With 30 million children participating in sports,1 there are more than 3 million athletic injuries and more than 10 million primary care visits each year, with sports being one of the most common causes of injury.2,3 In addition, understanding of the negative physical and mental effects of injury4–6 has increased clinicians’ awareness of the need for comprehensive evaluation of injured adolescent athletes through whole person health care.
Whole person health care requires a comprehensive patient evaluation covering the spectrum of disablement from specific anatomical structure to functional limitation in activity and participation, as well as environmental and personal factors.7 However, often overlooked are activity limitations and participation restrictions, which are measured through the use of patient-oriented outcome measures.8 One common patient-oriented outcome is health-related quality of life (HRQOL), which is defined as the physical, psychological, and social domains of health that depend on personal experiences, beliefs, expectations, and perceptions.9 The multidimensionality of HRQOL allows clinicians to consider personal, social, and environmental factors of the patient, addressing the whole aspect of a person.9–11 Two outcome measures, the Medical Outcome Study 36-item Short-Form Health Survey (SF-36) and the Pediatric Outcomes Data Collection Instrument (PODCI), are frequently used assessments of HRQOL that focus on the individual’s perspective of health status, allowing for delivery and management of health care that is more meaningful for each patient.8,12
Due to the multidimensionality of HRQOL, many factors have the potential to influence it, gender being one of those factors. Significant differences in HRQOL between genders have been found in many populations, including adults of working age,13 patients with cystic fibrosis,14 and those with asthma.15 Those studies have found that female subjects report lower scores on several components of HRQOL and that differences may be attributed to variation in health perceptions. For example, girls and women tend to be more sensitive to injury or illness, and boys and men tend to have a lower recognition of symptoms and disease severity.14–17 Girls and women also have a propensity to report a greater number of symptoms, both physically and psychologically, than boys and men.15–17
In the case of athletes, differences in the relationship of females and males with their coaches seem to affect HRQOL.18 After sustaining injury, more female athletes reported negative experiences and lack of sympathy from their coaches than did male athletes.18 Female athletes have also reportedly used feedback to establish their competence level in physical activity.18 That is, reassurance from coaches through feedback provides an indication to female athletes that they are performing well. Losing feedback from coaches, perhaps as a result of injury, may leave a female athlete feeling isolated and unsupported. Similar findings among male athletes have not been reported. Differing relationships with coaches and variations in responses to feedback may be contributing factors to the effects of injury on HRQOL.
To date, little information regarding representative values for the adolescent athlete population in terms of HRQOL exists, including whether gender differences affect overall well-being. Without further research, it is difficult to appreciate the true impact of injury on HRQOL, interpret meaningful changes as a result of recovery, and tailor injury evaluation and management specifically to gender. In addition, the lack of insight into the HRQOL of adolescents, as well as the potential long-term effects of injury on a person’s overall health status, is critical given the physical and psychological developmental changes in this population.19 Therefore, the purpose of this study is to determine the representative values of HRQOL among female and male adolescent athletes and to investigate whether gender differences exist in HRQOL.
This study is a retrospective database review. Data for this investigation came from a larger study assessing HRQOL in adolescent athletes experiencing sport-related injury. This study was approved by the university’s institutional review board.
The operational definition of an athlete was determined using the activity guidelines from the state interscholastic association. To capture a heterogeneous sample, participants were included regardless of injury status at the time of data collection.20 Participants were excluded if they did not participate in interscholastic sponsored athletics (eg, an adolescent athlete involved in a nonschool-sponsored activity). In addition, participants with incomplete data sets were excluded from review and subsequent analysis.
Medical Outcome Study 36-Item Short-Form Health Survey. The SF-36 is a widely used generic patient-oriented outcome instrument21 for evaluating HRQOL. Generic instruments are appropriate for most populations, interventions, and disease severities.22 The SF-36 consists of 36 questions that are combined to produce 8 subscales—physical functioning; role limitation due to physical health problems; bodily pain; social functioning; general mental health; role limitations due to emotional problems; vitality; and general health perception—and 2 summary scales—physical component summary and mental component summary.21 The SF-36 is a self-administered survey validated for patients older than age 14 and requires approximately 5 minutes to complete.21 A score is reported on a scale of 100, and higher scores indicate better overall HRQOL. Previous reports indicate that the instrument has good construct validity, concurrent validity (Pearson’s r = 0.81 to 0.93), and internal consistency reliability (alpha = 0.83 to 0.95) in the general population.23,24 The minimum clinically important difference for the SF-36 has been reported to be 2 to 3 points for group score comparison, except for role limitations due to emotional problems at 4 points, and 3 to 6 points for an individual patient’s score.24
Pediatric Outcomes Data Collection Instrument. The PODCI is a generic self-report outcome instrument specifically targeting the adolescent population that is used for the evaluation of functional health, musculoskeletal conditions, and HRQOL.25 Subscales include upper extremity and physical functioning, transfers and basic mobility, sports and physical functioning, pain and comfort, happiness, and a global function score.25,26 The PODCI consists of 83 questions, and scores sum to 100, with higher scores indicating better HRQOL. It requires approximately 10 to 12 minutes to complete the PODCI. A previous study25 reported good internal consistency (alpha = 0.76 to 0.92), test-retest reliability (Pearson’s r = 0.87 to 0.97), construct validity, and sensitivity to change. Information regarding the minimum clinically important difference for the PODCI is limited and has only been reported in a study of patients with cerebral palsy; that study reported a varying range of points, such as 3.0 for the transfers and basic mobility subscale score and 6.9 for the happiness subscale score.27
Data Collection and Statistical Analysis
During the initial data collection efforts, participants were asked to complete 2 questionnaires, the SF-36 and the PODCI, in a counterbalanced manner during a single testing session in local athletic training facilities or high school classrooms. Participants completed the instruments individually but in a group setting. For this retrospective analysis, all data were deidentified. All analyses were exploratory, and no adjustments for multiplicity were made. Scores for both the SF-36 and PODCI were translated into normed values. Data were analyzed using SPSS version 16 software (SPSS Inc, Chicago, IL). The Kolmogorov-Smirnov test was conducted to assess the normality of the data. Data were not normally distributed; therefore, nonparametric pairwise tests (Mann-Whitney U test) were conducted to identify gender differences. Significance was set at P < .05.
A total of 219 adolescent high school athletes (121 females: mean age, 16.1±1.0; 98 males: mean age, 15.8±1.2) representing 22 sports in 7 local high schools were included in this study. Detailed characteristics of participants are presented in Table 1. All participants reported involvement in school-sponsored interscholastic or club sports (eg, football, soccer, basketball, track and field). On the SF-36, female adolescent athletes had lower HRQOL values than did male adolescent athletes on the vitality subscale (P = .035; females = 50.7±9.4; males = 53.2±9.9) and mental composite score (P = .024; females = 48.5±10.0; males = 51.1±8.8) (Table 2). The other 7 subscales and 1 summary score showed no significant differences between female and male adolescent athletes. Female adolescent athletes also had lower HRQOL scores than did male adolescent athletes on the PODCI happiness subscale (P < .001; females = 49.8±8.9; males = 53.8±8.9), as indicated in Table 3. There were no differences in the other 4 PODCI subscales or the global function score.
Table 1: Demographic Data of Participants
Table 2: Normed Mean and Standard Deviations of the Medical Outcome Study 36-Item Short-Form Health Survey in Male and Female Adolescent Athletes
Table 3: Normed Mean and Standard Deviations of the Pediatric Outcomes Data Collection Instrument in Male and Female Adolescent Athletes
Our results provide representative values of HRQOL in female and male adolescent athletes for the SF-36 and PODCI, 2 commonly used instruments for evaluating HRQOL. To our knowledge, there are limited studies on HRQOL in the adolescent population. Evidence suggests there are differences in the representative values of HRQOL in athletes and nonathletes, with athletes demonstrating significantly better HRQOL than nonathletes in several HRQOL domains.6,28,29 Snyder et al29 found that adolescents involved in school-sponsored athletic activities report higher levels of physical and social functioning and mental and general health, and more bodily pain than their nonathlete peers. Therefore, when caring for adolescent athletes, norms based on a general population may not be as appropriate as values obtained from athletes. Our results may represent a better comparison than those of an age-matched general population due to variations in the two groups (general versus athletic populations).
When comparing HRQOL between female and male athletes, there were few differences in health status related to physical, social, or psychological functioning. The most noteworthy finding from our study is that female athletes reported lower overall psychological well-being in vitality, mental health, and happiness compared with male athletes. Not only were the differences in vitality and mental health statistically different, but they suggest a clinically meaningful difference as well. As detailed by Ware et al,24 a change of 2 to 3 points is considered clinically meaningful for most of the SF-36 subscales and composite scores when evaluating group differences. The 4-point difference observed for the PODCI happiness scales did not meet the suggested clinically important difference value of 6.9 points that has been previously reported27; however, this value was determined with a population of patients with cerebral palsy and therefore may not translate to other populations. Similar findings to ours have been reported in previous studies14,30 that have investigated gender differences in HRQOL. Arrington-Sanders et al14 evaluated the HRQOL of adolescents with cystic fibrosis using the Child Health Questionnaire. After controlling for age and lung disease severity, female patients reported significantly lower scores in mental health, global health, and perceptions of general health, with no difference in physical functioning. Jorngarden et al30 studied adolescent and young adults in Sweden using the SF-36 and also reported that female subjects had decreased scores compared with male subjects on 4 subscales (general health perceptions, vitality, role limitations due to emotional problems, mental health) and on the mental composite score. Their results suggest an association between gender and mental and emotional aspects of health, which is consistent with our results.30 However, a study28 that investigated the HRQOL of collegiate athletes using the SF-36 found that male athletes reported significantly higher scores than female athletes in only the general health subscale.
Although there is no definitive interpretation for the differences in psychological well-being between genders, a few hypotheses have been discussed.31–33 One potential explanation is related to the variability in the perception of health status across gender.31 Evidence suggests that females report a significantly higher stress level33 and more psychological suffering than males on depression, anxiety, symptom distress, tension, and negative mood.17,31 On the other hand, male patients tend to have a less accurate perception of health status and severity of disease,15 which suggests that male patients may be underreporting their true health status. The combination of females’ high sensitivity toward their health status and their potential overreporting coupled with males’ poor recognition of their health problems may explain our finding of decreased psychological well-being in female adolescent athletes. Interrelated with this theory is the difference in societal expectations for the expression of disability or dysfunction between genders.32,33 For example, females are socialized to recognize pain and discomfort, whereas males are socialized to tolerate and ignore discomfort. The differences in societal expectation and acceptance seem to play a role in the different psychological aspects of HRQOL.
Lower self-esteem seen in female youth may be another interpretation for the gender difference in the psychological aspect of HRQOL. Evidence suggests a strong relationship between level of self-esteem and the presence of depression in adolescents,33 which may be a contributing factor in the lower psychological well-being of female athletes in our study. In addition, different coping strategies are used by the genders to overcome distress. Female adolescents often direct coping patterns inwardly, whereas male adolescents direct coping outwardly. This inward coping style may leave female adolescents susceptible to psychosomatic disorders.33,34 Wilson et al17 found that female adolescents used problem-focused, avoidant, and emotion-focused coping styles to a much greater extent than did male adolescents when under stress. Because the problem-focused coping style is correlated with increased psychological problems,17 greater use of this particular coping style may help explain our findings.
The importance of considering the psychological component of health when providing care for athletes is highlighted by the differences we found in the mental component of overall health status between female and male adolescent athletes. One potential concern is that the lower ratings of psychological HRQOL reported by female athletes could be enhanced by negative experiences, such as injury, lost practice days, illness, or repeat injury. Studies6,35 report that, after a sports-related injury, an athlete will undergo emotional disturbance that may interfere with the rehabilitation and recovery process and necessitate psychological intervention. For example, in both collegiate6 and high school36 athletes, a significant decrease in HRQOL has been reported after sustaining injury.
In the case of female athletes, because they tend to have lower baseline psychological well-being to begin with,30 injury may cause a greater negative impact. In addition, once injury is sustained, more female athletes report negative experience with coaches and a sense of lack of sympathy from them.18 For female athletes, feedback is used as an indication that they are performing well. Therefore, when injury restricts female athletes from participating, they lose the feedback, potentially producing feelings of isolation and lack of support. Considering the impact of injury on the mental aspect of health status, psychological intervention may be a necessary component of the injury rehabilitation process depending on the severity of the injury.
On the other hand, although male adolescent athletes reported better HRQOL than female adolescent athletes in general, this difference may be due to the less accurate perception that men have of their health status.15 Thus, clinicians should pay close attention when treating male patients to ensure that the true health status is reported by the individual. Overall, properly managing the psychological component of adolescent athletes should be a priority, incorporating a whole person approach to health care tailored to individual patients.
However, lack of education in psychology and counseling among athletic trainers is an important consideration. Although it is required that athletic trainers have knowledge regarding psychological issues and concerns, not all athletic trainers take formal sports psychology courses and therefore may feel unprepared to manage and address mental health issues accompanying athletic injuries.37 Athletic trainers need enough knowledge regarding psychological issues to appropriately refer athletes for counseling or other psychological interventions, as needed. Unfortunately, this knowledge may be lacking. A study by Larson et al38 found that 85% of athletic trainers surveyed reported that a sports psychology course is important in athletic training education, but only 54% of athletic trainers had completed a formal sports psychology course. These findings suggest the necessity for educational improvement in psychology and counseling in athletic training to better prepare athletic trainers to address psychological well-being in patient care.
Contrary to studies15,34 that have identified differences in physical well-being between genders, our results demonstrated no significant difference in the physical component of HRQOL. Considering that most of our subjects were healthy high school athletes, it is reasonable that we did not find significant differences in the physical aspect between female and male athletes in our study. However, some studies15–17 suggest that the genders respond differently to injury and illness, demonstrating variability in the physical component as well.
There are limitations to our investigation. Because our data were collected from 7 high schools located in close proximity, a potential regional bias must be considered. In addition, we did not perform a prospective power analysis because our study was a retrospective database review. Another limitation is that participants completed the questionnaires in a single session, and we did not attempt to review the effects of events such as injury, illness, or practice days missed on these adolescent athletes. Future research should administer outcome measurements over time to see the long-term effects of negative events, such as injuries or illnesses, on adolescent athletes, as well as investigate the effects of the number or severity of injuries on HRQOL in this population.
We reported representative values of HRQOL using the SF-36 and PODCI, 2 frequently used patient-oriented outcome measures, among female and male adolescent athletes. In addition, we found that there was no major difference in the overall HRQOL between female and male adolescent athletes. However, we found differences that suggest female adolescent athletes report poorer psychological well-being compared with male adolescent athletes, despite the similarity in their physical well-being. Therefore, educational improvements in psychology and counseling in athletic training may be necessary. Further research on HRQOL should look at the potential gender difference after injury is sustained.
Implications for Clinical Practice
Female and male adolescent athletes may warrant unique care during injury evaluation and management, as there appears to be slight differences in their overall well-being, especially related to the psychological component of HRQOL. Clinicians, in their routine daily care of patients, should consider the psychological component of injury through a whole-person approach tailored toward individuals.
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- Snyder AR, Parsons JT, Valovich McLeod TC, Bay RC, Michener LA, Sauers EL. Using disablement models and clinical outcomes assessment to enable evidence-based athletic training practice, part I: Disablement models. J Athl Train. 2008;43:428–436. doi:10.4085/1062-6050-43.4.428 [CrossRef]
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- Arrington-Sanders R, Yi MS, Tsevat J, Wilmott RW, Mrus JM, Britto MT. Gender differences in health-related quality of life of adolescents with cystic fibrosis. Health Qual Life Outcomes. 2006;4:5. doi:10.1186/1477-7525-4-5 [CrossRef]
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Demographic Data of Participants
|Sports (no. of participating athletes)b|
| Ice Hockey||1||1|
| Water polo||1||0|
Normed Mean and Standard Deviations of the Medical Outcome Study 36-Item Short-Form Health Survey in Male and Female Adolescent Athletes
|Role limitations due to physical health problems||52.0±7.4||52.4±6.7||.720|
|Role limitations due to emotional problems||50.9±8.1||48.6±10.3||.093|
|General health perceptions||49.4±5.3||48.4±5.5||.127|
|Physical composite score||53.0±5.3||53.3±5.6||.386|
|Mental composite score||51.1±8.8||48.5±10.0||.024a|
Normed Mean and Standard Deviations of the Pediatric Outcomes Data Collection Instrument in Male and Female Adolescent Athletes
|Upper extremity and physical functioning||51.4±4.1||50.0±7.9||.079|
|Transfer and basic mobility||47.9±12.2||48.1±9.3||.524|
|Sports and physical functioning||50.9±9.2||50.4±6.6||.084|
|Pain and comfort||43.6±11.5||42.7±12.7||.716|