Small Rural winner:
Lānaʻi High and Elementary School
Lānaʻi City, Hawaii
In many parts of rural America, the way Lāna‘i High and Elementary School cares for its high school athletes would be unthinkable. Lāna‘i, a school of 173 high school students located on the smallest of Hawaii’s publicly accessible islands, utilizes a full-time athletic trainer.
If this sounds like an unspectacular occurrence, it’s not. More than 78% of schools nationally with low athletic trainer availability are in rural and inner-city areas, according to the National Athletic Trainers’ Association. Athletes in these communities are 50% more likely to have a sports-related concussion that goes unidentified, unassessed, or mismanaged.
Hawaii is the only state with at least one athletic trainer in every high school, earmarking $4.28 million annually in the public-school budget for 74 athletic trainer positions. That’s enough for all but the smallest high schools, such as Lāna‘i, to have at least two athletic trainers.
The state’s investment in athletic trainers is crucial for Lāna‘i, which spends $70,000 annually in travel costs alone hopping islands to games, accounting for 39% of its athletic budget. Longtime Lāna‘i athletic trainer Alicia Bennett provides a valuable service. She offers preventive care, treats ankle sprains and dislocations, manages concussions, teaches proper nutrition, and serves as a trusted confidante for athletes to feel comfortable reporting their injuries and getting vaccinated.
She’s part of a state-wide system that, while not perfect, tries to standardize care by having every school collect the same sports injury data. This model may not work in larger states since far fewer athletic trainers exist than schools in the U.S. Still, it’s promising. For its commitment to health and safety, among other factors, Lāna‘i is recognized as the Aspen Institute’s Project Play winner in the Small Rural Schools category of our Reimagining School Sports initiative.
The value of a full-time athletic trainer at such a small, rural school is apparent to many coaches and students. “Growing up 40 years ago, I didn’t even know there were trainers,” says Mary Lou Kaukeano, Lāna‘i girls basketball coach. “I had never seen a concussion in my years coaching until about six years ago. One girl banged her head on the ground, got up and said, ‘I’m fine.’ But because we had the trainer, she said, ‘No, she’s not fine at all.’ Turns out she was out six weeks because the symptoms were so bad. It’s so good for safety to have a trainer.”
Talia Agliam, a junior who participates in volleyball, wrestling and softball, says she felt really ashamed of her eczema that resulted in bleeding hands but was comfortable talking to Bennett about the problem. Bennett wrapped her hands and provided bandages for Agliam to take home too.
“A lot of people are hesitant giving out wrap because it costs a lot of money. She makes sure we’re covered,” Agliam says. “I look at her more like a friend who’s not just there to care for your injury. Her being that kind of person makes it way easier to go to when you have an injury.”
How Lāna‘i even has an athletic trainer could be a case study for other states. In 1993, after 32 years of efforts by high school athletic directors to improve athlete care, Hawaii authorized $371,000 to hire 10 certified athletic trainers for a pilot program. The law allowed for a gradual increase in funding until, after five years, every public high school in the state had a full-time athletic trainer on staff.
Advocates for state funding turned the topic into a health care issue and came to the state legislature with data. One study showed 82% of athletic health care at the time was being provided by coaches – and 29% of those coaches had no health care training. The other 18% of athletic health care came from emergency medical technicians or non-certified athletic trainers who had no training in sports injuries. Other data showed that major injuries were regularly going untreated.
Advocates also showed state legislators a study of lawsuits involving injured high school students. Hawaii elected to start investing in athletic trainers instead of risking massive potential lawsuits. By 2012, Hawaii created a law requiring the State Department of Education and Hawaii High School Athletic Association to develop a concussion educational program for all public and private high school students.
The law also required that concussed high school athletes get immediately removed from practice or competition and receive written clearance from a licensed health professional before returning to play.
“But what happened was our kids were getting concussions and then going physician shopping,” Bennett says. “The athletic trainer would say, ‘No, you’re not clear,’ and then the parents would go to another physician, not tell them the history of the kid and say the kid got hurt and is fine, and the physician – not knowing the background – would write a note and clear the kid.”
In 2016, Hawaii passed another law to collect injury data and require cognitive testing of high school athletes. Today, one neurologist for the entire state is available to review whether concussed athletes need to receive additional cognitive testing before returning. The school athletic trainer has the final say on when the athlete returns, but Bennett likes leaning on the neurologist.
“I absolutely like that it’s not up to me and the neurologist has the final say,” Bennett says. “I’m one of those paranoid people where it’s nice to have an arsenal of experts to back you up on the care for somebody’s life. I don’t want to rush a kid back out and jeopardize them 10 years from now.”
Bennett estimates she cared for 15 to 20 concussions per year at Lāna‘i before the COVID-19 pandemic shut down sports at the school for 18 months. Most Lāna‘i athletes with a concussion take at least three weeks to return.
It’s a collaborative effort at Lāna‘i when a child has a concussion. Parents receive a list of symptoms to look for at home in case an ER visit is needed. Every day, the concussed athlete meets with Bennett to evaluate symptoms and check on the athlete’s cognitive level compared to a preseason baseline test.
The principal and other staff are made aware of the concussed athlete. The school’s student-care services coordinator emails all of the athlete’s teachers so they can apply return-to-learn protocol. Teachers provide updates to administrators if the student is sleeping or acting more irritable in class.
Joint efforts don’t stop there. Hawaii uses an injury management system that allows every athletic trainer and the state athletic trainer coordinator to see each other’s injury statistics, minus the names of students. Athletic trainers are required to report the same data, such as:
Specific injury
Location of injury on the body
Days missed from practices/competitions
How the injury happened
Information on specific treatment
The state athletic trainer coordinator collects and analyzes the data. If trends emerge, different injury management protocols and procedures are shared across the state. The injury management system recently became available for all athletic trainers to access on their phone, iPad or laptop.
“It’s really convenient to access it anywhere instead of needing to go to your work computer,” Bennett says. “When you’re at a practice or game, you can now get into your school’s athlete files and input injury data or look up if a child has a medical alert to be aware of, or medications they should or shouldn’t be taking.”
Bennett says this system has not always been properly used at her school. Athlete care is only as good as what individuals do with the information. For instance, she says, several years ago Lāna‘i’s wrestling program started showing a rash of head injuries, facial lacerations and cauliflower ear.
“We took the data to coaches and the AD and found out the new coach was not making them wear their protective head gear,” Bennett says. “Even though this data was brought up and preventive measures were advised, the coach did not want to follow it. Our principal at the time didn’t want to be the bad guy and tell the coach you need to follow these measures.”
Bennett says the coach resigned after a threat of an outside investigation. “Now everything is handled better,” she says.
Lately, the biggest challenge at Lāna‘i is vaccinations. Hawaii now requires all high school athletes, athletic staff and volunteers to be fully vaccinated to participate, or the person could apply for a religious or medical exemption and get tested twice a week.
Many fall athletes at Lāna‘i did not return to sports this season. School administrators are concerned about longterm participation trends as students lose interest in sports.
“I feel sorry for these students, but I personally think the vaccinate mandate makes sense to encourage them to get it,” says volleyball player Keela Montgomery. “One of my best friends was pretty against vaccination and wasn’t going to come back. Some of her family members have medical conditions, and I’m super glad she got it. Her getting it encouraged her whole family to get it.”
As athletic trainer, Bennett shows athletes research about the vaccines, takes them to the CDC website, and refutes rumors she hears in the training room.
“People were posting on Facebook that if you get a vaccination, you’re going to be sterile and you won’t be able to ovulate if you’re female,” Bennett says. “I was able to show them this is what the data is showing, and yeah, it’s pretty early, but they’re not finding anything in that direction yet. I had to remind them they’re adolescents and just starting their menstruation cycle so they’re probably not even on their regular cycle anyway. You have to educate them on what’s a reputable place to look and what’s not.”
This type of education underscores another value of the athletic trainer, even as the position remains underfunded. Bennett has been at Lāna‘i for 16 years and now makes $68,000. She stays because of the quality of life in a laid-back – but very expensive – state. When she first began, her starting salary was $39,000 even with two master’s degrees. Teachers with a bachelor’s degree made almost twice as much.
“Being an athletic trainer is a very fun job,” Bennett says. “But when you look at the pay, you wonder how you can survive. Athletic trainers across the state are all working side jobs and moonlighting. We’re working hours that are like second shifts and don’t get night differential or holiday pay. It’s hard to take vacations because you have Christmas tournaments.”
Imagine more investment into this profession and higher salaries so more students might enter the athletic training field. Bennett says she could spend more time on preventive care, such as limiting concussions before they happen, if a part-timer was hired to help with rehab.
“Not only are we helping the state with legal protections, we’re helping the families as well,” she says. “They don’t have to take that athlete to the clinic for every ankle sprain or finger dislocation. We’re helping them prevent that cost, especially if they don’t have insurance.”
Strategies that Lāna‘i High and Elementary School use that stood out as exemplary to the Aspen Institute and our project advisory board:
Sleep in gyms to save costs
The costs can be astronomical for Lāna‘i to play road games via airplane or ferry to other islands. To save on extravagant hotel costs, many teams sleep on cots or air mattresses in their opponents’ gym or wrestling room. “It’s very fun when you travel,” says three-sport athlete Talia Agliam. “You get to know everybody a little better, especially if there’s someone on the team you haven’t really talked to.”
Plan for worst-case travel scenarios
Travel is a financial and logistical headache for many rural schools. It’s even worse if something unexpected happens, such as a bus or van that breaks down. That’s why Lāna‘i Athletic Director Roderick Sumagit has backup plans for road trips, including if the ferry is closed due to weather. He keeps in contact with nearby athletic directors if help is needed and employs several roadside services. “You can’t plan enough,” Sumagit says.
Identify community partnerships to build capacity
The Lāna‘i High and Elementary School (LHES) Foundation is an important asset. It’s something of a hybrid – partly Parent Teacher Association and partly education-focused nonprofit – that focuses on youth events and programs involving the arts, STEM and athletics in non-school hours. For athletics, examples of LHES support includes paying for insurance, creating flag football and baseball activities, and providing funding for a basketball shooting machine and an online college recruiting service to promote athletes.