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Systematic review
Focus areas and methodological characteristics of North American-based health disparity research in sports medicine: a scoping review
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  1. Stephanie A Kliethermes1,2,
  2. Irfan M Asif3,
  3. Cheri Blauwet4,5,
  4. Leslie Christensen6,
  5. Nailah Coleman7,
  6. Mark E Lavallee8,
  7. James L Moeller9,
  8. Shawn F Phillips10,
  9. Ashwin Rao11,
  10. Katherine H Rizzone12,
  11. Sarah Sund2,
  12. Jeffrey L Tanji13,
  13. Yetsa A Tuakli-Wosornu14,
  14. Cleo D Stafford II15
  1. 1 Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, Wisconsin, USA
  2. 2 The American Medical Society For Sports Medicine, Leawood, Kansas, USA
  3. 3 Family and Community Medicine, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
  4. 4 Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation; Spaulding Hospital/Brigham and Women’s Hospital, Harvard Medical School, Charlestown, Massachusetts, USA
  5. 5 Kelley Adaptive Sports Research Institute, Boston, Massachusetts, USA
  6. 6 Department of Library Science, University of Wisconsin-Madison, Madison, Wisconsin, USA
  7. 7 Pediatric Primary Care, Children's National Hospital, Washington, District of Columbia, USA
  8. 8 Department of Orthopedics, UPMC, Harrisburg, Pennsylvania, USA
  9. 9 Orthopaedic Surgery, West Virginia University, Morgantown, West Virginia, USA
  10. 10 Department of Family and Community Medicine, Penn State Health, Mount Joy, Pennsylvania, USA
  11. 11 Family Medicine, University of Washington, Seattle, Washington, USA
  12. 12 Orthopaedics, University of Rochester Medical Center, Rochester, New York, USA
  13. 13 Orthopedics, UC Davis Sports Medicine, Sacramento, California, USA
  14. 14 Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, Connecticut, USA
  15. 15 Department of Orthopaedics and Rehabilitations Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
  1. Correspondence to Dr Stephanie A Kliethermes, Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, WI 53705, USA; kliethermes{at}ortho.wisc.edu

Abstract

Objective Health disparities are widely prevalent; however, little has been done to examine and address their causes and effects in sports and exercise medicine (SEM). We aimed to summarise the focus areas and methodology used for existing North American health disparity research in SEM and to identify gaps in the evidence base.

Design Scoping review.

Data sources Systematic literature search of PubMed, Scopus, SPORTDiscus, CINAHL Plus with Full Text, Web of Science Core Collection and Cochrane Central Register of Controlled Trials.

Eligibility criteria Full-text, peer-reviewed manuscripts of primary research, conducted in North America; published in the year 2000 or after, in English; and focusing on organised sports were included.

Results 103 articles met inclusion criteria. Articles were classified into five focus areas: access to and participation in sports (n=45), access to SEM care (n=28), health-related outcomes in SEM (n=24), provider representation in SEM (n=5) and methodology (n=1). Race/ethnicity (n=39), socioeconomic status (n=28) and sex (n=27) were the most studied potential causes of health disparities, whereas sexual orientation (n=5), location (rural/urban/suburban, n=5), education level (n=5), body composition (n=5), gender identity (n=4) and language (n=2) were the least studied. Most articles (n=74) were cross-sectional, conducted on youth (n=55) and originated in the USA (n=90).

Conclusion Health disparity research relevant to SEM in North America is limited. The overall volume and breadth of research required to identify patterns in a heterogeneous sports landscape, which can then be used to inform positive change, need expansion. Intentional research focused on assessing the intersectionality, causes and consequences of health disparities in SEM is necessary.

  • Health promotion
  • Sports medicine

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

https://doi.org/10.1136/bjsports-2023-107607

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    WHAT IS ALREADY KNOWN ON THIS TOPIC

    • Health disparities disproportionately impact underserved and under-represented populations, leading to restricted access to healthcare and lower quality of care.

    • In sports and exercise medicine (SEM), there have been efforts to identify and investigate health disparities in areas such as injury prevention, diagnosis, access to care and management of injuries.

    WHAT THIS STUDY ADDS

    • Most North American health disparity research in SEM focuses on the populations being cared for, with less research on sports medicine professionals, the sports medicine profession itself or the dynamic interaction between patients, clinicians and the SEM field which operates as a multilayered and interdependent system.

    • Many North American studies measure multiple potential causes for health disparities; however, most of these studies only consider these potential causes in isolation when compared with the outcome. The assessment of the intersection of multiple potential causes (eg, rural adaptive athletes) and their impact on health disparities in SEM is an important research gap in this area.

    • There is a need for methodological guidance on how to appropriately conduct health equity research in SEM.

    Introduction

    Health disparities disproportionately impact historically underserved and under-represented populations, leading to restricted access to healthcare and lower quality of care. While these inequities have been shown to lead to negative health outcomes and poor quality of life,1 little has been done to understand and address their causes and effects, particularly in the field of sports and exercise medicine (SEM). Health disparities, defined as a particular type of health difference that is closely linked with social, economic and/or environmental disadvantage,2 are evident across all facets of healthcare, encompassing inadequate access to care, reduced healthcare utilisation and elevated rates of morbidity and mortality.3 They predominantly arise due to inequities experienced by individuals with a historical background of oppression or among those who have faced significant challenges related to specific social determinants of health (ie, non-medical factors that influence health outcomes).4 It has been shown that sports participation and regular physical activity have positive impacts on physical, mental and emotional well-being. Differences in activity levels reduce life expectancy and quality of life for members of underserved and under-represented groups in the USA.5 6 Increasingly, members of the sports medicine community are calling for more research and attention on health disparities and their implications in all areas of sports.7–10 Ultimately, eliminating health disparities and inequities in SEM will require increased understanding about their causes and the formulation of multifaceted and sustainable interventions for health promotion and delivery of appropriate care for diverse populations.

    Research gaps in health equity within the SEM field hinder sports medicine clinicians from implementing evidence-based strategies that promote health and well-being in diverse populations. The sports ecosystem is complex and interdependent,11 meaning decisions and actions within this ecosystem have varying effects on athletes and individuals from different backgrounds. Many individuals may also belong to more than one underserved and/or under-represented group creating numerous layers of intersection. This complexity, and the intrinsic intersectionality of health disparities, makes the study of health disparities in SEM challenging. It is therefore vitally important to identify the root cause/source of various social determinants of health on health outcomes. As such, there is a demonstrated need for a scoping review of existing literature regarding health disparities in SEM and their implications on clinical practice, to help inform the development of a research agenda and an approach for addressing the most critical issues related to inequities in SEM

    In April 2023, the American Medical Society for Sports Medicine’s Collaborative Research Network hosted a research summit ‘Sports Medicine for All: A CRN Research Summit on Justice, Equity and Inclusion’ to, in part, highlight research on health disparities in SEM and identify existing knowledge gaps. As part of this work, a team of summit leaders conducted this scoping review to summarise (1) focus areas of existing health disparity research in SEM and (2) existing methodology used in current health disparity SEM research. This review not only highlights gaps that require attention but also provides recommendations for researchers seeking to conduct future studies in this space.

    Research questions

    The following research questions were used to guide the scoping review:

    1. What are the existing focus areas of current evidence in North America regarding health disparities, and their potential causes and consequences, in sports medicine?

    2. What methodology has been used in current North American research on health disparities, and their potential causes and consequences, in sports medicine?

    The scope of these research questions was narrowed from the original question of interest due to the large number of retrieved articles. The original question was as follows: what evidence exists on health disparities and potential causes of health disparities in SEM? Details on a posteriori changes to the review protocol are described in online supplemental table S1.

    Supplemental material

    Objectives

    We aimed to categorise existing sports medicine research into broad focus areas or research themes related to health disparities. Within each focus area, we further categorised each article based on the potential cause(s) of health disparities (eg, social determinants of health) that the study assessed in relation to its primary outcomes. We also aimed to characterise various methodological aspects of the existing studies, including study design, population studied, primary outcome measures and any measurement instrument(s) used to assess health disparities.

    Methods

    This scoping review was conducted in accordance with the updated 2021 scoping review guidance from JBI12 and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Review guidelines.13 An unpublished protocol was developed using the Arksey and O’Malley framework for scoping reviews14 and was agreed on by the authors and members of other summit working groups prior to beginning the scoping review.

    Equity, diversity and inclusion statement

    This work sought to assess the current SEM literature and uncover areas in which SEM research priorities and clinical guidelines have inadequately addressed equity and diversity in the field. In order to produce an appropriate end product, our author team was specifically designed to be gender, perspective, age, ability and culturally balanced. Junior and senior faculty members from various SEM-related disciplines and professions in North America carried out the project together, and formal consensus was sought at regular intervals, so data were synthesised, interpreted and presented in a balanced way.

    Sources

    Studies were included if they met the following inclusion criteria: peer-reviewed primary research, focused on assessing existing health disparities or their causes and consequences in sports medicine, conducted in North America, published in the year 2000 or beyond and with full text available in English. The year 2000 was chosen to ensure that included articles represented current understandings of social determinants of health and health disparities and because in the development of our search strategy, we identified few articles available prior to this year. Studies were limited to North America due to concerns over the time and resource constraints necessary to synthesise the immense number of articles available for a global review while accurately and effectively accounting for the different contextual and sociopolitical meanings of various social determinants of health across the world. Studies were excluded if they were systematic reviews, editorials/commentaries, other types of reviews, published abstracts without full text or ongoing research. An additional inclusion criterion was added a posteriori (at the beginning of the abstract screening process) due to the overwhelming number of articles captured related to physical activity. To keep the project feasible, the investigators further limited the retrieved articles to those involving organised sports, defined as follows:

    Organised sports is every recreational or competitive sporting activity that is as follows: voluntary, which takes place within the context of a club or organisation outside the school curriculum and involves an element of training or instruction, including sports camps and organised extracurricular sporting activities at school. We exclude physical education (PE), as governance for PE lessons falls within the education sector rather than the sports sector. We also exclude informal or casual sports activities (eg, self-organised running and swimming) and other informal physical activities (eg, dog walking and gardening).15

    Search strategy

    The search strategy focused on two general concepts: (1) sports medicine/athletes and (2) health disparities and inequities. Using these concepts, the search strategy was developed, tested and finalised in collaboration with a librarian (LC) at the University of Wisconsin-Madison Ebling Library. The detailed search strategies are available in online supplemental table S2. A search was conducted in the following databases from database inception to 6 June 2022 without any language, age or date restrictions: PubMed, CINAHL Plus with Full Text (EBSCO), SPORTDiscus (EBSCO), Scopus (Elsevier), the Cochrane Central Register of Controlled Trials (Wiley) and Science Citation Index Expanded, Social Sciences Citation Index and Emerging Sources Citation Index as a multifile search in the Web of Science Core Collection (Clarivate). Results were downloaded to EndNote (Clarivate) and underwent manual deduplication by LC using the method described by Bramer.16 Unique records were uploaded to Covidence (Veritas Health Information, Melbourne, Australia) for further screening and review by the study team.

    Study selection

    The inclusion and exclusion criteria were pilot tested on the first 50 abstracts for initial title and abstract screening, and all study team members reviewed the results prior to beginning the screening process. For efficiency, 9 of the 12 investigators participated in the initial title and abstract screen and determined if full-text articles should be reviewed for potential inclusion. All articles were independently screened by two investigators, and, if there was a disagreement, a third independent investigator who did not participate in the primary screening process (YTW or KHR) adjudicated conflicts. Articles that made it to full-text review prior to the change in study inclusion (ie, must include organised sport) were pushed back to abstract screening and review for the study team to revisit. Authors of abstracts were contacted, when needed, to obtain the full text of an abstract that could not otherwise be located. A similar screening process was used for full-text reviews; all full texts were reviewed independently by two study team members, with conflicts resolved by a third member who was not part of the primary review.

    Data extraction

    Prior to beginning data extraction, investigators reviewed and agreed on the information to be extracted. Extracted information included aims of study, study design, country in which the study originated, potential causes of health disparities assessed, primary focus area, measurement instruments used, method of recruitment, study setting, number of participants, baseline population characteristics, primary study outcome measured and the study conclusion. An extraction template was created in Covidence, and investigators collectively reviewed a handful of articles using the template to ensure that data extraction was consistent. After this review, minor refinements were made to the template to enhance the clarity and accuracy of the data being extracted. Two investigators independently extracted data from the included articles and a third investigator, who was not part of the primary review, adjudicated any differences.

    Results

    The initial search, after library deduplication, identified 9355 articles for title and abstract screening (online supplemental table S3). Following title and abstract screening, 245 full texts were reviewed, and 103 met the specified inclusion and exclusion criteria (figure 1). Primary reasons for study exclusion were a study focus different than health disparities (n=31), studies outside of North America (n=30), not focused on organised sports (n=23) or not primary research (n=15).

    Figure 1
    Figure 1

    Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram for scoping review.

    Overall

    The included research articles were classified into five mutually exclusive primary focus areas during the data extraction phase: (1) access to and participation in sports, (2) access to SEM care, (3) health-related outcomes in SEM, (4) study methodology and (5) provider representation in SEM (table 1, online supplemental table S4). Most included studies were related to access to and participation in sports (n=45, 44%),17–61 followed by access to SEM care (n=28, 27%),62–89 health-related outcomes in SEM (n=24, 23%),90–113 provider representation in SEM (n=5, 5%)114–118 and methodology (n=1, 1%).119

    View this table:
    Table 1

    Number of articles identified (n=103) by primary domain and potential causes of health disparities

    Across all domains, race/ethnicity (n=40, 39%), socioeconomic status (SES, n=27, 26%) and sex (n=27, 26%) were the most studied potential causes of health disparities (table 1). Insurance (n=14, 14%), age (n=14, 14%) and physical ability (n=12, 12%) were also frequently studied across all domains. Gender identity (n=4, 4%) and language (n=2, 2%) were the least studied potential causes. Figure 2 shows the various combinations of potential causes of health disparities that were assessed and the number of articles that addressed these combinations. The combination of race/ethnicity and sex was the largest combination, with 13 articles looking at both characteristics (and in some cases additional characteristics) in relation to health disparities.21 32 35 62 95 97 103 105 107 108 115 116 118

    Figure 2
    Figure 2

    Upset plot of the number of articles identified within a potential cause(s) of health disparities across primary domains. The vertical bar chart represents the number of articles identified that reported a particular combination of potential causes of health disparities. The graphical table underneath shows the combinations. The horizontal bar chart displays the unconditional frequency of each factor studied across all articles. SEM, sports and exercise medicine; Ability-P, physical ability; Ability-I, intellectual ability; SES, socioeconomic status. Other category includes athletic identity, occupational characteristics and family structure.

    Access to and participation in sport

    Numerous gaps were noted when identifying potential causes of health disparities studied within each focus area specifically. Although SES (n=15 articles),22 24 29–31 34–37 40 44 47–49 race/ethnicity (n=12),19–21 25 32 35 40 47 49 52 55 57 sex (n=11)21 23 26 27 32 34–36 38 58 60 and physical ability (n=10)17 18 20 28 39 43 50 51 53 56 were well represented within the access to and participation in sports domain, certain topic areas, such as body composition (n=3),25 38 47 educational level (n=3)24 49 52 and sexual orientation (n=2),23 45were under-represented in the literature captured (figure 3A). Moreover, other potential causes of disparities such as location (urban, suburban and rural), insurance status, primary language and gender identity retrieved zero articles within this domain.

    Figure 3
    Figure 3

    Upset plot of the number of articles identified within a potential cause(s) of health disparities by primary domain. The vertical bar chart represents the number of articles identified that reported a particular combination of potential causes of health disparities. The graphical table underneath shows the combinations. The horizontal bar chart displays the unconditional frequency of each factor studied across all articles. SEM, sports and exercise medicine; Ability-P, physical ability; Ability-I, intellectual ability; SES, socioeconomic status. Other category includes athletic identity, occupational characteristics and family structure.

    Access to sports and exercise medicine care

    Within the access to SEM care domain, insurance (n=11 articles)62 64 66 67 74 77 78 82 88 89 and SES (n=7)65 68 72 73 79 80 82 were most represented (figure 3B), while other areas, such as intellectual ability, body composition and education level, were not studied at all. Additionally, only one article81 was identified that considered physical ability as it relates to access to sports medicine care.

    Health-related outcomes in sports medicine

    Of the 24 articles identified in the health-related outcomes in sports medicine domain, race/ethnicity was the dominant potential cause of health disparities identified (n=20 articles, figure 3C).86 90–93 95 97–99 101 103–108 110–113 Other causes such as ability (both physical94 and intellectual,96 education level,103 location, language, nationality, gender identity and sexual orientation) were under-represented in this domain, with one article or no articles identified. Health-related outcomes assessed in this set of manuscripts included athlete survival/mortality, mental health and quality of life, sports-related injury, health literacy and incidence and symptoms of sports-related concussion.

    Provider representation in sports and exercise medicine

    Many gaps were identified in the provider representation in SEM domain (figure 3D). Considerations of sex were considered in all articles classified into this domain, whereas implications of race/ethnicity (n=3)115 116 118 and age (n=1)116 were the only other potential causes of health disparities considered in the included articles. Notably, research on provider representation as it relates to location, language, nationality, sexual orientation and ability were not identified in this review.

    Study methodology

    There was only one study captured in the methodology domain, which looked at age, education level and sex.119 The particular methodological focus of this study was to identify risk factors associated with failure to complete patient-reported outcome measures in a prospective anterior cruciate ligament reconstruction study.

    Methodological characteristics of studies

    Most included studies used a cross-sectional study design (n=74), which was inclusive of retrospective cohort studies (table 2, online supplemental table S5). 18 studies included qualitative methodology,21 31 33 35 39 43 46 53 54 56 61 69 75 87 94 95 117 118 with 3 using mixed methods.33 69 94 Nine studies were prospective cohort studies,27 28 60 68 77 89 90 107 119 and only two studies used a community-based participatory research framework.42 55 Of the populations studied, a majority focused on youth (n=55), followed by adults (n=18), college and university students (n=12), providers (n=11), professional athletes (n=5) and the general community (n=2) (table 2). Within studies focusing on youth, 24 studied youth in general (primarily from national datasets), 12 focused on athletes, 8 focused on youth with physical or intellectual disabilities, 7 were clinic oriented and 4 included aboriginal, indigenous or immigrant populations. Among the 18 articles focusing on adults, 5 focused on adults with physical or intellectual disabilities, 5 were clinic oriented and 4 focused on general adults and athletes. Most of the college and university studies focused on athletes (n=10), with only two focusing on the general population. Athletic trainers (n=6), orthopaedic surgeons (n=4) and physical therapists (n=1) were represented in studies on sports medicine providers. 90 studies were conducted solely in populations within the USA, 11 in Canada and 2 in both the USA and Canada. No North American studies originating from Mexico were identified (online supplemental table S6). Finally, studies were conducted in a variety of settings including community settings (n=27), primary and secondary schools (n=20), clinics (n=20), colleges and universities (n=16) and via national surveys, registries or databases (n=9).

    View this table:
    Table 2

    Study type and population studied of identified articles

    Discussion

    The primary purpose of this review was to summarise the focus areas and methodology used for existing health disparity research in SEM in North America and to identify gaps in the evidence base. From over 9000 articles reviewed, only 103 met the inclusion criteria. These results affirm the inherent complexity and paucity of investigations discussing health disparities and inequities in SEM. Although studies assessing access to and participation in sports and access to sports medicine care were well represented in this review, our investigation identified several gaps in the literature related to specific causes of disparities that have not been addressed.

    We examined health disparities in sports medicine research across five primary focus areas: (1) access to and participation in sports, (2) access to sports medicine care, (3) health-related outcomes in sports medicine, (4) study methodology and (5) provider representation in sports medicine. Unsurprisingly, race/ethnicity, SES and sex were the three most commonly studied causes of health disparities across all domains. Our study uncovered significant gaps in certain topic areas, such as body composition, education level, sexual orientation, location (urban, suburban and rural), gender identity and primary language which were all under-represented in the literature (n=5 or fewer articles identified). Importantly, only one study focused on research methodology in this space. The most common study design was cross-sectional, including retrospective cohort studies. Although relatively easy to conduct in comparison to other research designs, cross-sectional studies cannot determine causation, limiting their ability to explain the impact of health disparities in SEM. While qualitative methodology was also used, mixed methods and community-based participatory research were used much less frequently. In many cases, these study designs may provide the richest data regarding health disparities due to their ability to capture quantitative outcomes and qualitative rationale and reasoning informing those outcomes.

    Intersectionality of these topics on health outcomes was not readily studied. 13 articles considered outcomes related to both race/ethnicity and sex in the same study; even fewer (n=5)21 35 95 115 118 considered the actual intersection of race/ethnicity and sex on health and sports-related outcomes (eg, black female). Similarly, the importance of the intersection of race/ethnicity and SES on health outcomes has been observed in various areas of healthcare research.120 121 A growing body of evidence suggests that institutional and systemic racism plays a role in poor health outcomes, in part due to individuals from racialised backgrounds being more likely in lower SES communities because of the racial wealth gap.122 123 Despite these findings in the broader medical community, our SEM-focused review only identified nine articles reporting on both race/ethnicity and SES in the same study, and of those nine studies, three40 68 92 considered the impact of the intersection of the two (eg, low-income Hispanic patient) on health outcomes. These findings should encourage future SEM research to include the evaluation of the potential impacts on patients who belong to multiple under-represented groups with regard to their access to sports medicine care and health-related outcomes.

    Beyond race/ethnicity, sex and SES, our investigation identified large gaps in the literature related to ability (physical and intellectual), gender identity and sexual orientation in SEM. 83% (10/12) and 86% (6/7) of the articles that considered physical and intellectual ability, respectively, as a potential cause of health disparities looked at their role in relation to access and participation in sports. Only one article considered physical ability as it relates to access to sports medicine care,81 and no articles (for both physical and intellectual ability) were identified in relation to provider representation in SEM. Future studies that differentiate between physical, intellectual and sensory disabilities as well as the intersection of multiple disabilities will add to our understanding of disability for athletes. Similarly, the review located only five articles that assessed health disparities with regard to sexual orientation,23 45 69 76 84 three of which were related to access to sports medicine care. Only four articles focused on gender identity,69 75 76 84 and they all related to access to SEM care, with zero identified in relation to access to and participation in sports. These findings are consistent with gaps in other aspects of the medical literature for these marginalised groups.124–126 As the SEM community continues to strive for equitable care for all individuals, the sizeable gaps in knowledge reported here should provide guidance to future research efforts aimed at identifying causes and consequences of inequities in this field.

    Limitations

    Although this scoping review aimed to review a broad swath of the SEM literature, there are some limitations that should be mentioned. In the development of the search strategy, it was determined that a focus on sports medicine and athletes was necessary to keep the project feasible. Therefore, specific words, such as exercise or physical activity, which are inherent to SEM, were not included in the search. As a result, articles that are relevant to SEM may have been missed in the initial search. The search was also limited to North America due to feasibility concerns regarding the ability to accurately and effectively synthesise the global evidence base in the given timeframe. As such, the findings from this study cannot and should not be extrapolated to represent our global understanding of health disparities in SEM. There is a need for further research to fully understand focus areas and gaps in health disparities in SEM globally, especially in low-income and middle-income countries. We hope this review can serve as a guiding template to growing our understanding of health disparities in SEM worldwide. Moreover, due to the number of retrieved articles that included physical activity, the decision was made a posteriori during the title and abstract screen to further limit articles to only those involving organised sports. Again, this necessarily limited the focus of the scoping review and introduces a potential selection bias against certain groups that are known to be affected by health disparities (eg, elderly, young kids and individuals with intellectual disabilities) because they are less likely to participate in organised sports. Future reviews may choose certain subsets of the identified categories that would be important to explore further, while striving to be inclusive of these groups. Finally, although scoping reviews provide a systematic framework for (1) better understanding of the dimensions and framework of a given topic and (2) determining gaps in the literature, studies are not regularly assessed for quality. This review did not assess the quality of included articles, nor did it aim to synthesise what we know about health disparities in SEM from the included articles.

    Nevertheless, our current work should assist with illuminating the existing landscape of health disparity research in SEM and propel efforts towards eliminating these inequities with subsequent research in needed areas identified as part of this review.

    Conclusion

    Although general health disparity research is prevalent in SEM, there is still a paucity of research when it comes to assessing the impact of certain social determinants of health on sports medicine-related outcomes. Even within the more prevalent categories (race/ethnicity, socioeconomic status and sex) and focus areas (access to and participation in sports and access to SEM care), the overall volume of research necessary to identify patterns in the heterogeneous and interdependent sports landscape that can then be used to inform positive change is limited. Thus, we have numerous recommendations for intentional research on health disparities in the field (figure 4). Despite the limited available data, this review elucidates the need for researchers, policy makers and clinicians to consider the intersectionality of patient backgrounds and experiences on health outcomes, as well as their position(s) within the broader sports medicine ecosystem, when conducting research, creating policy or providing care. Future sports medicine research should strive to include a more diverse and representative sample of sports people (eg, athletes, clinicians and coaches) and incorporate more diverse methodological approaches, such as prospective cohort studies, community-based participatory research, user-friendly qualitative methodologies (eg, photovoice and document analysis) and mixed methods. Increased focus on better understanding the existence of health disparities in SEM is important, yet research in the field should also seek to identify interventions that successfully reduce these health disparities. Together, these efforts will facilitate a more comprehensive understanding of health disparities in SEM, their underlying determinants and the interaction of intersectional athlete experiences and SEM structures, with the goal of advancing SEM, augmenting the SEM evidence base, and improving outcomes in underserved and under-represented athletes.

    Figure 4
    Figure 4

    Recommendations for sports medicine researchers conducting health disparity research. SDOH, social determinants of health.

    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplementary information.

    Ethics statements

    Patient consent for publication

    Ethics approval

    Not applicable.

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    Footnotes

    • Twitter @stephklie2, @CheriBlauwetMD, @jmoellermd, @badash13, @YetsaTuakli, @CleoStaffordMD

    • Contributors All authors meet the requirements for authorship. Specifically, SAK and LC developed the search approach, LC performed the literature search and all authors contributed to article review, selection and extraction. SAK and CDS II drafted the initial review, and all authors critically reviewed and revised the work. All authors approved the final draft of this manuscript prior to submission. SAK serves as the guarantor of this manuscript and accepts full responsibility for the work and conduct of the study.

    • Funding Research reported in this publication was supported, in part, by the National Institute on Minority Health And Health Disparities of the National Institutes of Health under Award Number R13MD018272. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

    • Competing interests SAK, YAT-W and AR are associate editors for BJSM.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.