Perceived social norms and concussion-disclosure behaviours among first-year NCAA student-athletes: implications for concussion prevention and education

A Biopsychosocial Model for Understanding Training Load, Fatigue, and Musculoskeletal Sport Injury in University Athletes: A Scoping Review

ABSTRACT

McClean, ZJ, Pasanen, K, Lun, V, Charest, J, Herzog, W, Werthner, P, Black, A, Vleuten, RV, Lacoste, E, and Jordan, MJ. A biopsychosocial model for understanding training load, fatigue, and musculoskeletal sport injury in university athletes: A scoping review. J Strength Cond Res 38(6): 1177-1188, 2024-The impact of musculoskeletal (MSK) injury on athlete health and performance has been studied extensively in youth sport and elite sport. Current research examining the relationship between training load, injury, and fatigue in university athletes is sparse. Furthermore, a range of contextual factors that influence the training load-fatigue-injury relationship exist, necessitating an integrative biopsychosocial model to address primary and secondary injury prevention research. The objectives of this review were (a) to review the scientific literature examining the relationship between training load, fatigue, and MSK injury in university athletes and (b) to use this review in conjunction with a transdisciplinary research team to identify biopsychosocial factors that influence MSK injury and develop an updated, holistic biopsychosocial model to inform injury prevention research and practice in university sport. Ten articles were identified for inclusion in this review. Key findings were an absence of injury surveillance methodology and contextual factors that can influence the training load-fatigue-MSK injury relationship. We highlight the inclusion of academic load, social load, and mental health load as key variables contributing to a multifactorial, gendered environmental, scientific inquiry on sport injury and reinjury in university sport. An integrative biopsychosocial model for MSK injury in university sport is presented that can be used to study the biological, psychological, and social factors that modulate injury and reinjury risk in university athletes. Finally, we provide an example of how causal inference can be used to maximize the utility of longitudinally collected observational data that is characteristic of sport performance research in university sport.

Applying the National Institute on Minority Health and Health Disparities Research Framework to Social Determinants of Health in the Context of Sport-Related Concussion: A Clinical Commentary

Sport-related concussion (SRC) is a prevalent injury. Significant disparities in SRC outcomes exist across racial and ethnic groups. These disparities may be attributed to the unequal distribution of political power (or influence) and resource allocation in various communities, shaping individuals' social determinants of health (SDOH). However, the influence of SDOH on SRC outcomes remains understudied. In this clinical commentary, we use the National Institute on Minority Health and Health Disparities Research Framework and describe how its application can help address gaps in our understanding of SDOH and SRC. This framework provides a comprehensive approach to investigating and addressing health disparities by considering SDOH along multiple levels and domains of influence. Using this framework, athletic trainers can identify areas requiring intervention and better understand how SDOH influence SRC outcomes. This understanding can help athletic trainers develop tailored interventions to promote equitable care for patients with SRC.

Determinants of Intention to Disclose Musculoskeletal Injury in Adolescent Athletes

CONTEXT

Although research indicates that the key to minimizing the effect of musculoskeletal injury, improving care, and mitigating long-term effects is to improve early injury care seeking, little is known about barriers to early musculoskeletal injury disclosure and care seeking.

OBJECTIVE

To identify which determinants predicted sport-related musculoskeletal (MSK) injury disclosure by adolescent athletes.

DESIGN

Cross-sectional study.

SETTING

Online survey.

PATIENTS OR OTHER PARTICIPANTS

A total of 564 adolescent athletes (58% male, age = 15.81 ± 1.8 years).

MAIN OUTCOME MEASURE(S)

Online survey exploring determinants of age, gender, race, socioeconomic status, injury knowledge, attitudes, perceived social norms, and perceived behavioral control surrounding MSK injury disclosure, intention to disclose MSK injury, and actual behavior of disclosing MSK injury.

RESULTS

Of the respondents, 457 (80.2%) reported having sustained ≥1 (mean = 3.2 ± 2.2; range = 1-10) MSK injuries related to sport. Those who endorsed having experienced an MSK injury disclosed not reporting or purposefully hiding 77% of their suspected MSK injuries. Several factors influenced a high intention to disclose MSK injury. Specifically, for each unit increase in total MSK injury knowledge (Exp[β] = 1.061, β=0.054, P = .020, 95% CI = 1.031, 1.221) and attitude (Exp[β] = 1.070, β = 0.064, P < .001, 95% CI = 1.027, 1.115) score, 6% and 7% increases in the likelihood of a high intention to disclose an MSK injury, respectively, were observed. Moreover, for each unit increase in the social norm score (Exp[β] = 1.178, β=0.164, P < .001, 95% CI = 1.119, 1.241), an 18% increase in the likelihood of a high intention to disclose an MSK injury was noted.

CONCLUSIONS

Designing interventions geared toward increasing the knowledge of signs and symptoms of MSK injury, improving attitudes surrounding disclosure, and better understanding the social context of disclosing MSK injuries may improve MSK injury disclosure behavior and reduce the associated social and economic burdens of these injuries.

Sex differences in college students' knowledge of concussion and concussion education sources

Aim

To understand sex differences and sources of concussion education for college students. The literature for college students primarily focuses on sports concussions and general knowledge. Understanding how non-students-athletes learn is critical to developing interventions to improve concussion knowledge.

Participants

A random sample of 208 students from four-year institutions.

Methods

A 22-question online survey explored postsecondary students' current knowledge and education regarding concussions.

Results

Findings indicated that sex differences emerged with concussion knowledge and sources of concussion knowledge (e.g., leaflets, pamphlets, parents, and television). The top choices for where they wanted to learn about concussions were health educators, health centers, and campus peer educators.

Conclusion

This study provides an initial evaluation and implications for future research on providing concussion education.

Randomized Evaluation of Centers for Disease Control and Prevention HEADS UP Concussion Education Materials for Youth Sport Coaches

The Centers for Disease Control and Prevention (CDC) HEADS UP youth sports coach materials are the most widely adopted form of concussion education for coaches across the United States-reaching millions of youth sports coaches over the last decade. These materials focus on concussion symptom identification, response, and management (e.g., return to school and sports), while also addressing the importance of communicating to athletes and their families about concussion safety. The purpose of this study was to assess the effectiveness of CDC HEADS UP materials on coach knowledge and communication with youth athletes about concussion safety. This is the first randomized control study of the CDC HEADS UP materials in real world youth sport conditions. Participants were 764 coaches at 15 YMCA associations. Cluster randomization was used to assign branches within associations to intervention (CDC HEADS UP) and control (treatment as usual) conditions. Coaches completed surveys prior to and at the end of the competitive season. Communication with athletes about concussion increased among coaches in the intervention group (adjusted risk ratio [aRR] = 1.24, 95% confidence interval [CI] = 1.14, 1.36) but not the control group (aRR = 1.09, 95% CI = 0.90, 1.31), in multi-variate analyses controlling for coach demographic characteristics and baseline communication practices. Concussion symptom knowledge and communication intentions also significantly increased in the intervention group but not in the control group. This study provides evidence that CDC HEADS UP materials increase the likelihood that youth sport coaches communicate with their athletes about concussion safety. As youth sports organizations increasingly mandate concussion education for coaches, CDC HEADS UP materials may be considered a leading resource for adoption and setting-relevant implementation.

The Identification and Comparison of Factors Affecting Musculoskeletal and Concussion Injury Disclosure

CONTEXT

Despite the increased risk of musculoskeletal (MSK) injury after a concussion, little is known about the determinants of such a risk. Moreover, the authors of previous reports of increased risk of MSK injury after a concussion have neglected to account for the high level of undisclosed concussions.

OBJECTIVE

To explore the association between the intention to disclose a possible concussion and the intention to disclose an MSK injury.

DESIGN

Cross-sectional study.

SETTING

Online survey.

PATIENTS OR OTHER PARTICIPANTS

One hundred seven National Collegiate Athletic Association Division I athletes (females = 79%, age = 19.4 ± 1.4 years).

MAIN OUTCOME MEASURE(S)

Online survey exploring determinants such as injury knowledge, attitudes, perceived social norms, and perceived behavioral control surrounding concussive and MSK injury disclosure.

RESULTS

A significant association between high intention to disclose a concussion and high intention to disclose an MSK injury (χ2 = 19.276, P < .001, Cramer V = 0.482) was observed. Spearman rank correlations suggested no correlation between concussion nondisclosure (25%) and MSK injury nondisclosure (52%). Multivariate binomial regressions indicated that perceived social norms were the strongest determinant (β = 1.365, P = .002) of high intention to disclose concussion, while attitudes toward MSK injury (β = 1.067, P = .005) and perceived social norms (β = 1.099, P = .013) were the strongest determinants of high intention to report MSK injury.

CONCLUSIONS

Individuals with high intention to report concussion symptoms also demonstrated high intention to report MSK injury. Strong positive associations were seen between known determinants of intention to disclose concussion and adapted versions of those same determinant domains in intention to disclose MSK injury. As those with high intention to disclose concussion also displayed high intention to disclose MSK injury, intention to disclose injuries generally may play a role in explaining the increase in MSK injury after a concussion.

Concussion Education for Athletes: Symptom Reporting and Safe Return to Sport

» Educational programs on concussion have been demonstrated to improve knowledge for athletes, families, athletic trainers, and coaches about concussion, with the goal of reducing concussion incidence, duration, severity, and complications.» Despite the widespread availability and often mandatory concussion education provided to high school and collegiate athletes, there has not been an adequate change in knowledge, attitudes, and self-reporting behavior in this population.» Recently published studies suggest improving concussion education by emphasizing athletes' symptom reporting behavior, to contrast with current emphasis on knowledge-based outcomes.» Future educational programs about concussions for athletes, families, athletic trainers, and coaches should aim to emphasize cultural and behavioral changes that demonstrate outcome changes rather than solely evaluating knowledge improvements to determine effective programming.

Factors and expectations influencing concussion disclosure within NCAA Division I athletes: A mixed methodological approach

BACKGROUND

Participation in sports is associated with many benefits to all aspects of health; however, it also comes with the risk of injury, particularly concussions. Self-disclosure and care seeking following a concussion are especially important because of the lack of outwardly visible signs and/or symptoms. Although recent research has explored factors affecting concussion disclosure, use of isolated methodologies limits the ability to contextualize how disclosure or nondisclosure occurs. Therefore, the purpose of this study was to describe the factors and expectations of National Collegiate Athletic Association (NCAA) athletes that may influence concussion disclosure.

METHODS

This mixed-methods convergent parallel research study included 25 NCAA Division I athletes representing 13 sports, all of whom completed a concussion-education session with pre-/post-test surveys and a semistructured interview. Eligible athletes were at least 18 years old and on an NCAA roster. The surveys focused on previous concussion-related disclosure behaviors, knowledge, attitudes, beliefs, norms, and intentions about disclosing concussion. Interviews focused on the athletes' experiences related to concussion disclosure. Survey data were analyzed using descriptive statistics and Mann-Whitney U tests. Interviews were analyzed using a Consensual Qualitative Research tradition.

RESULTS

Participants had good concussion knowledge (median = 46.0), positive attitudes (median = 38.0), strong beliefs (median = 13.0), and strong intentions to disclose concussion symptoms (median = 7.0). None of the constructs differed by participants' gender. Although quantitative findings were mostly positive, interview data highlighted factors that may explain why some participants are successful in disclosing concussions and why others may find disclosure difficult. Educational efforts, sport culture, and medical professional presence were the primary facilitators discussed by participants. Stigma, pressure, and a lack of team support were perceived as disclosure barriers.

CONCLUSION

The context in which concussion disclosure occurs or does not occur is vital to the success of educational interventions. Interventions must prioritize stakeholder- and team-based perspectives on concussion to establish a network supportive to disclosure.

Optimizing Concussion Care Seeking: Identification of Factors Predicting Previous Concussion Diagnosis Status

PURPOSE

There is limited understanding of factors affecting concussion diagnosis status using large sample sizes. The study objective was to identify factors that can accurately classify previous concussion diagnosis status among collegiate student-athletes and service academy cadets with concussion history.

METHODS

This retrospective study used support vector machine, Gaussian Naïve Bayes, and decision tree machine learning techniques to identify individual (e.g., sex) and institutional (e.g., academic caliber) factors that accurately classify previous concussion diagnosis status (all diagnosed vs 1+ undiagnosed) among Concussion Assessment, Research, and Education Consortium participants with concussion histories ( n = 7714).

RESULTS

Across all classifiers, the factors examined enable >50% classification between previous diagnosed and undiagnosed concussion histories. However, across 20-fold cross validation, ROC-AUC accuracy averaged between 56% and 65% using all factors. Similar performance is achieved considering individual risk factors alone. By contrast, classifications with institutional risk factors typically did not distinguish between those with all concussions diagnosed versus 1+ undiagnosed; average performances using only institutional risk factors were almost always <58%, including confidence intervals for many groups <50%. Participants with more extensive concussion histories were more commonly classified as having one or more of those previous concussions undiagnosed.

CONCLUSIONS

Although the current study provides preliminary evidence about factors to help classify concussion diagnosis status, more work is needed given the tested models' accuracy. Future work should include a broader set of theoretically indicated factors, at levels ranging from individual behavioral determinants to features of the setting in which the individual was injured.

Association between Sensation-Seeking Behaviors and Concussion-Related Knowledge, Attitudes, Perceived Norms, and Care-Seeking Behaviors among Collegiate Student-Athletes

There are limited data connecting personality and behavioral tendencies and traits related to concussion care-seeking/disclosure behaviors and minimal research exists surrounding the relationship between risky behaviors, sensation-seeking, and concussion-related outcomes. This study examined the association between sensation-seeking and a student-athlete's concussion-related knowledge, attitudes, perceived social norms, and concussion care-seeking/disclosure behaviors (intention to disclose concussion symptoms, perceived control over symptom disclosure, self-removal from play due to concussion symptoms, continued play with concussion symptoms, and disclosure of all concussions at the time of injury). The current study utilized a retrospective cohort of collegiate student-athletes at a single National Collegiate Athletic Association Division I institution. Separate multivariable linear regression models estimating mean differences (MD) and 95% Confidence Intervals (CI) estimated the association between sensation-seeking and concussion knowledge, concussion attitudes, and perceived social norms. Separate multivariable binomial regression models estimating adjusted prevalence ratios (PR) and 95%CI estimated the association between sensation-seeking and intention to disclose concussion symptoms, perceived control over symptom disclosure, self-removal from play due to concussion symptoms, continued play with concussion symptoms, and disclosure of all concussions at the time of injury. All models were adjusted for sex, sport participation, and concussion history. Higher sensation-seeking was significantly associated with less favorable concussion attitudes (adjusted MD = -1.93; 95%CI = -3.04,-0.83), less favorable perceived social norms surrounding concussion (adjusted MD = -1.39; 95%CI = -2.06,-0.72), and continuing to play while experiencing concussion symptoms (adjusted PR = 1.50; 95%CI = 1.10, 2.06). Student-athletes with increased sensation-seeking could be at risk for failing to disclose a concussion, decreasing athlete safety and resulting in less optimal care post-injury. Results will inform future theory-based concussion education programs which consider behavioral tendencies and traits as well as sport culture to promote concussion care-seeking/disclosure and individualized interventions based on risky behavior engagement.

Participating in Two Video Concussion Education Programs Sequentially Improves Concussion-Reporting Intention

Undiagnosed concussions increase the risk of additional concussion and persistent symptoms from concussion. Because there are no reliable objective markers of concussion, self-reporting of subjective and non-visible symptoms are critical to ensuring proper concussion management. For this reason, educational interventions target concussion reporting, but the majority of studies have examined the efficacy of single educational interventions or compared interventions to one another. This randomized crossover study sought to identify whether there was benefit to administering multiple concussion education programs in tandem, back to back. The study randomized 313 male high school football players to first receive CrashCourse concussion education (CC) or Centers for Disease Control and Prevention video concussion education (CDC) followed by crossover with the other education. Athlete concussion-reporting intention, attitudes, subjective norms, perceived behavioral control, and enjoyment of education were assessed at baseline and after each intervention. There were statistically significant improvements across all measures, both after single intervention and crossover (all p < 0.001). Secondary analyses examining differences between education found that athletes reported higher enjoyment of concussion education immediately after participating in CC, as compared to CDC (p < 0.001). These findings demonstrate an additive benefit to implementing CC and CDC education in tandem, without decrement in enjoyment of concussion education after experiencing dual educations; in fact, enjoyment of concussion education improved after receiving education programs back to back. These educational programs appear to complement one another, and the results support the use of multi-modal concussion education to differentially target and maximize concussion reporting.

Examining Concussion Nondisclosure in Collegiate Athletes Using a Health Disparities Framework and Consideration of Social Determinants of Health

CONTEXT

Limited research exists concerning the relationship between the social determinants of health (SDOHs), including race, socioeconomic status (SES), health care access and physical environment and concussion nondisclosure in collegiate athletes. However, among high school athletes, disparities have been noted, with Black athletes who attended under-resourced schools and lacked access to an athletic trainer (AT) disclosing fewer concussions.

OBJECTIVE

To investigate whether concussion nondisclosure disparities existed by (1) race, (2) SES, or (3) AT health care access before college and understand the differential reasons for concussion nondisclosure between White and Black collegiate athletes.

DESIGN

Cross-sectional study.

SETTING

Collegiate athletics.

PARTICIPANTS

A total of 735 college athletes (84.6% White, 15.4% Black).

MAIN OUTCOME MEASURE(S)

Participants completed a questionnaire that directly assessed concussion nondisclosure, including reasons for not reporting a suspected concussion. With the premise of investigating SDOHs, race was the primary exposure of interest. The outcome of interest, nondisclosure, was assessed with a binary (yes or no) question, "Have you ever sustained a concussion that you did not report to your coach, AT, parent, teammate, or anyone else?"

RESULTS

Among the White and Black athletes, 15.6% and 17.7%, respectively, reported a history of concussion nondisclosure. No differences were found by race for distributions of history of concussion nondisclosure (P = .57). Race was not associated with concussion nondisclosure when evaluated as an effect modification measure or confounder, and no significant associations were noted by SES or high school AT access. Differences by race for reported reasons for nondisclosure were present for "At the time, I did not think it was a concussion" (P = .045) and "I thought my teammates would think I am weak" (P = .03), with Black athletes selecting these more frequently than White athletes.

CONCLUSIONS

These data help to contextualize race and its intersection with other SDOHs that could influence concussion nondisclosure outcomes in collegiate athletes.

Leadership Lessons in Concussion Management for Team Physicians

Over the last decade, with emphasis on concussion awareness and potential long-term deficits, concussions have become a public health concern. Although common, concussions are complex in nature and often require a collaborative treatment approach across multiple disciplines. In an athletic setting, the Team Physician plays a critical leadership role in the organization, management, and provision of care for concussed athletes. However, leadership strategies for the provision of concussion care utilized by the Team Physician have not been adequately described. This manuscript intends to describe advanced planning for concussion management and highlight best practices for the provision of care for the concussed athlete, to assist the Team Physician in coordinating optimal care. Specific emphasis will be placed on outlining a concussion management protocol aligned with evidence-based best practices.

Epidemiology of Injuries in National Collegiate Athletic Association Men's Ice Hockey: 2014-2015 Through 2018-2019

CONTEXT

The National Collegiate Athletic Association has supported men's ice hockey, a distinct sport that mandates high-velocity gamesmanship, since 1974.

BACKGROUND

Injury surveillance systems are designed to identify evolving injury trends and their temporal qualities. Continual monitoring of collegiate men's ice hockey athletes remains essential.

METHODS

Exposure and injury data collected in the National Collegiate Athletic Association Injury Surveillance Program from 2014-2015 through 2018-2019 were analyzed. Injury counts, rates, and proportions were used to describe injury characteristics, and injury rate ratios (IRR) were used to examine differential injury rates.

RESULTS

The overall injury rate was 7.65 per 1000 athlete-exposures. Injuries from competition occurred at a rate nearly 7 times that from practice injuries (IRR = 6.54, 95% CI = 6.08, 7.04). The most common specific injury diagnoses were concussions (9.6%), acromioclavicular sprains (7.3%), and medial collateral ligament tears (3.7%).

SUMMARY

Injury rates by event type and season segment were higher than previously reported. Contusions accounted for nearly a quarter of all injuries, and acromioclavicular sprain rates increased notably across the study period.

Pluralistic Ignorance as a Contributing Factor to Concussion Underreporting

BACKGROUND

Concussion underreporting is endemic, and social norms are an established predictor of concussion reporting behavior. However, pluralistic ignorance-a situation in which most individuals in a group hold the belief that their peers' views differ from their own, despite views actually being similar-has not been studied in this context.

AIM

To assess whether pluralistic ignorance contributes to concussion underreporting.

METHOD

We surveyed 2,504 military service academy cadets. Each cadet was presented with a survey asking about their willingness to self-report a concussion, their perception of other cadets' willingness to report a concussion, and personal and demographic factors.

RESULTS

Most cadets viewed themselves as more willing to report a concussion than others (mean difference = 1.12, 95% CI [1.02, 1.21]), a belief consistent with pluralistic ignorance. Demographic characteristics were associated with holding this belief. For example, female cadets and upper-class cadets were more likely to show this disparity than male or under-class cadets, respectively. Collegiate athletes not only showed similar willingness to report concussion as nonathletes but also perceived other cadets as less likely to report concussions. Meanwhile, future pilots showed less self-report willingness and perceived that others were similarly unwilling to report concussions.

DISCUSSION

A majority of this economically and geographically diverse population displays characteristics of pluralistic ignorance: They largely share proconcussion reporting sentiments but incorrectly perceive that others do not. This belief is not held uniformly in all subpopulations, which may inform how these beliefs are developed and maintained.

CONCLUSIONS

Pluralistic ignorance is an important consideration in concussion education efforts.

Association Between Previous Concussion Education and Concussion Care-Seeking Outcomes Among National Collegiate Athletic Association Division I Student-Athletes

CONTEXT

Limited data exist concerning differences in concussion-education exposure and how education exposures relate to care seeking and symptom disclosure, specifically by National Collegiate Athletic Association Division I student-athletes.

OBJECTIVE

To investigate demographic characteristics associated with concussion-education exposure and examine whether overall education exposure (yes versus no) and education-source exposure number (multiple sources versus a single source) affect concussion care-seeking and disclosure factors in Division I student-athletes.

DESIGN

Cross-sectional study.

SETTING

Classroom or online survey.

PATIENTS OR OTHER PARTICIPANTS

Division I student-athletes (n = 341).

MAIN OUTCOME MEASURE(S)

Frequencies and proportions were computed for sex, race, school year, sport, and concussion history across concussion-education groups. Prevalence ratios (PRs) and 95% CIs were calculated to quantify the associations between student-athlete characteristics and (1) overall concussion-education exposure and (2) source-exposure number. Separate multivariable linear regression models estimated adjusted mean differences (MDs) and 95% CIs, which allowed us to assess differences in concussion knowledge, attitudes, and perceived social norms relative to concussion-education exposure and exposure to multiple sources. Separate multivariable binomial regression models were performed to estimate adjusted PRs and 95% CIs in order to evaluate associations of intention, perceived control, and care-seeking or disclosure behaviors and overall concussion-education exposure and exposure to multiple sources. All models controlled for sex, sport, and concussion history.

RESULTS

Overall, 276 (80.9%) participants reported previous concussion education, with 179 (64.9%) being exposed to multiple sources. Student-athletes who participated in a contact sport (adjusted PR = 1.24; 95% CI = 1.06, 1.44) and those who had a concussion history (adjusted PR = 1.19; 95% CI = 1.09, 1.31) had higher prevalences of concussion-education exposure. Females had a lower prevalence of reporting multiple sources (adjusted PR = 0.82; 95% CI = 0.68, 0.99). Overall concussion-education exposure was significantly associated with more favorable perceived social norms surrounding concussion care seeking (adjusted MD = 1.37; 95% CI = 0.13, 2.61).

CONCLUSIONS

These findings highlighted the potential differences in overall concussion-education exposure and provide clinicians with information on groups who may benefit from additional targeted education.

Evaluating the Effect of Concussion Education Programs on Intent to Report Concussion in High School Football

CONTEXT

Concussion underreporting leads to delays in diagnosis and treatment, prolonging recovery time. Athletes' self-report of concussion symptoms therefore reduces risk.

OBJECTIVE

Evaluate the efficacy of three concussion education programs in improving concussion-reporting intention.

DESIGN

Randomized controlled clinical trial with assessment immediately and one-month after education.

SETTING

Three high schools in California.

PATIENTS OR OTHER PARTICIPANTS

118 male football players were randomly assigned to receive concussion education via: CrashCourse (CC), Centers for Disease Control (CDC) video educational materials (Vi), or CDC written educational materials (Wr).

MAIN OUTCOME MEASURES

Concussion-reporting intention was assessed at baseline, immediately after education, and at one-month follow-up. Secondary outcomes included concussion knowledge, attitudes, perceived reporting norms, and perceived behavioral control.

RESULTS

Athletes across all educational formats had significant improvement in concussion-reporting intention immediately following education and at one-month follow-up (mean improvement 6.8% and 11.4%, respectively; p<0.001). Similar findings were observed across all education formats in secondary analyses examining knowledge, attitudes, and perceived behavioral control. However, there were significant differences by education and time (p=0.03). On post-hoc analysis, athletes who received CC had increased concussion-reporting intention immediately and at one-month (baseline=4.7, immediate=6.1, one-month=6.0; p=0.007 compared to significant increases only at one-month for CDC-Vi (baseline=4.3, immediate=5.2, one-month=5.8; p=0.001), and no significant improvement for CDC-Wr (p=0.10). Secondary analyses indicated significant differences between CC and both CDC interventions, in concussion knowledge and attitudes, immediately after education and at one-month. There were no significant differences in perceived behavioral control between-interventions or in perceived concussion-reporting norms across or between interventions.

CONCLUSION

All athletes exhibited improved intent to report concussions, increased concussion knowledge, better concussion attitudes, and more perceived behavioral control, both immediately after education and at one-month follow-up. However, athletes randomized to CC reported greater intent to report concussion, more knowledge, and improved concussion-reporting attitudes, when compared to CDC-Vi and CDC-Wr.

TRIAL REGISTRY

ClinicalTrials.gov trial ID number is XXX.