participants included a racially and ethnically diverse group of student-athletes, medical and mental health professionals, athletics administrators, diversity, equity and inclusion experts, health educators and representatives from leading organisations involved in athlete mental health. Through the consensus process, participants identified 42 concepts that member institutions might consider implementing on their campuses. Concepts were largely focused on organisational policies and practices such as staffing diversity and inclusion, expanded options for clinical support (ie, identity-relevant support groups) and within-organisation accountability. Concepts related to specific areas for stakeholder education were also identified. Institutions have the potential to play an important role in supporting the mental well being of student-athletes of colour, and the present concepts can help inform institutional action. While concepts proposed are believed to be broadly relevant across athletics settings, they would need to be further considered and tailored to reflect setting-specific organisational structures, resources and needs.
- Psychology
- Public health
- University
- Anxiety
- Depression
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Key points
The majority of concepts were focused on organisational policies and practices, including staffing diversity, mechanisms for reporting experiences of discrimination and feedback and accountability.
Externally reinforced athlete identity and the transition from sport were identified as sources of stress for athletes. Support for non-sport skill building was identified as one organisational strategy that could help mitigate these sources of stress.
Clinical care considerations included access to appropriate care and care continuity, and the potential for different models (eg, telemedicine, identity-relevant support groups) to help meet care needs in some settings.
Education/training was proposed as being important for all stakeholders involved in collegiate athletics (eg, athletes, coaches, clinicians, athletics administrators and families of athletes), addressing role-relevant topics (eg, trauma-informed coaching).
College students of colour, including student-athletes, are at elevated risk of poor mental health.1–5 Race itself is not a risk factor for poor mental health6. Rather, race is a social construction based on visible characteristics and ancestry,7 and racial inequities are the result of racism.8 Exposure to interpersonal and institutional racism and other forms of trauma and chronic stress across the lifespan that are rooted in systemic racism can negatively impact mental health.9 Systemic marginalisation of individuals of colour in mental healthcare settings can negatively impact mental healthcare experiences and outcomes10 11 Given this context, as the National Collegiate Athletic Association (NCAA) and its member institutions continue to focus on student-athlete mental health,12 13 the mental health needs of student-athletes of colour must be addressed explicitly. We use the term ‘student-athletes of colour’ to refer to all student-athletes who identify as a race or ethnicity other than non-Hispanic white, while recognising that different racial and ethnic groups will have different lived experiences that impact their mental health and well-being. In 2021, 16% of NCAA student-athletes identified as black, 6% as Hispanic or Latino, and 5% as two or more races.14
As part of the NCAA’s Summit on Diverse Student-Athlete Mental Health and Well-Being (“Summit”), consensus methods were used to identify concepts that the NCAA and its member institutions might consider to address the mental health and well-being needs of student-athletes of colour. We describe this stepwise process and discuss the results with reference to implementation considerations.
Methods
Overview
The consensus process was guided by modified Delphi methodology, broadly organised with an exploration phase and an evaluation phase.15 The exploration phase began with a scoping review on factors in the collegiate sport setting that may impact the mental health needs of student-athletes of colour. This was done to help identify knowledge gaps that could be addressed by the Summit, and so that Summit participants would have a common knowledge base of current scholarship that may be relevant to identifying concepts for member institutions. Subsequently, the NCAA convened a 2-day Summit, attended by a diverse group of stakeholders, during which the exploration phase continued with didactic presentations and discussions, leading to drafting of preliminary foundational concepts. The evaluation phase followed the conclusion of synchronous Summit activities, and included anonymous ratings and revisions of foundational concepts by Summit participants. Details on consensus participants and procedures are provided below.
Scoping review
Theoretical framework
Contemporary scholarship about the unique mental health needs and challenges of people of colour emphasises a multilevel16–18 and intersectional19 20 aetiology, and provides frameworks that can structure our thinking about this topic. A commonly used theoretical framework, the National Institute of Minority Health Disparities (NIMHD) framework, considers different potential domains of influence (ie, individual behaviour, physical environments, sociocultural environments and the healthcare system) and levels of influence (ie, individual, interpersonal, community/organisational and societal).16 Applying this framework to understanding the relationship between race and mental health outside of sport highlights how individual behaviour is nested in contexts that produce and maintain disparate health outcomes.8 18 21 This multilevel theoretical framework guided the scoping review.
Search procedure
Literature included in this review was retrieved from two electronic databases (PubMed and PsycINFO). Our article keyword search included “(athletes or sports or athletics) AND (mental health) AND (minorities or ethnic groups or race or racial).” Additional articles were identified through manual review of reference lists of eligible articles. There were no restrictions on study designs. Grey literature, such as unpublished studies and dissertations, was not included. The search was conducted in July 2020. Articles were eligible for inclusion if they were original primary research published between January 2010 and July 2020, in an English language peer-reviewed journal, and they quantified or qualitatively described determinant(s) of racial or ethnic differences in athlete mental health or mental healthcare. Publications were not restricted to NCAA student-athlete study populations or any specific geography.
Analysis
A standard coding form was developed based on the NIMHD framework16 and Boyd et al’s standards for publishing on racial differences.22 Boyd et al’s standards are designed to ensure that research is not ‘incorrectly assigning race as a risk factor when racism is the risk factor for racially disparate outcomes’,22 and that research on racial inequities is situated in a critical theoretical framework that prioritises systemic change. This meant we first coded articles based on whether they defined race, specified its reason for use, and named racism and other intersecting forms of oppression that may be influencing the outcomes observed. Next, we extracted the primary mental health outcome(s) for the study (ie, symptomatology, health service utilisation), and categorised the theorised determinant(s) of racial differences in this outcome in terms of the corresponding domain and level of influence from the NIMHD framework.16 Although coding was primarily deductive, we remained open to other determinants not listed in the NIMHD framework. Codes and code definitions are provided in table 1.
Race-related and racial inequity-related coding framework
Summit
Participants
A total of 45 individuals participated in the consensus process (see online supplemental table 3). Paid NCAA staff members helped facilitate consensus procedures, including conducting the scoping review and facilitating Summit activities, but they were not involved in rating any foundational statement. Summit co-chairs and steering committee members were identified via a key informed-led process that prioritised relevant clinical expertise and lived experiences. These individuals provided feedback to paid NCAA staff members on Summit participant recruitment and consensus procedures. Representatives from NCAA member institutions (ie, colleges and universities that participate in NCAA competition) serve on voluntary committees that provide feedback to the paid NCAA staff on member institution needs and priorities. Committees with responsibilities relevant to the mental health of student-athletes of colour (eg, Committee on Promoting Cultural Diversity and Excellence) were asked to identify one member to participate in Summit activities. Additionally, leading national organisations involved in sport and mental health (eg, Alliance of Social Workers in Sport) were provided with information about Summit goals and invited to send an individual with relevant expertise to the Summit. Finally, individuals with relevant lived experiences and identities not otherwise represented through the aforementioned recruitment process, including student-athletes of colour, were invited to participate using key informant-led purposive recruitment. Of participants who self-reported their racial and ethnic identity, 62% identified as African American, 7% as Hispanic or Latino, and 3% as Native Hawaiian or Pacific Islander. Of participants who self-reported their gender identity, 52% identified as male and 48% as female. In sum, Summit participants had relevant professional expertise (ie, licensed mental healthcare provider, athletics administrator, student-athlete, health educator), there was over-representation by individuals of colour, and there was relative balance across male and female gender identities.
Supplemental material
Exploration procedure
Prior to the Summit, participants received a copy of results from the scoping review. The first day of the Summit included didactic presentations addressing the content of the scoping review and other issues such as epidemiology, risk factors, and current practices and resources. Small group breakout sessions allowed participants to discuss and reflect on the content shared. At the end of the first day, participants were invited to use an anonymous online link hosted on the Qualtrics survey platform to submit their preliminary recommendations about steps that institutions can take to improve the mental health and well-being of student-athletes of colour.
Prior to the start of day 2, an internal working group synthesised this feedback. The internal working group was comprised of the Summit co-chairs, steering committee members and NCAA staff members. One member of the working group assigned inductive descriptive codes to passages of text. Codes were subsequently grouped into higher order themes reflecting core recommendations (eg, ‘provide education about racism in sport’). Next, these themes were organised by stakeholder target (athlete, coach, healthcare staff, athletics administration). The other members of the working group subsequently reviewed open-ended written data to affirm the coding and thematic grouping decisions.
On the second day of the Summit, participants broke into small groups that were purposively organised to include a range of professional roles and lived experiences. Groups sequentially reviewed recommendation themes by stakeholder group that were emergent from day 1. They were tasked with working together to discuss potential implementation barriers/facilitators, and to contest or further refine and operationalise ideas. After each stakeholder-specific small group discussion, Summit participants gathered as a large group to share their main discussion points. Each small group identified a note-taker, and at the end of the Summit, they submitted a written record of their group discussion, highlighting their ideas and implementation considerations. At the conclusion of the Summit, this written documentation was aggregated and synthesised by the internal working group, following the coding process previously described. Next, preliminary statements describing concepts to facilitate and support mental wellness of racial minority student-athletes were generated. These concepts incorporated the ideas and implementation considerations provided by Summit participants, such as cost, time demands and prioritisation from athletics administration. The internal working group reviewed proposed concepts to confirm consistency with emergent themes and written documentation from the Summit.
Evaluation procedure
Summit participants were contacted by email with a link to an online survey containing the preliminary statements that were generated during the exploration phase. They were asked to rate each proposed concept in terms of its perceived utility and feasibility. Utility was defined as their perception that, if implemented with fidelity, it would benefit student-athletes of colour. Feasibility was defined as their perception about how possible it would be for it to be implemented by institutions. Response options for each dimension were on a 1–9 scale, where higher scores indicated the concept was more useful/feasible. When participants rated a statement 6 or lower, they were asked to provide open-ended written feedback about their rationale. Summary statistics were calculated for each proposed concept for utility and feasibility. Modelled on prior similar consensus processes,23 24 utility and feasibility means of >7.00 were established a priori as thresholds for consensus. The internal working group also inspected the distribution of responses by calculating the percentage of proposed concepts with a score of >7.00, with a target of 75% or more.
For concepts not reaching these thresholds, the internal working group reviewed the open-ended participant feedback to identify emergent reasons for lack of consensus on utility or feasibility. Where possible, proposed concepts were modified based on this feedback. Modified concept proposals, along with the results of the first round of ratings, were sent back to Summit participants. They were asked to follow the same rating and open-ended feedback as before on this limited subset of proposed concepts.
Proposed concepts reaching consensus thresholds at the end of these two rounds of review were included in the final set of concepts. These were shared with key NCAA committees and governance bodies that have responsibilities related to the areas of diversity and inclusion, and health and safety. No modifications were made to statements in this phase. The goal of this communication was to allow committees and governance bodies to identify whether and how the consensus process results can inform ongoing efforts to support and address the specific mental health needs of student-athletes of colour.
Results
Scoping review
As presented in figure 1, a total of 285 articles were identified through database searching and 11 additional articles through manual search. After screening, a total of five studies met inclusion criteria. Of the five eligible papers, four were original analyses of quantitative data, and one was qualitative. All related to US college-level sport participants. Three papers used the word ‘racism’ and none defined race using a sociopolitical framework. Determinants were largely at the individual and interpersonal level, and are detailed in table 2 and summarised below.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart for study selection.
Determinants of racial/ethnic disparities in athlete mental health
Help-seeking
Two quantitative papers addressed topics related to race and help-seeking. Ballesteros and Tran2 conducted a secondary analysis of American College Health Association’s National College Health Assessment II survey data, restricting the sample to a subset of 241 varsity athletes who self-identified as African American, Latinx or Asian American, and were categorised as ‘in need’ of mental health services. They found no statistically significant pairwise differences by race in the percentage of athletes who said they would consider seeking mental health services in the future. Steinfeldt and Steinfeldt25 collected original survey data from 245 male football players at four US colleges, with athletes in the sample self-identifying as white, Black, Hispanic, Asian, American Indian, multiracial or other. The primary goal of the study was to determine how help-seeking stigma was associated with different profiles (or ‘clusters’) of conformity to traditionally masculine norms. Results indicated that perceived stigma was lowest among non-conforming male athletes. Additional analyses found that race was not significantly associated with cluster membership, suggesting that racial differences in help-seeking stigma may not be explained by differences in conformity to masculine norms.
Treatment preferences
Naoi et al 26 surveyed 271 varsity athletes from two US colleges, and grouped them into two racial categories (‘Caucasian’ and ‘minority’) based on their self-reported race. No significant differences between the two groups were observed for self-reported interest in discussing mental health concerns (depression, anxiety, eating disorder) during a hypothetical sports psychology consultation, or in their acceptance of taking medication to treat hypothetical mental health issues. Significantly, more athletes categorised as Caucasian (46.9%) as compared with those categorised as minority (29.0%) expressed interest in discussing dealing with pressure/stress during a hypothetical sport psychology consultation.
Response to discrimination
Sadberry and Mobley27 surveyed 98 collegiate athletes at four colleges in the USA (two historically Black colleges and universities (HBCUs) and two predominantly white institutions (PWIs)), with participants restricted to those self-identifying as African American, Black, biracial/multiracial, African, Haitian, Jamaican or Central/South American. Individuals experiencing more stress related to their minority racial identity (as measured by higher scores on the Minority Student Stress Scale) tended to have significantly more depressive symptoms (as measured by the Depression domain of the College Adjustment Scale). The Minority Student Stress Scale reflects experiences of stress related to institutional, interpersonal and internalised racism, with subscales for social climate stressors (eg, few professors of my race, few students of my race in my classes), inter-racial stressors (eg, white-oriented campus culture, negative relationship between different ethnic groups), intragroup or within-group stressors (eg, pressure to show loyalty to own race), racism and discrimination stressors (eg, being treated rudely or unfairly due to race) and achievement stressors (eg, doubts about abilities, family expectations).
Patient–clinician relationship
In their sample of 271 varsity athletes from two US colleges, Naoi et al 26 found that compared with athletes categorised as ‘Caucasian’, racial minority athletes reported a stronger preference for seeing a sport psychology consultant of the same race, and for seeing a sport psychology consultant who has experience working with diverse populations.
Norms and stigma
Wilkerson et al 28 conducted a qualitative study with nine Black male Division I football players from a US college characterised as ‘highly competitive’. Individual interviews explored attitudes about mental health help-seeking. Primary themes relating to help-seeking included ‘silence’ and perceptions that it indicated ‘weakness’, with family-reinforced cultural context contributing to their communication and help-seeking practices.
The current state of research on determinants of racial disparities in the mental health of athletes is highly limited in terms of the number of articles published, the types of determinants studied, and the theoretical conceptualisation and discussion of race. Individual-level determinants (help-seeking attitudes, treatment preferences and individual stress in response to discrimination) were the focus of most studies that we identified as eligible for inclusion. These determinants were largely not situated in a multilevel theoretical framework addressing structural mechanisms for hypothesised relationships between race and mental heath-related outcomes. With the exception of Sadberry and Mobley’s27 study, mention of racism was largely with respect to interpersonal interactions rather than structural conditions and institutional policies and practices.
Focus on individual, rather than systemic or institutional, causes of racial inequities is a trend that is also observed in recent consensus statements/position stands on athlete mental health. For example, the International Olympic Committee’s consensus statement notes that ‘negative attitudes about mental health services are associated with several factors, including identification as male, younger age, Black (vs Caucasian) race’.12 We note that the two quantitative papers that addressed topics related to help-seeking found no significant racial differences in self-reported likelihood of future help-seeking, or in conformity to traditionally masculine norms that were associated with help-seeking stigma. However, significant methodological limitations make it difficult to determine whether these findings reflect a true lack of racial differences in help-seeking among athletes. Limitations include outcomes that were not actual help-seeking behaviour, and small samples that limit power to detect differences even if present or to examine potentially important risk modifiers related to intersectional identities. These and other papers included in this review are also limited in how race is measured. Others have cautioned that how race is operationalised (eg, grouping all non-white athletes into a ‘minority’ category) and how reference categories are selected (eg, foregrounding white race as the default reference category) can obscure and affect the interpretability of results.29
In sum, the literature review was useful largely in identifying significant gaps in research on the mental health of college-level athletes of colour. This included a lack of data about organisational and systemic determinants of mental health-related behaviours and outcomes. These gaps meant that the current evidence base did not provide a robust set of data or information that could be used to directly generate concepts for NCAA member institutions to consider as they seek to address the mental health needs of student-athletes of colour. We note that recently several authors have described their lived experiences and observations of racism in sports medicine,30–32 perspectives and experiences that provide an important starting point for a more expansive approach to research in this area.
Consensus ratings
The exploration phase generated 45 proposed concepts, grouped broadly across 6 categories of stakeholders involved in NCAA college athletics (coaches, student-athletes, athletics department administrative staff, families of student-athletes, healthcare personnel and athletics department administration). Eighteen Summit participants participated in the first round of concept ratings. Eleven of the initially proposed concepts did not meet a priori consensus thresholds for perceived feasibility, and one of the concepts also fell short of the threshold for perceived utility (‘documented plan for coach support of student-athletes in non-sport skill development opportunities, including accommodation of such opportunities as part of practice, competition and travel schedules’). Proposed concepts were revised based on themes emergent from open-ended participant feedback and in some cases, initial concepts were combined. Ten modified concept proposals were rated in a second round. Of these, all met thresholds for perceived utility, and two were marginally below thresholds for perceived feasibility, with 69% of respondents rating the respective concepts 7 or more out of 9. The working group decided to include these two statements with additional minor modifications to address identified feasibility concerns. Final foundational concepts are presented in box 1, and concepts and corresponding scores from the first and second round of ratings are provided as an online supplement (online supplemental tables 1 and 2).
Proposed concepts from consensus process that may be leveraged by National Collegiate Athletic Association member institutions to support the mental health needs of racial minority student-athletes
Athletic department personnel and prctices
Training: athletic department staff annual training that addresses:
The history of racism in sport.
Anti-racism, as applied to the sport and college setting.
Self-assessment of implicit biases and attitudes as they relate to the experiences and well-being of student-athletes of colour.
Reporting experiences of discrimination
Department and/or campus policies/processes that encourage and facilitate the reporting of experiences of racial discrimination and support individual reporting of experiences of racial discrimination.
Annual student-athlete surveys designed to anonymously solicit information about experiences of racial trauma and discrimination in athletics settings (ie, as perpetuated by coaching staff, teammates medical staff, athletics department administration, fans).
Annual dissemination of information to all athletics personnel (student-athletes, coaches, staff) about institutional process for reporting experiences of discrimination.
Communication
Annual statement affirming that discrimination on the basis of race, gender or sexual orientation will not be tolerated.
Public identification and recognition of positive contributions to diversity and inclusion within athletics department.
Staff hiring and retention
Regular review of policies and practices related to inclusion in the employment process (eg, recruiting, hiring, retention), and engagement in goal setting and action planning related to supporting increased staff diversity.
Processes for considering racial and ethnic diversity as a factor in staff hiring.
Review of relevant anonymous and other feedback about discrimination as part of annual review process for coaches and other athletics department staff.
Non-sport skill development and career planning
Cross-campus department support of students of colour (including student-athletes) in learning about, preparing for and pursuing careers in mental health professions (eg, psychology, social work, nursing).
Meetings, at least annually, between faculty athletics representatives, coaching staff, and team captains to identify barriers and opportunities to support non-sport skill development.
Annual student-athlete surveys designed to anonymously solicit feedback on engagement in non-sport skill building activities, and on barriers in the athletics setting (ie, scheduling) to engaging in such activities.
Regular self-evaluation, goal setting and action planning related to athletic department initiatives designed to support student-athletes’ transition to life after sport.
Inclusion of coach engagement in supporting athletes in non-sport skill development as part of coach evaluations performed by the athletics department.
Quality improvement and accountability
Annual student-athlete surveys to anonymously solicit feedback on athletic department initiatives related to racism (eg, reporting, education).
Annual athletics department self-evaluations of current racial and ethnic representation among student-athletes, coaches, sports medicine staff, athletics administration and other student-athlete support positions such as student-athlete development personnel.
Regular review of internal student-athlete survey data with a multidisciplinary group that includes representatives from outside of athletics.
Regular meetings with an advisory board that includes student-athletes of colour to review and discuss race-related initiatives, including but not limited to: education, non-sport skill building and transition from sport.
Healthcare personnel and practices
Training: healthcare personnel annual training that addresses:
The history of racism in healthcare/medicine.
Culturally competent healthcare.
Trauma-informed clinical practices.
Screening
Inclusion of screening for mental health disorders as part of the annual pre-participation examination, administered in a manner that allows for student-athlete privacy.
Dissemination of information about institutional services to support mental health as part of annual mental health screening for student-athletes.
Clinical care
Student-athlete-accessible identity-based support groups that are supervised by a licensed mental healthcare professional.
Student-athlete-accessible telehealth and/or other clinical care alternatives that recognise that different student-athletes will prioritise different types of care and characteristics of care providers.
Annual reviews of institutional procedures that support continuity of coverage for student-athlete mental healthcare, including aspects of off-campus care (eg, during school breaks or remote schooling due to external events) and care away from and after collegiate competition (eg, during periods of injury, graduation or other departure).
Coaches
Training: coach annual training that addresses:
The history of racism in US sport.
Anti-racist coaching practices.
Trauma-sensitive coaching practices.
Self-assessment of implicit biases, attitudes, and coaching practices as they relate to the experiences and well-being of student-athletes of color.
Self-assessment of the extent to which team members are encouraged or supported to participate in non-sport skill development opportunities.
Communication
Annual statement to team members affirming that they will not tolerate discrimination on the basis of race, ethnicity or other identities, including but not limited to gender or sexual orientation.
Dissemination of information to team members on an annual basis about institutional process for reporting experiences of discrimination.
Student-athletes
Training: student-athlete annual training that addresses:
The history of racism in US sport.
Anti-racism, as applied to the sport and college setting.
Culturally sensitive skills for coping with stress.
Career planning
Meetings with career services or similar personnel at least annually to discuss career planning for life after sport.
Families of student-athletes
Share information: annual dissemination of information to families of student-athletes that addresses:
The mental health services on campus and how to access those services.
The benefits of mental healthcare for athletic and academic performance.
Normalisation of mental health help-seeking including, for example, statistics on use of mental health services and/or affirmation by key athletics stakeholders (eg, coaches) about the value of mental healthcare.
Discussion
The consensus process resulted in proposed concepts that were largely focused on organisational policies and practices related to staffing, feedback and accountability, and programming to support student-athlete well-being. Other concepts were focused on modifications to interpersonal determinants through education/training. Only one proposed concept focused on individual athlete behaviour (training in culturally sensitive skills for coping with stress).
Stakeholder education
Proposed concepts related to education/training included all stakeholders involved in collegiate athletics: athletes, coaches, clinicians, athletics administrators and families of athletes. Broadly, education/training is thought to have the potential to increase the knowledge, motivation and ability of stakeholders to engage in role-relevant behaviours that positively impact the mental health of racial minority student-athletes. For all stakeholder groups, education related to the history of racism in sport/sports medicine was believed to be important. Other content varied by stakeholder group, including topics such as implicit biases, trauma-informed coaching and healthcare practices, and culturally competent healthcare practices. Summit participants cautioned that not all educational programmes/training about the same topic are of equivalent quality, meaning that institutions should pay close attention to the evidence base about the effectiveness of the programmes they are selecting.
Screening
Screening for mental health disorders and the use of screening as an opportunity to strengthen help-seeking were also included in proposed concepts. Summit participants emphasised the importance of pairing of screening activities with communication with student-athletes about the resources available, procedures and benefits of mental health help-seeking. We note that screening is also addressed in the NCAA Mental Health Best Practices,33 which emphasises the importance of having procedures in place for what to do if an individual has a positive screen, including access to licensed professionals from which care can be sought. While screening is an initiative that has the potential to benefit athletes broadly, it has the potential to disproportionately benefit individuals who might otherwise have missed being identified as needing support.
Clinical care
Proposed concepts focused broadly on organisational practices for expanding options for clinical care while recognising that in many settings, there are unmet mental healthcare needs. Summit participants acknowledged the importance of each institution in identifying the types and levels of services that are needed and appropriate for their respective student-athletes. One key area of feedback from stakeholders during the consensus process was the benefit of increased diversity among mental healthcare providers. The group also shared concerns that, at this time and at many institutions, there are limitations on the number of trained clinicians who are competent to work with the specific mental health issues facing student-athletes, and that this shortage of trained individuals means that access to counsellors of colour may be even further limited. Community collaborations or partnerships, telehealth and/or other clinical care alternatives were identified as approaches to explore that may help expand access to care. Summit participants also addressed the need for wellness services to support student-athletes of colour who are not necessarily experiencing clinical mental health issues, but nonetheless experiencing stressors that are impacting their well-being, including racism and balancing athletic and academic demands. Proposed concepts included convening identity-based support groups that are supervised by a licensed mental healthcare professional to meet the subclinical needs of these student-athletes. A final proposed clinical care-related concept addressed continuity of coverage for mental health services (eg, during school breaks or remote schooling due to external events) and care away from and after collegiate competition during the sport-career transition. Stakeholder feedback emphasised that such transitions can be a source of stress and present structural challenges to continuity of care.
Staffing
Proposed concepts related to the benefits of diversity in organisational staffing, and the need for organisational quality improvement procedures related to staffing diversity. This included the importance of regularly reviewing policies and practices related to inclusion in employment practices (eg, recruiting, hiring, retention), and engaging in goal setting and action planning related to staff diversity. Also raised for consideration was having relevant anonymous and other feedback about discrimination included as part of the annual review process for coaches and other athletics department staff.
Support for whole person/transition from sport
Stakeholder feedback during the exploration phase identified internal and external conflicts between athlete and non-athlete roles, and the transition from sport, as potential stressors for student-athletes of colour. Proposed concepts focused on organisational strategies that address athlete identity and supporting non-sport skill building. To the extent such initiatives are implemented universally, institutions should monitor uptake and obtain feedback about acceptability and impact to determine whether they are being used by, and meeting the needs of, student-athletes of colour. Also addressed was cross-campus departmental support for student-athletes of colour in learning about, preparing for and pursuing careers in mental health professions (eg, psychology, social work, nursing). At an individual level, such practices have the potential to support non-sport identity and transition from sport; at a systemic level, such steps could help address the shortage of mental health clinicians of colour.
Reporting experiences of discrimination
Summit participants discussed the importance of student-athletes of colour being able to safely report experiences of discrimination, and the need for organisational accountability about reports of discrimination. Participants expressed concerns about retribution, and a possible reluctance by student-athletes to use existing reporting mechanisms. Concepts did not address specific reporting mechanisms, as more research is needed to evaluate the acceptability and impact of different reporting mechanisms across sport settings. Recognising that not everyone will feel comfortable engaging in formal and identifiable reporting processes, Summit participants suggested an annual student-athlete survey designed to anonymously solicit information about experiences of racial trauma and discrimination in athletics settings (eg, as perpetuated by coaching staff, teammates medical staff, athletics department administration, fans). This was framed as a possible mechanism for increasing organisational accountability.
Organisational communication
Summit participants emphasised the importance of explicit communication (at least annually) by coaches and athletics department staff that they will not tolerate discrimination on the basis of race, ethnicity or other identities, including but not limited to gender or sexual orientation. However, they also cautioned that such statements cannot stand alone, and must be a reflection of the organisation’s engagement in real and sustained efforts to address discrimination.
Accountability
A major theme in stakeholder feedback throughout the consensus process was the importance—and difficulty—of accountability. Proposed ideas included conducting an annual student-athlete survey to anonymously solicit feedback on athletic department initiatives related to racism (eg, reporting, education) and conducting an annual athletic department self-evaluation of current racial and ethnic representation among student-athletes, coaches, sports medicine staff, athletics administration and other student-athlete support positions such as student-athlete development personnel. Recognising that simply collecting this information is not sufficient, proposed concepts also attended to how this information might be used by institutions. Regularly reviewing internal student-athlete survey data with a multidisciplinary group that includes representatives from outside of athletics and engaging diverse stakeholders in agenda setting was one idea that was specifically referenced.
Limitations
The small number of relevant original peer-reviewed publications available at the time of the Summit limited the exploration phase of the study. As more research is conducted, concepts should be revisited. The present consensus process was focused narrowly on identifying concepts that might facilitate the efforts of NCAA member schools as they aim to support the mental health needs of student-athletes of colour. Concepts were perceived by Summit participants to be usable, feasible and otherwise appropriate for the range of resource levels and administrative structures of NCAA member schools. Further research is needed to evaluate their adoption, implementation and effectiveness in improving athlete well-being within collegiate athletics. Such information can inform a continued process of refining the guidance and support that is provided to member institutions. We note that the consensus process focused broadly on student-athletes of colour, while recognising that this group of more than one-quarter of all collegiate athletes in the USA have noteworthy variability in terms of their identities, lived experiences, and risk and protective factors related to mental health. Further, the majority of student-athletes of colour in the USA attend predominantly PWIs, with an additional group attending HBCUs. Representatives from HBCUs participated as part of the consensus process; however, the resulting foundational concepts may not fully reflect the experiences of this group of student-athletes. More research is needed on determinants of racial and ethnic differences in mental health among student-athletes, including the role of institutional and peer factors—at HBCUs and PWIs. Generalisability to other sport systems within the USA, and in other countries, may be limited. Statements require further consideration and potentially adaption to fit with setting-specific organisational structures, resources and cultural contexts.
Conclusion
The present consensus process produced a number of concepts that can serve to inform and shape NCAA membership efforts and potentially those of other sporting organisations, to support the mental health needs of student-athletes of colour.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants but the University of Washington IRB (STUDY00011065) exempted this study. Participants (eg, summit attendees involved in rating concepts) were provided with information about the study, per IRB-approved methods.
Acknowledgments
We thank all participants in the NCAA Summit on Diverse Student-Athlete Mental Health and Well-Being (see online supplemental table 3). Special thanks to Victor Kidd for assistance with the narrative review.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @ekroshus
Contributors All authors made substantial contributions to the conception or design of the work or the acquisition, analysis or interpretation of data for the work; and drafting the work or revising it critically for important intellectual content; and provided final approval of the version to be published; and agree to be accountable for all aspects of the work.
Funding This study was funded by the National Collegiate Athletic Association.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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