Date of Completion


Embargo Period



Policy, Institutional Theory, Heat Acclimatization, Sudden Death

Major Advisor

Stephanie M. Mazerolle

Associate Advisor

Douglas J. Casa

Associate Advisor

Carl M. Maresh

Associate Advisor

Laura J. Burton

Associate Advisor

William A. Pitney

Field of Study



Doctor of Philosophy

Open Access

Open Access


Context: Every year high school athletes die or are injured while participating in sports. Several policies can be implemented by high school athletic associations (HSAA) to reduce the incidence of sudden death in sport. While these policies may not prevent incidences, they certainly reduce the risk associated with sport. There are consensus statements and recommendations made by professional organizations such as the National Athletic Trainers’ Association (NATA), however nothing is mandated, allowing each state the freedom to create, implement and adapt policies, as they deem necessary. An example of a recommended policy is heat acclimatization for the reduction in exertional heat illnesses. Anecdotal evidence suggests variability in implementation of this policy despite its endorsement and impact on reduction of sudden death related to heat stroke. Objective: Retroactively examine why and how 3 states were able to facilitate the successful creation and adoption of heat acclimatization guidelines. Design: Case study design utilizing semi-structured phone interviews Setting: HSAA in Arkansas, Georgia and New Jersey Patients or Other Participants: A gatekeeper from each state identified members of the HSAA or sports medicine advisory committee (SMAC) who were instrumental in the change process. Seven males, 3 females (n=10) (5 athletic trainers (ATs), 2 members of HSAA, 2 parents, 1 physician) participated.

Participant recruitment ceased when data saturation was reached. Data Collection and Analysis: All phone interviews were digitally recorded and transcribed verbatim. A grounded theory approach guided analysis, while multiple analysts and peer review were used to establish credibility. Results: The catalyst to implementing the policy was different for each state (student athlete death, empirical data and proactivity). Once the decision to implement change was made, the states had two similarities: shared leadership and open communication between the SMAC and the leadership of the HSAA. Each state’s SMAC, which included an AT as a key member, utilized the recommendations from the NATA when developing the state’s proposed guidelines. The SMAC then presented the proposed guidelines to the members of the HSAA allowing for open dialogue about the policies. This open communication allowed the policies to be implemented with little resistance. The adoption of the policy by each state reflects the institutional change theory which individuals can help foster change. Conclusions: While the initiating factor that spurred the change can vary, shared leadership and communication fundamentally allowed for successful adoption of the policy. SMACs, specifically the ATs, were influenced by the recommendations from national governing bodies, which aligns with the institutional theory on change. As more states begin to examine and improve their current health and safety policies this information could serve as a valuable resource for ATs on SMACs within other states, and future health and safety initiatives.