Authors: Martha G. Dettl-Rivera1, Diane L. Gill2, Erin Reifsteck2

1Physical Education, Sport and Human Performance Department, Winthrop University, Rock Hill, SC, USA
2Department of Kinesiology, University of North Carolina at Greensboro, Greensboro, NC, USA

Corresponding Author:
Martha G. Dettl-Rivera, EdD, SCAT, ATC
116A West Center
Rock Hill, SC 29732

Martha G. Dettl-Rivera is an assistant professor of Athletic Training at Winthrop University in Rock Hill, SC. Her research interest includes mental health in college athletics.

Diane L. Gill is a professor in the Department of Kinesiology at the University of North Carolina at Greensboro in Greensboro, NC. Her research interests include social psychology and physical activity.

Erin Reifsteck is an assistant professor in the Department of Kinesiology at the University of North Carolina at Greensboro in Greensboro, NC. Her current research focuses on promoting lifelong physical activity and health among athletes.

Self-efficacy in college athletics: An exploratory study


This research examined the self-efficacy scores of National Collegiate Athletic Association (NCAA) college athletic trainers from Division I and Division III Southeastern universities. Implementing mental health best practices for college athletic trainers to recognize and to refer student-athletes with mental health issues and disorders have been top priorities of the NCAA and National Athletic Trainers’ Association (NATA). Purpose: This research explored the influence of the USA Mental Health First Aid (MHFA-USA) course of NCAA college athletic trainers’ self-efficacy levels of college student-athletes’ mental health referrals. Methods: A survey approach was adopted to measure participant (n=8) confidence levels of referring student-athletes to qualified mental health care practitioners utilizing a valid self-efficacy scale. Results: Overall, there was improvement in self-efficacy scores immediately following the course as well as consistent improvement at the one-month follow-up survey. Conclusions: There has been no current research on mental health formal trainings of practicing athletic trainers at the NCAA level. Findings from this study were promising as NCAA college athletic trainers’ self-efficacy improved following completion of the MHFA-USA course. Application in Sports: This study offers exploratory insight of the potential training of NCAA college athletic trainers to appropriately and to confidently refer student-athletes to appropriate care. Findings suggest mental health training programs focused on improvement of confidence levels of NCAA college athletic trainers should be considered.

Key Words: mental well-being, NCAA, athletic trainers, depression, Mental Health First Aid


At least one in four adults suffer from some form of mental health illness, a statistic frequently utilized in research. Approximately 18.5% American adults (18 and over) reported experienced mental health illnesses; however, young adults between the ages of 18 and 25 years old stated a higher number at nearly 19.4% (8). College student-athletes are included in this research statistic and are equally susceptible to a myriad of signs and symptoms of mental health illnesses. The population is unique because of the various stressors associated with identifying as a college student-athlete compared to the general college student population. The pressures to win competitions and to gratify coaches adds stress not experienced by college nonathletes (27). Additionally, student-athletes have an abundance of time commitments to manage and full schedules to balance, including but not limited to: classes; study sessions; practices and competitions; traveling; and treatments or rehabilitations in the athletic training room. These additional commitments leave little to no personal time for college student-athletes, thereby potentially increasing stress levels (4, 14, 19). Lastly, college student-athletes are at risk for depressive-like symptoms after sustaining an injury, especially if the individual’s self-confidence is associated with the student-athlete identity (20).

Mental Health Stigma

Mental health stigma is prevalent amongst college student-athletes. Only 10% of student-athletes experiencing a mental health illness such as depression or anxiety seek mental health services (6). There are numerous reasons that diminish the likelihood of a student-athlete seeking help for a mental health issue. Specifically, student-athletes are viewed to be mentally tough and show no signs of weakness due to society’s stigma regarding mental health. There is a fear, shame, or inadequacy of being labeled or seen as mentally ill or crazy if discovered seeking help for a mental health illness (7). Additional explanations as to why college student-athletes fail to seek help or treatment from a mental health professional include: uncertainty or lack of trust of mental health professionals; limited awareness of mental health illness significance; and practical barriers such as unavailability of provider or inability to pay for treatments (4, 7, 25). If left untreated due to stigma, mental health illnesses that go undiagnosed in college student-athletes have a potential negative effect on their athletic and academic successes (26).

Mental Health Best Practices

The National Collegiate Athletic Association (NCAA) recognizes the importance of mental health among college student-athletes. In 2013, the NCAA developed a multidisciplinary task force to address mental health issues that face college student-athletes. A supporting document, Inter-Association Consensus Document: Best Practices for Understanding and Supporting Student-Athlete Mental Wellness includes key input from experts and organizations in the field of mental health. This document describes mental health best practices, providing sports medicine and athletics departments various recommendations to provide support and to promote mental health well-being (15). Additionally, the NCAA Mental Health Best Practices (2016) provides examples of emergent situations that may arise in college athletics departments, including suicidal ideation (13).

Athletic Trainers

Athletic trainers play a crucial role in the college athletics department by promoting the overall physical and mental well-being of college student-athletes and can facilitate them seeking further mental health help during the referral process (3, 15). On the contrary, athletic trainers are not equipped to use the necessary tools or resources to promote mental health wellness. Within the Commission on Accreditation of Athletic Training Education (CAATE) educational competencies, the Psychosocial Strategies and Referral domain states that athletic trainers will have “the ability to intervene and refer these individuals as necessary” (12, pg. 27). Athletic trainers are not required (per CAATE competencies) to learn strategies to mediate an individual with a mental health crisis or non-crisis situation. Previous research has shown that athletic trainers lack formal clinical training directly related to referring college student-athletes to advanced mental health care (5, 11, 24). With the proper training, college athletic trainers are in a pivotal role to assist college student-athletes with mental health recognition and referral processes, thus potentially improving their overall mental well-being.

USA Mental Health First Aid

The USA Mental Health First Aid (MHFA-USA) course was designed to provide participants with the knowledge to recognize early signs and symptoms of mental health issues, to improve self-efficacy helping a person in distress, and lastly, to identify appropriate professional help for a person with mental health issues (22). The MHFA-USA course emphasizes early recognition and responsive skills in both mental health crisis and non-crisis situations. Focusing on five topics: 1) substance use disorder; 2) psychosis; 3) suicide and/or non-suicidal self-injury; 4) anxiety; and 5) depression, the MHFA-US course teaches participants what signs and symptoms to recognize, what to say and do if warning signs are present, and how to mediate if there is a mental health crisis or non-crisis situation. This course has shown significant improvements in self-efficacy within various populations such as: student affairs staff at a university (9); fire service personnel (10); and pharmacy students (16). The effectiveness of the MHFA-USA course in improving self-efficacy has not been evaluated in a college athletic training population. Implementing the MHFA-USA course could improve college athletic trainers’ confidence levels in referring college student-athletes with mental health issues to professional mental health care providers.

The purpose of this study was to explore the influence of the MHFA-USA course on college athletic trainers’ confidence in their referral skills for student-athletes experiencing mental health issues. Based on previous research related to the MHFA-USA course, the author predicted there would be an increase in self-efficacy scores from pre-course to post-course.



Participants were NCAA college athletic trainers enrolled in MHFA-USA courses within the Southeastern United States region. All participants (n=8) enrolled in the courses were required to complete the course itself; participation in the research was voluntary and all eight participants agreed to participate in the study.


The participants were recruited via electronic mail. The consent form, demographics form, and surveys assessing confidence levels in referring student-athletes with mental health issues were pre-labeled questionnaire packets for the pre- and post-course. A Qualtrics® link with the surveys was emailed to the participants for the one-month follow-up. There was a minor adjustment to the MHFA-USA course, changing the scenarios’ generic person to a “student-athlete.” For example, instead of “Charles, a friend of your parents,” the scenario would read, “Charles, a student-athlete on your colleague’s team.” This minor adjustment permitted the MHFA-USA instructor to adhere to the course curriculum while relating the scenarios to possible real-life situations for the participants.


The Mental Health Efficacy Questionnaire (MHEQ) was developed and validated by Van Raalte et al. (2015) for an online mental health tool, (23). The participants completed the MHEQ pre-, post-course and one-month follow-up to measure confidence levels with mental health referrals. The eight-item evaluation measured self-efficacy levels in different scenarios: mental health resources (“How confident are you that you can locate useful information about mental health problems?”) and mental health referrals to professionals (“How confident are you that you can refer a student-athlete to a professional for help with a mental health problem?”). The college athletic trainers used a 10-point Likert scale (1: not confident at all; 10: Very confident) to rate the statements.

The MHFA-USA Course Effectiveness (MCE) form included items that evaluated different aspects of the course related to the Theory of Planned Behavior previously used in MHFA-USA trainees (1). The form included self-efficacy questions (2 items) that were solely evaluated. The participants used a five-point Likert scale (1: Not at all likely; 5: Extremely likely or 1: Do not agree at all; 5: Strongly agree) to rate the statements.

Data Analyses

To determine changes in self-efficacy, repeated measures ANOVA was used to compare pre-, post-, and one-month follow-up scores from the MHEQ and MCE forms.


The MHEQ revealed an overall significant improvement of self-efficacy from pre-course to post-course for a small sample size. The college athletic trainers’ scores increased from “Moderately confident” to “Very confident.” One item, “Refer a student-athlete to a professional for help with a mental health problem” improved slightly post-course; the remaining seven questions significantly improved following post-course. Additionally, one-month follow-up results remained higher than pre-course results (See Table 1).

Table 1: MHEQ Pre-/Post-/Follow-Up Comparisons

“How confident are you that you can…Pre M ± SDPost M ± SDF/U M ± SDp
 Find resources related to mental health problems?”  6.75 ± 1.58a  9.00 ± 1.20b  9.26 ± 1.04bc  0.001*
Find a professional who can help with a mental health problem?”7.88 ± 1.25a8.88 ± 1.25b9.13 ± 1.13bc0.001*
Refer a student-athlete to a professional for help who has a mental health problem?”7.63 ± 1.858.75 ± 1.048.50 ± 1.200.203
Help a student-athlete who has a mental health problem?”6.88 ± 1.36a8.88 ± .99b8.63 ± .92bc0.006*
Locate useful information about a mental health problem?”6.88 ± 1.25a9.00 ± 1.07b9.25 ± 1.04bc0.041*
Find someone who can help a student-athlete with a mental health problem?”7.75 ± 1.49a9.00 ± 1.41b9.13 ± 1.13bc0.008*
Help a student-athlete get treatment for a mental health problem?”7.37 ± 1.30a9.13 ± .99b8.75 ± 1.04bc0.011*
Provide assistance to a student-athlete who has a mental health problem?”7.13 ± 1.25a9.35 ± 1.04b8.88 ± 1.13bc0.004*
Overall Average7.28 ± 1.02a8.98 ± 1.06b8.94 ± .99bc0.00*

*p ˂ .05, Means with different letters (a, b, c) are significantly different. F/U = follow-up

The MCE form results exhibited significant improvements in self-efficacy levels from pre-course to post-course, pre-course to one-month follow-up and the overall average for a small sample size as well (See Table 2). The scores improved from “Disagree/Neutral” to “Agree” for both statements.

Table 2: MCE (Self-Efficacy Questions) Pre-/Post-/Follow-Up Comparisons.

“Please rate your confidence in performing the following actions…”  Pre M ± SD  Post M ± SD  F/U M ± SD  p
Refer a person with mental health problems to appropriate help  3.38 ± .92a  4.63 ± .52b  4.25 ± .463bc  0.00*
Talk with someone who is suicidal2.88 ± .84a4.13 ± .35b4.25 ± .46bc.001*
Overall Average3.13 ± .79a4.38 ± .35b4.44 ± .42bc.001*

*p ˂ .05, Means with different letters (a, b, c) are significantly different. F/U = follow-up


The research is an original study exploring the influence of the MHFA-USA course on the confidence levels of college athletic trainers with mental health referrals to advanced medical care. This course has previously shown improvements in confidence levels in other populations (9, 10, 16); findings suggested that the small sample of college athletic trainers improved their self-efficacy in mental health referrals following the MHFA-USA course immediately and at one month post certification. The participants’ scores improved in the areas of speaking to a college student-athlete regarding a mental health issue and knowing when to refer for further help. However, there was only a slight improvement evident in the participants’ self-efficacy with finding support for a student-athlete and referring to a professional for help within the community. This small improvement could be explained by the limited accessibility to local mental health resources at universities (17) as well as the availability of a mental health care provider who has a core understanding of student-athlete experiences (4, 20).


The study comprised of a small sample of college athletic trainers in one specific geographical location. Additionally, the college athletic trainers may not have encountered a student-athlete with a mental health illness during data collection as they are not highly prevalent compared to athletic-related injuries due to student-athletes not always seeking help (20). Despite the limitations, the research findings provide a promising direction and a need for further evaluation of mental health trainings within the college athletic training population.


Despite the small sample size, the research discovery provides a promising direction and demonstrates a need for further evaluation of mental health trainings within an athletic training population. Another potential mental health training includes Question, Persuade, Refer (QPR) Gatekeeper Training, focusing mainly on intervention skills during distress if an individual expresses suicidal ideation or self-harm (18). However, there is a higher prevalence of other mental health issues, such as depression and anxiety that is experienced by college-aged adults, including college student-athletes (2). 

Previous research has shown that athletic trainers’ knowledge in the area of mental health has been provided through didactic coursework; however, implementation of the knowledge and techniques through practical experiences is the philosophy of athletic training education programs (21). The MHFA-USA course improved participants’ overall self-efficacy levels of mental health referrals of student-athletes to advanced medical care logically because the course expanded upon the existent knowledge and applied it to real-life scenarios. Overall the MHFA-USA course demonstrated the potential applicability and practicality in an athletic training setting. When applied to this setting, college athletic trainers could possibly be more prepared to meet the current needs to promote and to support the mental well-being of college student-athletes.


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