Mandated High School Concussion Education and Collegiate Athletes' Understanding of Concussion

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.

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.

Sports-Related Concussions and Adverse Health Behaviors Among Middle and High School Students

BACKGROUND

Concussions affect millions of youths in the United States each year, and there is concern about long-term health effects from this injury.

PURPOSE

To examine the association between sports- or physical activity-related concussion and health risk behaviors among middle and high school students in 9 states.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Data from the 2019 middle school and high school Youth Risk Behavior Survey were used for this analysis. Nine states were identified that included the same question on concussion and similar questions on health risk behaviors in their 2019 Youth Risk Behavior Survey. Students were asked to self-report whether they had ≥1 sports- or physical activity-related concussions during the 12 months preceding the survey. Self-reported concussion was the primary outcome of interest. Other variables included sex, race/ethnicity, played on a sports team, were physically active 5 or more days/week, ever tried cigarette smoking, ever used an electronic vapor product, academic grades, drank alcohol, were in a physical fight, seriously considered attempting suicide, made a suicide plan, and attempted suicide.

RESULTS

Among the 9 states, 18.2% of middle school students and 14.3% of high school students self-reported ≥1 sports- or physical activity-related concussions. Among both middle school and high school students, the prevalence of ≥1 sports- or physical activity-related concussions was higher among students who played on a sports team, were physically active 5 or more days per week, had ever tried cigarette smoking, had ever used an electronic vapor product, had seriously considered attempting suicide, had made a suicide plan, and had attempted suicide compared with those who had not engaged in those behaviors. The prevalence of sports- or physical activity-related concussion was consistently higher among middle school students than high school students across sex, race/ethnicity, and adverse health behaviors.

CONCLUSION

Middle school students with a history of concussion warrant attention as an at-risk population for concussions and adverse health behaviors. Health care providers may consider screening students for adverse health behaviors during preparticipation examinations and concussion evaluations.

Assessment of Concussion Knowledge, Attitudes, and Behaviors Among Adolescent Female Club Soccer Athletes

Concussion education for athletes is essential for informed decision making to aid recovery. Education about concussion symptoms, treatment, and protocols can improve symptom recognition, reporting behaviors, protocol compliance, and overall health outcomes. This pilot study aimed to understand current concussion knowledge, attitudes, and beliefs among female club soccer players aged 12–18 years. Findings identified gaps in concussion education and knowledge among these athletes. Continued concussion education efforts are needed to increase concussion knowledge and players’ confidence, focusing on creative education practices.

Compliance with State Concussion Legislation in Non-School-Affiliated Youth Sport Leagues

Youth league administrators (N = 172) documented knowledge of/compliance with state concussion legislation, and were assigned to groups based on whether their state concussion legislation extended to non-school-affiliated (NSA) youth sport leagues: EXTEND (50.6%) or NOT EXTEND (49.4%). Administrators within the EXTEND group were 2.7x more likely to report having a formal concussion policy. Only 90.7% confirmed a policy for removing concussed athletes from play, and 75% required independent medical clearance, and 82% mandated education for coaches, 49.1% for parents, and 35.9% for athletes. These results raise questions regarding compliance with state concussion legislation, especially for NSA youth sports leagues.

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.

Racial disparities in parent knowledge of concussion and recognition of signs and symptoms

INTRODUCTION

Concussion is a type of traumatic brain injury that can be sustained through participation in different sports. It is important that a parent be able to identify common and uncommon symptoms of a concussion to ensure the safety and good health of their child. The purpose of this study was to compare knowledge of concussion scores among White and African American parents and guardians.

METHODOLOGY

This cross-sectional study consisted of a single survey of 53 questions that was given to parents/guardians of high school athletes at a preseason parent meeting. Parent and guardian knowledge of concussion was assessed through a series of 45 questions. Participants were asked to correctly identify signs and symptoms of concussion, answer questions regarding the anatomy of a concussion (i.e. a concussion is an injury to the brain), answer true/false questions about general concussion knowledge, select from a list the consequences of multiple concussions and select from a list the consequences of returning to play too soon from a concussion. Knowledge of concussion was calculated by summing correct responses for the 45 knowledge questions. Racial differences were calculated using an ANCOVA, controlling for socioeconomic school type. The statistical significance level was set a priori p ≤ 0.05 for all analyses.

RESULTS

Participants of this study consisted of 176 [115 (65.3%) White, 61 (34.7%) African American] parents/guardians of high school athletes. Significant differences in knowledge of concussion scores between White parents/guardians [38.50 ± 4.55 (85.6% correct)], and African American parents/guardians [35.15 ± 4.97, 78.1% correct)] were identified (F_(1,172) = 4.82, p = 0.03).

CONCLUSION

Knowledge of concussion disparities exist between African American and White parents/guardians. This disparity could cause complications from concussion to surface among children and adolescents participating in sport as their parents/guardians may not be able to correctly identify the signs and symptoms in order to seek proper medical care. Practical Application: Findings from this study highlight quantitative differences in concussion knowledge of parents from different demographics. These findings underline disparities and inequities in access to concussion-health resources that need to be addressed.

Content analysis of concussion education for coaches of youth and high school sport

OBJECTIVE

Describe the extent to which concussion education provided to coaches of US high school and youth sport is inclusive of information necessary for them to engage in target behaviors related to the prevention, identification and management of concussion.

METHODS

Sport organizations included in the sample were US state high school governing bodies and national governing bodies (NGBs) for youth sports with the highest concussion incidence rates. The concussion education resources made available online for coaches by these organizations were coded for content relevant to concussion prevention, identification and management.

RESULTS

All but one state high school governing body required coach concussion education, two NGBs required coach education, seven recommended it and only one did not require or recommend it. All educational materials covered at least 84% (n = 16/19) of the relevant knowledge domains.

DISCUSSION

Existing concussion education for coaches is addressing most, but not all, topics that may help coaches engage in concussion prevention, identification and management. Additional program development work is warranted to augment educational content related to coach communication about concussion safety with athletes and parents. Content appropriateness notwithstanding, further research is needed to understand the acceptability, efficacy, and implementation of concussion education for coaches.

A Systematic Review of Barriers and Facilitators for Concussion Reporting Behavior Among Student Athletes

Despite increasing attention to concussion safety, many young athletes still do not report concussion-like symptoms to athletic staff. This systematic review was conducted to identify barriers and facilitators to reporting of concussions by high school and collegiate athletes. The review was conducted using PubMed, SCOPUS, CINAHL Complete, and Cochrane Library. Original research articles were deemed eligible if they contained either qualitative or quantitative data on barriers and facilitators of high school and collegiate athletes self-reporting concussion symptoms to athletic staff. For those articles that met inclusion criteria, both authors critically read each article, summarized reasons given by the authors, and then categorized this information into a barrier or a facilitator of concussion-reporting behavior. Of the 878 articles returned, 24 articles met inclusion criteria. Major facilitators were female sex and younger age. Major barriers were a fear of losing current or future playing time, a misconception that concussive injury is not serious, a fear of letting one's team down, and a lack of knowledge of concussion signs and symptoms. Future interventions should address these issues, incorporate primary and secondary prevention strategies, and emphasize the long-term risks of playing while concussed.

Making Headway for Discussions About Concussions: Experiences of Former High School and Collegiate Student-Athletes

In order to better understand how to identify and treat student-athletes who experience concussions, better insight into reporting behavior of athletes is needed. This study aims to identify information influencing athletes' attitudes toward reporting their concussions and the perceived trajectory of their recovery both athletically and academically. Twenty-five former high school and collegiate athletes who experienced concussions in a wide variety of sports, organizational levels, and time periods gave insight through structured, qualitative interviews. A number of factors regarding education about concussions, proper diagnosis of concussions, and motivational pressures within high school and collegiate athletics were assessed. Eight major themes were identified regarding the participants' experiences with sport-related concussion: optimism bias, invisibility of the injury, diagnostic barriers, desire to play, external support and pressures, uncertainty of long-term prognosis, generational factors, and protection of future athletes. The findings support that underreporting of concussions among those players interviewed is related to misperceived risk, lack of education, and a struggle between internal and external pressures to play through injury. However, those who did seek medical and academic support, often did receive the necessary aid.

Reporting Skill: The Missing Ingredient in Concussion Reporting Intention Assessment

BACKGROUND

Extant literature suggests that a substantial portion of athletes may not report a possible concussion and that concussion knowledge is insufficient to predict concussion reporting behavior. One area that has not been explored is reporting skill; that is, mastery of the actions required to report a concussion. This study evaluated the relationship between reporting skill and reporting intention, introducing a measure of the reporting skill construct.

HYPOTHESES

Reporting intentions will be more closely associated with reporting skill than with concussion/symptom knowledge. The relationship between concussion (or symptom) knowledge and reporting intentions will differ by level of reporting skill.

STUDY DESIGN

Repeated cross-sectional study.

LEVEL OF EVIDENCE

Level 2.

METHODS

A set of items was administered to young adults aged 18 to 24 years from the Survey Sampling International panel. Exploratory/confirmatory factor analyses were conducted on 2 waves of data to develop the scale (n = 899). Hypotheses were tested using structural equation modeling on the responses from the third wave of participants (n = 406).

RESULTS

Knowing the actions to take in reporting was more important than having knowledge of concussions or concussion symptoms. Reporting skill, not concussion or concussion symptom knowledge, was associated with higher intentions to report symptoms. Among those with higher levels of reporting skill, concussion symptom knowledge (but not general concussion knowledge) was associated with higher intentions to report symptoms.

CONCLUSION

Reporting skill is an important and, until now, missing ingredient in the concussion literature and practice.

CLINICAL RELEVANCE

Incorporating reporting skill development in concussion education and team activities to teach athletes how to report is likely to improve actual reporting intentions. While further study is needed with particular sports and additional age groups, reporting skill holds promise as a new avenue for increased concussion reporting.

Improving Concussion-Reporting Behavior in National Collegiate Athletic Association Division I Football Players: Evidence for the Applicability of the Socioecological Model for Athletic Trainers

CONTEXT

Few researchers have examined the views of important stakeholders in football student-athletes' spheres of influence and whether their views map well in a systems approach to understanding concussion-reporting behavior (CRB).

OBJECTIVE

To examine the extent to which stakeholders' beliefs about what influences football players' CRBs reflect system-level influences that go beyond individual-level factors.

DESIGN

Qualitative study.

SETTING

Four National Collegiate Athletic Association Division I university athletic programs.

PATIENTS OR OTHER PARTICIPANTS

A total of 26 individuals (athletic directors = 5, athletic trainers [ATs] = 10, football coaches = 11).

DATA COLLECTION AND ANALYSIS

Semistructured interviews with stakeholders were transcribed and analyzed using the socioecological model according to the Miles and Huberman coding methods.

RESULTS

Stakeholders largely identified individual-level factors (attitudes), followed by exosystem-level factors (university policies and support for ATs), with fewer microsystem- and mesosystem-level factors (coach influence and communication between coaches and ATs, respectively) and almost no macrosystem-level factors (media influence, cultural norms about aggression and toughness in football).

CONCLUSIONS

Promising evidence indicates growing stakeholder awareness of the importance of exosystem-level factors (eg, medical personnel and CRB policies) in influencing CRB rates. However, frontline stakeholders and policy makers may benefit from practices that bridge these influences (eg, coach involvement and communication), allowing for a more integrated approach to influence student-athletes' willingness to improve their CRBs.

Pros and Cons of 19 Sport-Related Concussion Educational Resources in Canada: Avenues for Better Care and Prevention

Objective: The goal of this research was to assess the effectiveness of available concussion educational resources in Canada, the means used to disseminate this knowledge and the impact of these educational resources on players' concussion prevention knowledge. Methods: We assessed concussion knowledge before and after exposure to one or more of 19 resources introduced through a national program aimed to increase awareness and knowledge of concussion. The effectiveness of the mode of delivery was measured by changes in concussion knowledge scores (CKS) between pre and pro scores. Measures: Concussion knowledge scores (CKS) were calculated for pre- and post- exposure to concussion educational resources and used as a measure of both, the effectiveness of each resource as well as the effectiveness of the delivery method. The effectiveness of each educational resource was also measured by the respondents' rating of each concussion educational resource. Results: Respondents in post-survey had higher CKS than those in pre-survey. Two out of the 19 newly developed concussion educational resources were effective in improving the resource users' CKS. Linear regression showed that using more resources further increased CKS. Four out of six modes of delivery enhanced respondents' concussion knowledge. Conclusion: Our findings demonstrate that the newly developed Canadian concussion educational resources were effective at improving users' concussion knowledge. Our data demonstrates that using three or more resources further enhanced the users' concussion knowledge. Future research, however, is critical to assess whether concussion prevention knowledge is sufficient to reduce injuries and factors influencing it.

What can family medicine providers learn about concussion non-disclosure from former collegiate athletes?

BACKGROUND

Despite the risks, concussion symptoms often go underreported by athletes, leading to delayed or forgone treatment and increased potential for concussion recurrence. One of the most serious long-term consequences of sports-related concussions is Chronic Traumatic Encephelopathy (CTE), a disorder associated with progressive neurological deterioration. The purpose of this study was to explore former collegiate athletes' understanding of concussions and motivations behind concussion non-disclosure in order to better assist family medicine providers in screening for and managing a history of concussions.

METHODS

Informed by the theoretical framework Social Cognitive Theory, we conducted focus groups with former collegiate athletes using a field-tested discussion guide. Discussions were transcribed, coded, and analyzed via content and thematic analyses using NVivo 10 software.

RESULTS

Thirty-two former collegiate athletes (24.5 ± 2.9 years old, 59.4% female, 87.5% white) participated in 7 focus groups. Three predominant themes emerged: 1) Concussions are Part of the Game: Participants believed that concussions were part of sports, and that by agreeing to play a sport they were accepting the inherent risk of concussions. Importantly, many were not familiar with concussion symptoms and what constituted a concussion; 2) Hiding Concussion Symptoms: Participants said they often hid concussion symptoms from coaches and trainers in order to avoid being taken out of or missing games. Participants were able to hide their concussions because most symptoms were indiscernible to others; and 3) Misconceptions about Concussions in Low Contact Sports: Several participants did not understand that concussions could occur in all sports including low contact or noncontact sports. The former athletes who participated in low contact sports and experienced concussions attributed their concussions to personal clumsiness rather than their sport.

CONCLUSIONS

Family medicine providers as well as coaches, athletic trainers, teachers, and parents/guardians should reinforce the message that concussions can occur in all sports and inform patients about the signs and symptoms of concussions. Further, providers should ask all patients if they engaged in high school or collegiate athletics; and if yes, to describe their hardest hit to their head in order to obtain a complete medical history.

Twitter and traumatic brain injury: A content and sentiment analysis of tweets pertaining to sport-related brain injury

Objectives:

Sport-related traumatic brain injuries are a significant public health burden, with hundreds of thousands sustained annually in North America. While sports offer numerous physical and social health benefits, traumatic brain injuries such as concussion can seriously impact a player’s life, athletic career, and sport enjoyment. The culture in many sports encourages winning at all costs, placing athletes at risk for traumatic brain injuries. As social media has become a central part of everyday life, the content of users’ messages often reflects the prevailing culture related to a particular event or health issue.

Methods:

We hypothesized that Twitter data might be useful for understanding public perceptions and misperceptions of sport-related traumatic brain injuries. We performed a content and sentiment analysis of 7483 Twitter^® tweets related to traumatic brain injuries in sports collected during June and July 2013.

Results:

We identified five major themes. Users tweeted about personal traumatic brain injuries experiences, reported traumatic brain injuries in professional athletes, shared research about sport-related concussions, and discussed policy and safety in injury prevention, such as helmet use. We identified mixed perceptions of and sentiment toward traumatic brain injuries in sports: both an understanding that brain injuries are serious and disregard for activities that might reduce the public burden of traumatic brain injuries were prevalent in our Twitter analysis.

Conclusion:

While the scientific and medical community considers a concussion a form of traumatic brain injuries, our study demonstrates a misunderstanding of this fact among the public. In our current digital age, social media can provide useful insight into the culture around a health issue, facilitating implementation of prevention and treatment strategies.