Using theory to understand high school aged athletes’ intentions to report sport-related concussion: Implications for concussion education initiatives

High School Girls' Volleyball Athletes' Self-Reported Management of Pain, Intentions to Report Overuse Injuries, and Intentions to Adhere to Medical Advice for Treating Overuse Injuries

CONTEXT

Girls' high school volleyball is a popular sport with a high rate of overuse injuries and sport specialization. Health professionals perceive that high school athletes are reluctant to follow treatment plans involving sport activity reduction. This study's purpose was to describe high school girls' volleyball athletes' self-reported shoulder and knee pain, the likelihood of adhering to medical advice, and the association of factors that influence the likelihood of reporting overuse injuries and sport specialization.

STUDY DESIGN

Cross-sectional.

METHODS

Participants completed an online survey (demographics, sport participation measures, shoulder and knee pain information, medical adherence likelihood [4-point Likert: not at all likely to extremely likely], and factors influencing overuse injury reporting intentions). A 2 × 2 chi-square analysis compared factors that influence athletes' intentions to "not report an overuse injury" (eg, I thought my coach would get mad; yes/no) and sport specialization (nonhighly specialized/highly specialized athletes).

RESULTS

There were 150 participants (highly specialized = 56%, grade: ninth = 33%, 10th = 28%, 11th = 22%, 12th = 17%). At least 60% reported shoulder and knee pain related to an overuse mechanism. Most reportedly did not seek rehabilitation led by a medical provider (shoulder pain = 66%, knee pain = 60%). Only 11% of athletes reported they were "extremely likely" to rest from sporting activity during the regular season if advised by a medical professional. Highly specialized athletes were more likely to report the pursuit of a college scholarship as a factor that influences their intention to report an overuse injury compared to nonhighly specialized athletes (13% vs 3%, respectively, P = .04).

CONCLUSIONS

Most girls' volleyball athletes did not treat their pain with guided rehabilitation, which may increase their risk of a worse overuse injury or even acute injury. Clinicians, athletes, parents, and coaches need to work together to create a sport culture that empowers athletes to discuss their pain and overuse injuries with medical professionals.

The importance of language in describing concussions: A qualitative analysis

BACKGROUND

Concussions are mild traumatic brain injuries that are often undiagnosed due to difficulties in identifying symptoms. To minimize the negative sequelae associated with undiagnosed concussion, efforts have targeted improving concussion reporting. However, knowing more about concussions does not indicate how likely an athlete is to report their concussion. Alternatively, the attitudes and beliefs of athletes and surrounding stakeholders have shown to be a better indication of whether an athlete intends to report their concussion. Prior research has shown that athletes report concussions less often when the injury is described using language that minimizes their severity, such as when it is referred to as a "ding." This study evaluated whether describing concussions using the word "brain" was associated with individuals' underlying attitudes and beliefs about the injury's severity.

OBJECTIVE

To measure the relationship between perceived concussion severity and the language used to describe concussions, specifically whether participants used the word "brain" in describing the injury.

METHODS

One-on-one semi-structured telephone interviews were conducted, and a cross sectional secondary qualitative analysis was performed to assess participants' perceived concussion severity and their use of the word "brain" to describe concussions.

DESIGN

Cross-sectional secondary qualitative analysis.

SETTING

One-on-one semistructured telephone interviews.

PARTICIPANTS

In 2017, 94 individuals involved in high school sports, including athletes, coaches, educators, parents of athletes, and athletic directors were recruited via convenience sampling.

MAIN OUTCOME MEASURES

Respondents' perceived severity of concussions.

RESULTS

Individuals who used a brain phrase to describe concussion also perceived concussions as more severe (p < .001). Specifically, those who described concussions with maximum severity had higher odds of using brain phrases than those who described concussions as having minimum (odds ratio [OR] = 0.05, 95% confidence interval [CI] = 0.002-0.299, p < .001) or moderate severity (OR = 0.24, 95% CI = 0.086-0.647, p = .003), with the most significant relationship found among coaches.

CONCLUSIONS

These findings demonstrate the relationship between medical terminology and perceived severity of concussions. This relationship may play a role in concussion reporting behavior for coaches, athletes, and parents. Education programs using similar medical terminology may promote concussion reporting behaviors.

Concussion Awareness Training Tool for Youth: Impact on Concussion Knowledge, Beliefs, and Reporting Intentions

BACKGROUND

Concussion education is recommended to increase concussion knowledge, beliefs, and reporting intentions. The Concussion Awareness Training Tool for Youth (CATT-Youth) is a 40-minute e-Learning module developed for high school-aged youth.

AIM

The aim of the study was to evaluate changes in concussion knowledge, beliefs, and reporting intentions in high school youth from Calgary, Canada, following completion of the CATT-Youth.

METHODS

This study used a modified stepped-wedge trial design. High school classes were randomly assigned to an intervention (Ix) or delayed intervention (DIx) group. Ix group participants completed a pre-CATT survey immediately followed by the CATT-Youth, then a post-CATT survey 2 to 6 weeks later. DIx group participants completed two pre-CATT surveys 2 to 6 weeks apart, with the CATT-Youth completed immediately following the second pre-CATT, then a post-CATT survey 2 to 6 weeks later. The pre-/post-CATT survey encompassed 11 subtests evaluating concussion knowledge, beliefs, and reporting intentions. Independent mixed linear regression models were conducted to examine changes in scores for each subtest.

RESULTS

Participants included 454 high school students: five Ix schools (16 classes, n = 323) and two DIx schools (six classes, n = 131). The CATT-Youth significantly increased general concussion knowledge, Ix δ = 0.546/8 (95% confidence interval [CI] = [0.243, 0.849]), DIx δ = 0.728/8 (95% CI = [0.389, 1.106]), and beliefs about capabilities, Ix δ = 2.462/28 (95% CI = [1.086, 3.838]), DIx δ = 3.219/28 (95% CI = [1.594, 4.844]) for both groups. For some subtests, improvements were noted in the DIx group only.

CONCLUSION

The CATT-Youth module improved concussion knowledge and beliefs about capabilities for students in both groups. Future studies should explore the utility of the CATT-Youth in changing knowledge, beliefs, and reporting intentions in high school students.

Headgear safety attitudes: a national survey of collegiate women's lacrosse stakeholders

Controversy exists among collegiate lacrosse about the use of headgear and whether its use will facilitate greater risk compensation by players and thus contribute to unsafe gameplay. We aimed to characterize the attitudes of headgear among women's collegiate lacrosse stakeholders. A total of 190 women's lacrosse stakeholders (players: n = 87; coaches: n = 71; officials: n = 32) participated in this study. Participants completed a survey surrounding attitudes of headgear in women's lacrosse. Descriptives, multiple regressions, and Kruskal-Wallis analyses compared attitudes surrounding headgear among stakeholder groups. Scales of Headgear Affects Play (β = -0.38, p < 0.001) and Sports Development and Safety Practices (β = 0.26, p < 0.05) significantly predicted endorsement on Headgear Safety Attitudes Scale. Among players, Aesthetics (β = 0.51, p < 0.001) and Intention to Wear Headgear (β = 0.31, p < 0.05) predicted endorsement on Headgear Safety Attitudes Scale. Stakeholders did not agree if headgear should be worn in women's lacrosse. Items related to sports development, safety and potential changes in gameplay predicted attitudes to headgear safety among all participants.

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.

The current state of concussion knowledge and attitudes in British American Football

OBJECTIVES

To examine concussion knowledge and concussion attitudes of players, coaches, and support staff in British American Football (BAF).

METHODS

Data from players, coaches and support staff (n = 236) were collected from across all leagues in BAF. An online survey tool was used which included the Rosenbaum Concussion Knowledge and Attitudes Survey (RoCKAS), and questions examining concussion education and perceived risk of participating in football.

RESULTS

The mean score on the RoCKAS concussion knowledge was 21.0 ± 2.1 of a possible score of 25 reflecting good knowledge. Of a possible score of 65, the mean concussion attitude score was 55.6 ± 6.1 showing safe attitude. Whilst an overall safe attitude was seen, almost half of participants (45.3%) noted they would continue to play with a concussion. No relationship was found between CAI and prior concussion history. Fifty seven percent of participants agreed the benefits of playing football outweighed the risks. Forty eight percent reported that they had received no concussion-related education in the past 12 months.

CONCLUSION

BAF participants have good concussion knowledge and safe attitudes. However, risky behavior is demonstrated through unsafe likelihood to report and attitude to long-term health risks. Access to the British American Football Association (BAFA) concussion policy and education was poor raising questions over what sources of information stakeholders are drawing their knowledge from. These findings can help form the foundation of educational interventions (e.g. coaching workshops) to challenge current misconceptions and improve likelihood to report concussion in BAF.

The knowledge and attitude concerning sport-related concussion among coaches: A survey study

Background

There are no studies investigating the level of knowledge about and attitude towards sports-related concussions (SRC) among sports coaches in Jordan.

Objectives

This study aimed to examine the knowledge about and attitude towards SRC among Jordanian sports coaches.

Method

Our study was based on a cross-sectional survey. An Arabic version of the questionnaire from the Centers for Disease Control and Prevention was used to collect data. The survey identified participants' demographics and knowledge about (0-10 points with higher scores indicating a higher knowledge) and attitude towards (8-40 with lower scores indicating favourable attitudes) SRC. Descriptive statistics and the Kruskal-Wallis test were used to examine knowledge and attitude differences by demographic factors. Spearman's correlation examined the correlation between the total knowledge and attitude scores.

Results

Participants included 193 coaches (62 basketball, 66 martial arts, 30 soccer, and 35 swimming). The median total knowledge and attitude scores were 4 and 30, respectively. The total knowledge score was the highest in martial arts coaches (median = 4) and those with graduate degrees (median = 5). The total attitude score was the lowest among basketball coaches (median = 28) and those who were 40-50 years old (median = 28). No significant correlation between knowledge and attitude scores was observed.

Conclusion

Jordanian coaches have a deficiency in knowledge about SRC and hold attitudes that are not consistent with current practice recommendations.

Clinical implications

Knowledge and attitude about SRC can be improved through education, access to healthcare providers, and adherence to SRC management guidelines.

Perceptions of personal control and treatment efficacy of sport-related concussions in collegiate athletes

OBJECTIVE

The purpose of this study was to examine healthy collegiate athletes' perceptions of personal control and beliefs regarding the treatment efficacy related to sport-related concussion (SRC) along with identifying factors that may be associated with these perceptions.

METHODS

This cross-sectional study included collegiate athletes (n = 956) between the age of 18-26 years. Participants completed a 10- to 15-min survey regarding their demographics, diagnosed SRC history, SRC knowledge, and Perceptions of Concussion Inventory for Athletes (PCI-A). Chi-squared analysis and multivariable logistic regressions were conducted to identify factors associated with the PCI-A outcomes of personal control and treatment efficacy perceptions.

RESULTS

24.2% of respondents reported higher perceptions of personal control, while 77.3% reported higher perceptions of treatment efficacy. The multivariable logistic regression revealed males had higher odds of greater perceptions of personal control (OR = 1.50; 95% CI: 1.10-2.03), while those with a history of diagnosed SRC had lower odds of having favorable treatment efficacy beliefs (OR: 0.69; 95% CI: 0.50-0.96).

CONCLUSIONS

This study established that collegiate athletes generally have lower perceptions of personal control and higher perceptions of treatment efficacy related to SRC recovery. Comprehensive SRC education should be expanded for individuals to understand that they have power over their own health outcomes and that SRC is a treatable injury.

Youth intentions to provide social support to a peer with a concussion

OBJECTIVES

1) To describe demographic factors, concussion knowledge, attitudes, subjective norms, self-efficacy and intentions to provide social support to a peer with a concussion and 2) to examine if demographic factors and concussion knowledge are associated with components of the Theory of Planned Behavior.

METHODS

The survey was completed between October 2018 and February 2019 by 200 youth (M = 15.30 years, SD = 1.52). Questions were designed for athletes and non-athletes and inquired about various types of social support. Data analysis included descriptive statistics, Wilcoxon Rank Sum Tests and Spearman's Rank-Order Correlation Coefficients.

RESULTS

More favorable attitudes and intentions to provide social support were observed among females (W = 2576, p ≤ 0.001; W = 2411, p ≤ 0.001), older youth (rho = 0.32, p ≤ 0.001; rho = 0.41, p ≤ 0.001) and those with higher concussion knowledge (rho = 0.29, p ≤ 0.001; rho = 0.22; p ≤ 0.001). Participating in sports with a high-risk of concussion was associated with lower attitudes and intentions to provide social support (W = 6677; p ≤ 0.001; W = 6721; p ≤ 0.001). Self-reported concussion history or knowing someone with a concussion history was not significantly associated with social support intentions.

CONCLUSION

This study identified characteristics of youth who had positive intentions to provide social support. These findings identify individuals who may model providing social support to a peer, as well as opportunities for future concussion education.

Development of a tailored concussion education program for athletes: a pragmatic multimethods design and integrated knowledge translation approach from needs assessment to design

OBJECTIVES

To understand Canadian university athletic programme concussion management needs, and to describe development and content of a tailored online concussion education tool for Canadian university/college athletes.

DESIGN

An integrated knowledge translation multiphased, multimethods approach was used. Phases included a needs assessment survey with university representatives and athletes, content selection, mapping behavioural goals to evidenced-based behaviour change techniques, script/storyboard development, engagement interviews with university athletes and tool development using user-centred design techniques.

SETTING

Canadian U SPORTS universities (n=56).

PARTICIPANTS

Overall, 64 university representatives (eg, administrators, clinicians) and 27 varsity athletes (52% male, 48% female) completed the needs assessment survey. Five athletes participated in engagement interviews.

OUTCOME MEASURES

Surveys assessed previous athlete concussion education, recommendations for concussion topics and tool design, concussion management challenges and interest in implementing a new course.

RESULTS

Institutions used a median (Med) of two (range 1-5) approaches when educating athletes about concussion. Common approaches were classroom-style education (50%), online training (41%) and informational handouts (39%). University representatives rated most important topics as: (1) what is a concussion, (2) how to recognise a concussion and (3) how to report a concussion (Medall=4.8/5). Athletes felt symptom recognition (96%) and effects on the brain (85%) were most important. The majority of athletes preferred learning via computer (81%) and preferred to learn alone (48%) versus group learning (7%). The final resource was designed to influence four behaviours: (1) report symptoms, (2) seek care, (3) encourage teammates to report symptoms and (4) support teammates through concussion recovery. Examples of behaviour change techniques included: knowledge/skills, problem-solving scenarios, verbal persuasion and social comparison. Athletes are guided through different interactions (eg, videos, flip cards, scenarios, testimonials) to maximise engagement (material review takes ~30 min).

CONCLUSIONS

The Concussion Awareness Training Tool for athletes is the first Canadian education tool designed to address the needs of Canadian university/college athletes.

Quest for clarity: investigating concussion-related responsibilities across the New Zealand Rugby Community System

There is a growing concern around concussions in rugby union, at all levels of the game. These concerns highlight the need to better manage and care for players. However, consistency around concussion-related responsibilities of stakeholders across the community rugby system remains challenging. Taking a systems thinking approach, this pragmatic, qualitative descriptive study explored key stakeholder groups within New Zealand's community rugby system's perceptions of their own and others' concussion-related responsibilities. Participants included players from schools and clubs, coaches, parents, team leads and representatives from four provincial unions. A total of 155 participants (67 females and 88 males) were included in the study. Focus groups and individual interviews were conducted. Thematic content analysis was used to analyse data. Thirty concussion-related responsibilities were identified. These responsibilities were contained within four themes: (1) policies and support (responsibilities which influence policy, infrastructure, human or financial resources); (2) rugby culture and general management (responsibilities impacting players' welfare and safety, attitudes and behaviour, including education, injury reporting and communication); (3) individual capabilities (responsibilities demonstrating knowledge and confidence managing concussion, leadership or role/task shifting) and (4) intervention following a suspected concussion (immediate responsibilities as a consequence of a suspected concussion). The need for role clarity was a prominent finding across themes. Additionally, injury management initiatives should prioritise communication between stakeholders and consider task-shifting opportunities for stakeholders with multiple responsibilities. How concussions will realistically be managed in a real-world sports setting and by whom needs to be clearly defined and accepted by each stakeholder group. A 'framework of responsibilities' may act as a starting point for discussion within different individual community rugby contexts on how these responsibilities translate to their context and how these responsibilities can be approached and assigned among available stakeholders.

The Influence of Athletic Identity, Passion, and Perceptions of Severity of Concussions on Athletes' Willingness to Report Concussion Symptoms

CONTEXT

The influence of several psychological characteristics on the willingness of athletes to report concussion behaviors has not been well explored. Therefore, the purpose of this study was to understand how athletic identity and sport passion predicted participants' willingness to report symptoms above what was explained by athlete demographics, concussion knowledge, and perceived seriousness of concussions.

DESIGN

The study was cross-sectional.

METHODS

Three-hundred and twenty-two male and female high school and club sport athletes completed survey measures of concussion knowledge, athletic identity, harmonious and obsessive passion, and degree to which athletes indicated they would report concussions and concussion symptoms.

RESULTS

Athletes scored moderately high on their knowledge of symptoms and other concussion information (mean = 16.21; ± = 2.88) and above the midpoint on their attitudes and behaviors toward reporting concussion symptoms (mean = 3.64; ± = 0.70). There were no differences between gender, t(299) = -.78, P = .44, and previous concussion education, t(296) = 1.93, P = .06, related to concussion knowledge. Results of a hierarchical regression indicated that after entering athlete demographics, concussion knowledge, and perceived seriousness of concussions, of the 3 psychological variables in the final stage of the model, only obsessive passion was a significant predictor of athlete's attitudes to report a concussion.

CONCLUSIONS

Perceived seriousness of concussion, perceived threat to long-term health, and obsessive passion were the strongest predictors of athlete's willingness to report concussions. Athletes who did not believe concussions posed a threat to their current or future health, and those that held an obsessive passion for sport were most at risk for not reporting concussions. Future research should continue to investigate the relationship between reporting behaviors and psychological factors.

A cross-sectional study examining Nigerian footballers' knowledge and attitudes towards sport-related concussion and associated contextual factors

OBJECTIVE

To examine Nigerian footballers' knowledge and attitudes towards sport-related concussion (SRC) and associated contextual factors.

METHODS

A cross-sectional study design was used with an online questionnaire distributed to Nigerian footballers affiliated with a registered team. The questionnaire included demographic information and the Rosenbaum Concussion Knowledge and Attitudes Survey (RoCKAS-ST). The concussion knowledge index (CKI, 0-25) and attitude index (CAI, 15-75) were calculated. The association between various contextual factors with "high" knowledge and attitude were determined.

RESULTS

A total of 331 participants completed the questionnaire from 10 football clubs. Mean CKI and CAI scores were 14.0 ± 3.0 (56.2 ± 13.2%) and 54.5 ± 9.4 (72.6 ± 12.5%), respectively, and the association between scores was considered large (r = 0.530; 28%). A small proportion (n = 25; 7.6%) of participants reported a previous diagnosis of an SRC, with a further 40 (12.1%) suspecting they have suffered SRC. Thirty-five participants (10.6%) reported sustaining a SRC but did not seek medical help. Results indicated that men were at 4.8 times greater odds of having a "high[er]" CKI than women, and that those with 5-10 years playing experience had lower odds of a "high" CKI than those with >10 years' experience. Men had 7 times greater odds of having a "high" CAI than women.

CONCLUSION

The results of this study suggest that Nigerian footballers have a moderate level of SRC knowledge, satisfactory symptom recognition, and high SRC attitudes. Those working with Nigerian football may consider these findings when seeking strategies to improve concussion knowledge, potentially by improving attitudes and considering sex and playing experience.

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.

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.

Concussion education for youth athletes using Pre-Game Safety Huddles: a cluster-randomised controlled trial

OBJECTIVES

Determine whether Pre-Game Safety Huddles, a novel and low-resource approach to concussion education, increase the expected likelihood of concussion reporting for youth athletes.

METHODS

A cluster-randomised trial compared Safety Huddles to usual care. Safety Huddles bring together athletes and coaches from both teams before the start of each game for coaches to briefly affirm the importance of speaking up if a concussion is suspected. Participants were athletes from 22 competitive community-based American football and girls and boys soccer teams (ages 9-14), and randomisation into intervention or control occurred at the level of the bracket (group of teams that compete against each other during the regular season). The primary outcome was expected likelihood of reporting concussion symptoms to the coach, measured via validated athlete survey at the beginning and end of the season.

RESULTS

Of 343 eligible participants, 339 (99%) completed baseline surveys and 303 (88%) completed surveys at season end. The mean (SD) age was 11.4 (1.1) years, 26% were female soccer athletes, 27% were male soccer athletes and 47% were football athletes. In adjusted analyses accounting for baseline values and clustering by sport and team via random effects, expected likelihood of concussion reporting at the end of the season was significantly higher in the intervention group compared to controls (mean difference=0.49, 95% CI 0.11 to 0.88; Cohen's d=0.35).

CONCLUSIONS AND RELEVANCE

Pre-Game Safety Huddles increased the expected likelihood of athletes reporting concussion symptoms. While further study is warranted, sport organisations should consider this approach a promising low-resource option for improving concussion safety in their setting.

TRIAL REGISTRATION NUMBER

NCT04099329.

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.

Concussion knowledge, attitudes, and norms: How do they relate?

BACKGROUND

Relationships between the constructs of concussion-related knowledge, attitudes, and norms and their influence on observed care-seeking behaviors have previously been examined. Current models posit that these constructs serve as potential mediators of care-seeking behaviors; however, the dynamics between them have yet to be reconciled.

METHODS

A cross-sectional, online survey explored relationships among the latent constructs of concussion-related knowledge, attitudes, and norms in parents of middle school children who participate in sports in multiple settings. A just-identified and two overidentified path models were explored and compared in an effort to understand such relationships.

RESULTS

A total of 426 parents of United States middle school students were surveyed and included in analyses (mean age = 38.7±9.9 years; 55.6% female; 51.4% white/non-Hispanic; 56.1% with at least a bachelor's degree). All parents had middle school aged children who participated in sport in both the club and school settings. The best fitting model was a just-identified model with concussion-related norms influencing concussion-related knowledge and attitudes, and concussion-related knowledge influencing attitudes. This model accounted for 14% of the variance in attitude and 12% of the variance in knowledge.

CONCLUSIONS

Study findings suggest that the constructs of concussion-related knowledge, attitudes and norms are directly related to one another, yet the dynamics of such relationships may be complex. As such, a parsimonious interpretation of these constructs may not be appropriate. Future research should work to further reconcile the dynamics between these constructs, and the impact these dynamics may have in influencing care-seeking behaviors beyond serving as mediators.

Use of sport-related concussion information sources among parents of United States middle school children

OBJECTIVE

Parents may use various information sources to obtain information about sport-related concussions (SRC). This study examined SRC-related information sources used by parents of United States middle school children (age: 10-15 years).

METHODS

A panel of 1083 randomly selected U.S. residents, aged ≥18 years and identifying as parents of middle school children, completed an online questionnaire capturing parental and child characteristics, and utilization and perceived trustworthiness of various sources of SRC-related information. Multivariable logistic regression models identified factors associated with utilizing each source. Adjusted odds ratios (OR) with 95% confidence intervals (95%CIs) excluding 1.00 were deemed significant.

RESULTS

Doctors/healthcare providers (49.9%) and other healthcare-related resources (e.g., Centers for Disease Control and Prevention, WebMD) (37.8%) were common SRC-related information sources; 64.0% of parents utilized ≥1 of these sources. Both sources were considered "very" or "extremely" trustworthy for SRC-related information among parents using these sources (doctors/healthcare providers: 89.8%; other healthcare-related resources: 70.9%). A 10-year increase in parental age was associated with higher odds of utilizing doctors/healthcare providers (adjusted odd ratio (OR_adjusted) = 1.09, 95%CI: 1.02-1.16) and other healthcare-related resources (OR_adjusted = 1.11, 95%CI: 1.03-1.19). The odds of utilizing doctors/healthcare providers (OR_adjusted = 0.58, 95%CI: 0.40-0.84) and other healthcare-related resources (OR_adjusted = 0.64, 95%CI: 0.44-0.93) were lower among parents whose middle school children had concussion histories versus the parents of children who did not have concussion histories.

CONCLUSION

One-third of parents did not report using doctors/healthcare providers or other healthcare-related resources for SRC-related information. Factors associated with underutilization of these sources may be targets for future intervention. Continuing education for healthcare providers and educational opportunities for parents should highlight accurate and up-to-date SRC-related information.

Headgear safety attitudes among women's lacrosse stakeholders: Qualitative results

OBJECTIVE

To explore diverse stakeholders' perceptions of headgear use in collegiate women's lacrosse.

PARTICIPANTS

189 collegiate women's lacrosse stakeholders (players: n = 87; coaches: n = 71; officials: n = 32).

METHODS

Participants completed online open-ended qualitative questions surrounding headgear use in the sport. Responses were coded by the research team via inductive reasoning.

RESULTS

Stakeholders felt that incorporating headgear use into women's lacrosse would increase aggression and change the nature of the sport. Some felt that headgear was important for injury risk mitigation and invoked a need for research and development. Stakeholders raised the need for coaching and officiating improvement as primary injury prevention measures. Players were concerned about esthetics and performance limitations. Finally, many felt that it should be left to player choice to wear headgear or not.

CONCLUSION

Most stakeholders invoke concerns of risk compensation and changing the nature of the sport of women's lacrosse, and are in favor of headgear remaining optional.

Masculinity, optimism bias, and perceived pressure from stakeholders influence on student-athlete concussion reporting intentions and behavior

Objective: Determine how a) masculinity, b) optimism bias, and c) perceived pressure from stakeholders predict concussion reporting intentions and behavior. Participants: Collegiate student-athletes (n = 369). Methods: Student-athletes completed surveys of Conformity to Masculine Norms Inventory-46 (nine sections), optimism bias (optimist, neutral, pessimist), perceived pressure from stakeholders (six stakeholder sections), reporting intentions (symptom and concussion), and behavior (symptom and concussion). Four separate stepwise multivariate regression analyses were conducted. Results: A one-point increase in playboy, heterosexual self-preservation, being neutral or optimist compared to a pessimist symptom reporting intention decreased. A one-point increase in sport primacy, perceived pressure from athletic administration, being neutral or optimist compared to pessimist concussion reporting intentions increased 0.05, and decreased 0.23, 0.35, and 0.32, respectively. A one-point increase in violence and playboy increased the odds of being a "non-reporter" by 30% and 40%. Conclusions: Pessimistic views regarding concussion risks may result in greater concussion reporting intentions, however these findings did not influence behavior.

Concussion education in medical students studying in Scotland: an assessment of knowledge and future needs

BACKGROUND

Physicians play a key role in ensuring athletes with concussion safely return to sport. Research has shown deficiencies in concussion education amongst physicians and medical students. However, studies have not previously been conducted in UK medical schools.

OBJECTIVES

To assess students' concussion knowledge and learning in Scottish Medical Schools.

DESIGN

A survey with 23 questions was distributed to Year 3-6 medical students studying in Scotland in October 2020. The survey included the following: (1) demographics, (2) concussion knowledge, e.g. 'What is the role of headgear in preventing concussion?' (3) concussion learning, 'In which part of the curriculum should concussion be taught?.' Frequencies of responses were calculated for each question.

RESULTS

200 students responded (response rate 8%). The average symptoms and management score were 87.3% and 31% respectively. 15% of participants knew that headgear has no role in preventing concussions and one participant identified the minimum "return to sport" timeframes for adults and children. 15% had learnt about concussion at medical school with 92.5% interested in receiving concussion teaching at medical school.

CONCLUSION

Knowledge gaps exist in managing and preventing sports-related concussion. There is a discrepancy between levels of concussion teaching and the desire and importance placed on concussion education.

Parent-Child Communication regarding Sport-Related Concussion: An Application of the Theory of Planned Behavior

Extant research has discussed the importance of social climates surrounding sport-related concussion (SRC) reporting, especially the need to address parents/guardians' role in concussion management. This study explores parents/guardians' intentions toward SRC-related conversations with their children and their seeking of conversational resources via the Theory of Planned Behavior (TPB). Data collected from 292 parents/guardians of 1^st-12^th graders who play contact sports are examined via a structural equation model. The results indicate that parents/guardians' intention toward communicating with their child about SRC reporting was determined by their attitudes and subjective norms but that perceived behavioral control was not a significant predictor of intention. Furthermore, parents/guardians' intention toward having these conversations was predictive of whether they sought information to aid these conversations. This study answers calls to address parents/guardians' involvement in SRC management and provides preliminary information for persuading parents/guardians to have conversations with their children about SRC reporting.

Parent influence on concussion reporting in first-year collegiate athletes

OBJECTIVE

To assess the relationship between sport-parenting practices and concussion reporting intentions of collegiate athletes across two levels of competition.

PARTICIPANTS

Entering first-year student-athletes (varsity and club) at a mid-sized university in the Southeast region of the United States (n = 327).

METHODS

Written surveys were completed prior to the start of the 2015 academic year. Structural equation modeling was used to test a model predicting concussion-reporting intentions.

RESULTS

College athletes were more likely to intend to report a suspected concussion when they believed their parents wanted them to report (B=-0.88, SD = 0.94), and when they experienced less sport achievement pressure from their parents (B=-0.12, SD = 8.07).

CONCLUSIONS

Parents influence the concussion safety of entering collegiate athletes at both the varsity and club level. Lower pressure sport parenting prior to college entry may help foster safer concussion reporting behaviors and may be an appropriate target for future intervention development work.

Factors Related to Concussion Knowledge, Attitudes, and Reporting Behaviors in US High School Athletes: A Systematic Review

BACKGROUND

Sport-related concussions are a major public health problem with only 50% of concussed teens reporting their symptoms. The purpose of this systematic review was to identify individual and institutional factors that contribute to concussion knowledge, attitude, and reporting behaviors among US high school athletes.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis protocol was used to direct the process of this systematic review. A search for English, peer-reviewed, quantitative studies published between 2010 and 2020 was conducted in 5 scholarly databases. The Joanna Briggs Critical Appraisal Tools were used to assess study quality.

RESULTS

Twenty-two studies met criteria for inclusion in this systematic review. The study designs were mostly cross-sectional (N = 18). Synthesis revealed individual factors including gender, age, race/ethnicity, grade level, and concussion history were associated with differences in concussion knowledge, attitude, and/or reporting behaviors. Institutional factors identified included school location, concussion education, access to an athletic trainer, sport played, and team climate. Six studies found concussion education had a positive impact on knowledge and reporting behaviors.

CONCLUSION

This systematic review identified certain populations which may be more vulnerable to underreporting concussion symptoms; therefore, a targeted approach to education and management may be more effective.

Knowledge of, and Attitudes Toward, Concussion in Japanese Male Collegiate Athletes

Japan has no streamlined concussion education for collegiate athletes, and guidelines vary by sport. In particular, research on knowledge of, and attitudes toward, concussion is necessary for the establishment of concussion education for Japanese collegiate athletes. The aim of the present study was to assess the knowledge of, and attitudes toward, concussion in Japanese male collegiate athletes and to investigate their experiences with suspected concussion symptoms. An online questionnaire was administered to 390 collegiate athletes participating in the following five sports with a high incidence of concussion: rugby union, soccer, basketball, American football, and judo. Of the 121 valid responses, 91 (77.1%) indicated that they had experienced suspected concussion symptoms at least once and 46 of these 91 respondents had not reported their symptoms of suspected concussion at least once. Athletes who had never experienced concussion symptoms were significantly less likely to recognize the symptoms of concussion (p &lt; 0.001). Most athletes recognized headache and dizziness as suspected concussion symptoms. However, the recognition rate for several symptoms was lower than the prevalence of these symptoms as shown in previous studies. This suggests that educational initiatives might be important to bridge the gap between athletes' knowledge and understanding of frequently occurring concussion symptoms and to improve reporting behavior.

Beliefs affecting concussion reporting among military cadets: advanced observations through machine learning

BACKGROUND

Untreated concussions are an important health concern. The number of concussions sustained each year is difficult to pinpoint due to diverse reporting routes and many people not reporting. A growing body of literature investigates the motivations for concussion under-reporting, proposing ties with knowledge of concussion outcomes and concussion culture. The present work employs machine learning to identify trends in knowledge and willingness to self-report concussions.

METHODS

2,204 cadets completed a survey addressing athletic and pilot status, concussion symptoms and outcome beliefs, ethical beliefs, demographics, and reporting willingness.

RESULTS

Clustering and non-negative matrix analysis identified connections to self-report willingness within: knowledge of symptoms, ethical beliefs, reporting requirements, and belief of long-term concussion outcomes. Support vector machine classification of cadet reporting likelihood reveals symptom and outcome knowledge may be inversely related to reporting among those rating ethics considerations as low, while heightened ethics may predict higher reporting likeliness overall.

CONCLUSIONS

Machine-learning analysis bolsters prior theories on the importance of concussion culture in reporting and indicate more symptom knowledge may decrease willingness to report. Uniquely, our analysis indicated importance of ethical behavior may be associated with general concussion reporting willingness, inviting further consideration from healthcare practitioners seeking increased reporting.

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.

Prevalence of Concussion-Related Policies and Practices Among Public School Districts in the United States, 2012 and 2016

BACKGROUND

Beginning in 2009, there was an increase in the number of states with laws addressing 3 different components of youth sports-related concussion prevention and management: concussion education, removal from play, and medical clearance requirements before allowing an athlete to return to play. Schools are an important setting to implement policies and practices related to concussions, as many youth participate in organized sports through school venues.

OBJECTIVE

To examine whether the prevalence of concussion-related policies and practices adopted by school districts changed from 2012 to 2016.

METHODS

This study used nationally representative data from the 2012 and 2016 School Health Policies and Practices Study to examine whether the prevalence of 4 concussion-related policies and practices changed during 2012 and 2016 and whether comprehensive policies changed during the same time frame. Comprehensive policies were defined as those that address removal from play after injury, medical clearance before returning to play, and concussion-related educational materials and sessions for parents and student athletes.

RESULTS

Among school districts nationwide, the prevalence of each of the 4 concussion-related policies and practices significantly increased during 2012 and 2016. The prevalence of comprehensive policies significantly increased from 51.6% in 2012 to 66.7% in 2016. While these findings are promising, it is important to note that one-third of districts still lacked comprehensive policies in 2016 and only 71% of districts provided educational sessions in 2016.

CONCLUSIONS

The findings in this study highlight improvements in school districts nationwide in adopting concussion-related policies and practices. Policies such as requiring educational sessions allow parents and student athletes to learn about concussions and understand the importance of reporting a concussion or concussion symptoms.

Concussion Knowledge and Reporting Behaviors Among Collegiate Athletes

OBJECTIVE

The purpose of the current study was to explore knowledge surrounding sport-related concussions (SRCs) and the impact on reporting behaviors in collegiate athletes, including sex differences.

DESIGN

Cross-sectional.

SETTING

Institutional.

PARTICIPANTS

Participants were 986 collegiate athletes (607 men), aged 19.7 years (SD = 1.4) from 6 institutions, who completed a survey, including items on personal/sport demographics and SRC knowledge and reporting behaviors.

INTERVENTIONS

Athletes were given a short (15-minute) survey to complete during team meetings and preparticipation physicals.

MAIN OUTCOME MEASURES

Athletes' scores on the survey, and reporting behaviors (ie, whether or not they failed to report a suspected SRC and reasons for not reporting SRCs), were examined.

RESULTS

Independent samples t tests revealed female athletes scored significantly higher than male athletes on total SRC knowledge [t (926.6) = -10.6, P < 0.01] and symptom knowledge (t (859) = -7.0, P < 0.01). Approximately one-quarter of athletes reported continuing to play after sustaining a suspected SRC. Chi-square analyses exposed significant differences between male and female athletes failing to report a suspected SRC (χ2 = 7.69, P < 0.01).

CONCLUSIONS

Given the current findings, educational efforts aimed at collegiate athletes may not be enough. Furthermore, it is apparent that sex differences exist in SRC knowledge and reporting behaviors among collegiate athletes.

Development of a scale to measure expected concussion reporting behavior

Background

Most concussion education aims to increase athlete self-report of concussive symptoms. Although the population burden of concussion is high, frequency with which this injury occurs on a given sports team in a given season is relatively low. This means that powering concussion education evaluation studies to measure change in post-injury symptom reporting behavior requires what is often a prohibitively large sample size. Thus, evaluation studies are typically powered to measure proximal cognitions. Expected reporting behavior, a cognition that reflects planned and reactive decision-making, is a theoretically indicated construct for inclusion in evaluation studies. However, previously no scales were available to measure this construct with demonstrated reliability and validity among youth athletes. The objective of this study was to develop and assess the validity of a brief single-factor scale to measure expected youth athlete concussion reporting behavior (CR-E) in a sample of youth athletes.

Methods

A mixed methods approach was used, including cognitive interviews with youth athletes, and quantitative item reduction and validation. Participants were youth athletes (aged 9–16) from the Seattle metropolitan and rural south-Georgia regions. After refining an initial pool of items using cognitive interviews with a diverse group of youth athletes (n = 20), a survey containing these items was administered to youth soccer and football players (n = 291). Item reduction statistics and sequential confirmatory factor analyses were used to reduce the initial scale using a randomly selected half of the sample. Then, a final confirmatory factor analysis and validation tests were applied to the other half of the sample of youth athletes. Predictive validation was conducted longitudinally in a separate sample of youth athletes (n = 155).

Results

Internal consistency was high (alpha = 0.89), model fit was excellent, validation tests were in the hypothesized directions, and the scale was feasible to use. Using the finalized 4-item scale, we observed that less than one-third of youth soccer and football athletes expect to “always” tell their coach about symptoms of a suspected concussion.

Conclusions

The CR-E measure should be included in future studies evaluating concussion education programming in youth athlete populations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40621-021-00364-4.

Number of prior concussions predict poorer concussion care seeking in military cadets

PRIMARY OBJECTIVE

To determine whether concussion history predicts concussion care seeking, self-management practices, or confidence to recognize/report.

RESEARCH DESIGN

Cross-sectional.

METHODS & PROCEDURES

706 United States Air Force Academy (USAFA) cadets completed survey items regarding concussion history (0,1,2,3+), likelihood of reporting a concussion, self-management, and confidence to recognize/report. We used multivariate ordinal and binary logistic regression models to predict responses using concussion history, sex, and race.Main outcomes & results: cadets with 1 (OR = 0.59, 95%CI:0.43-0.82), 2 (OR = 0.55, 95%CI:0.31-0.98), or 3+ (OR = 0.36, 95%CI:0.17-0.78) concussions while at USAFA had respective 41%, 45%, and 64% lower likelihood to report the concussion scenario (ref = no history, p < .001). USAFA cadets with more extensive concussion histories had higher prevalence of not seeking care for a concussion (p < .001); more strongly endorsed self-management (p = .001-0.010); and had greater confidence in their ability to recognize a concussion (p = .005), but not to report (p = .198-0.413).

CONCLUSIONS

Prior concussion experiences may deter cadets from seeking medical care for future concussions. Interventions should address concussion history and clinicians should consider how the post-concussion management process might deter care seeking.

Review of wearable technologies and machine learning methodologies for systematic detection of mild traumatic brain injuries

Mild traumatic brain injuries (mTBIs) are the most common type of brain injury. Timely diagnosis of mTBI is crucial in making 'go/no-go' decision in order to prevent repeated injury, avoid strenuous activities which may prolong recovery, and assure capabilities of high-level performance of the subject. If undiagnosed, mTBI may lead to various short- and long-term abnormalities, which include, but are not limited to impaired cognitive function, fatigue, depression, irritability, and headaches. Existing screening and diagnostic tools to detect acute andearly-stagemTBIs have insufficient sensitivity and specificity. This results in uncertainty in clinical decision-making regarding diagnosis and returning to activity or requiring further medical treatment. Therefore, it is important to identify relevant physiological biomarkers that can be integrated into a mutually complementary set and provide a combination of data modalities for improved on-site diagnostic sensitivity of mTBI. In recent years, the processing power, signal fidelity, and the number of recording channels and modalities of wearable healthcare devices have improved tremendously and generated an enormous amount of data. During the same period, there have been incredible advances in machine learning tools and data processing methodologies. These achievements are enabling clinicians and engineers to develop and implement multiparametric high-precision diagnostic tools for mTBI. In this review, we first assess clinical challenges in the diagnosis of acute mTBI, and then consider recording modalities and hardware implementation of various sensing technologies used to assess physiological biomarkers that may be related to mTBI. Finally, we discuss the state of the art in machine learning-based detection of mTBI and consider how a more diverse list of quantitative physiological biomarker features may improve current data-driven approaches in providing mTBI patients timely diagnosis and treatment.

Psychometric properties of concussion knowledge and cognitive mediators of reporting measures

Context: Concussion education and prevention programs require reliable and valid instruments to evaluate the theory, mechanisms, and outcome of these interventions Objective: To assess the psychometric properties of measures evaluating concussion education and prevention programsDesign: Descriptive epidemiological Setting: 10 NCAA-member universities Patients or Other Participants: 841 student-athletes in an RCT control group testing an ecological, peer-led concussion education program Main Outcome Measures: Instruments adapted for assessing concussion knowledge and Theory of Planned Behavior/Theory of Reasoned Action (TPB/TRA) cognitive mediators of reporting behavior (attitudes, subjective norms, perceived control, and intentions to report concussion). Participants completed measures at baseline, after one hour, and after one month Results: Internal consistency and test-retest reliability were moderate for both the concussion knowledge and cognitive mediator measures. TPB/TRA was supported subscale intercorrelation and item factor analysis in the cognitive mediator scale. Factor analysis of the concussion knowledge measure revealed subscales for physical/cognitive, psychological/affective, and non-symptoms. The intermediate TPB/TRA mediators of attitudes, norms, and perceived control predicted greater intention-to-report, which predicted increased likelihood of reporting concussion one month later.Conclusions: Measures of concussion knowledge and cognitive mediators of reporting adapted from the literature show adequate psychometric properties and support TPB/TRA application for concussion reporting behaviors.

Brain smart – Let's play safely: Evaluation of a concussion education program in schools

Objectives

There are two objectives for this paper. First, to determine effects of a concussion education program in a local school board in terms of concussion-specific knowledge in children and confidence in identifying and managing concussion in adults. Second, to identify differences and similarities in concussion knowledge between children who participate in sports and those who do not and between children with a history of one or more concussions and those without.

Design

A cross sectional survey regarding concussion knowledge was distributed randomly to students and adults at both pre- and posteducation timepoints. A concussion education program was disseminated across the school board for students between the distribution survey timepoints. Following the education program, adults and students completed their respective post-test surveys. Chi-squared tests in SPSS determined the significance of between-group differences.

Results

All 17 adults (100.0%) who had received concussion education recently reported confidence in their knowledge of concussion management, compared to 35.7% adults who had not received education for over a year (p = 0.020). For students, all of whom completed the concussion education training between the pre- and post-tests, there were no significant differences in concussion knowledge scores between athletes and non-athletes (either in or outside of school) or between those with a history of concussion and those without. There were no significant changes in concussion knowledge between the pre- and post-tests, except for one question.

Conclusion

Concussion education programs increase confidence of concussion management protocols in adults involved in sport, but they require improvements to better support knowledge amelioration, particularly for target groups that are at high risk of sustaining another injury.

Predictors of COVID-19 Preventive Behavior Adoption Intention in Malaysia

Preventive behavior adoption is the key to reduce the possibility of getting COVID-19 infection. This paper aims to examine the determinants of intention to adopt preventive behavior by incorporating perception of e-government information and services and perception of social media into the theory of reasoned action. A cross-sectional online survey was carried out among Malaysian residents. Four hundred four valid responses were obtained and used for data analysis. A partial least-square-based path analysis revealed direct effects of attitude and subjective norm in predicting intention to adopt preventive behavior. In addition, perception of e-government information and services and perception of social media were found to be significant predictors of attitude toward preventive behavior. The findings highlight the importance of digital platforms in improving people’s attitudes toward preventive behavior and in turn contain the spread of the infectious disease.

Athlete Enjoyment of Prior Education Moderates change in Concussion-Reporting Intention after Interactive Education

Undiagnosed concussions increase risk of additional injuries and can prolong recovery. Because of the difficulties recognizing concussive symptoms, concussion education must specifically target improving athlete concussion reporting. Many concussion education programs are designed without significant input from athletes, resulting in a less enjoyable athlete experience, with potential implications on program efficacy. Athlete enjoyment of previous concussion education programs moderates the improvement in concussion-reporting intention after experiencing the research version of CrashCourse (CC) concussion education. Prospective cohort study. Level of evidence: Level IV. Quantitative assessment utilizing ANOVA with moderation analysis of 173 male high school football players, aged 13 to 17, who completed baseline assessments of concussion knowledge, concussion reporting, and attitudes about prior educational interventions. Athletes were subsequently shown CC, before a follow-up assessment was administered assessing the same domains. At baseline, only 58.5% of athletes reported that they enjoyed their previous concussion education. After CC, athletes were significantly more likely to endorse that they would report a suspected concussion (from 69.3% of athletes to 85.6%; P < .01). Enjoyment of previous concussion education moderated concussion-reporting intention after CC (P = .02), with CC having a greater effect on concussion-reporting intention in athletes with low enjoyment of previous concussion education (b = 0.21, P = .02), than on individuals with high enjoyment of previous concussion education (P = .99). Enjoyment of CC did not have a moderating effect on concussion-reporting intention. Athletes who previously did not enjoy concussion education exhibited greater gains in concussion-reporting intention than athletes who enjoyed previous education. Given the potential risks associated with undiagnosed concussions, concussion education has sought to improve concussion reporting. Because most athletes participate in concussion education programs due to league or state mandates, improving concussion-reporting intention in these low-enjoyment athletes is of particular relevance to improving concussion-reporting intention broadly.

Collegiate athletes' perceptions of the culture of concussion reporting

The current study was designed to understand the culture of concussion among college student-athletes. Participants: Eight men's lacrosse and seven women's soccer players. Methods: A focus group was conducted to understand thoughts, barriers, team culture, and what was needed to feel safe reporting symptoms. Thematic analysis was conducted to identify key themes. Results: Themes included concerns about being taken out, pushing through, wanting to play, severity influencing reporting, changes about concussion reporting, uncertainty about symptoms, concussion have changed the game, reporting a teammate, wanting someone else to make the call, desire to raise awareness, deception, wanting professors to have more understanding, circumstances influencing reporting, helmets specific for concussion, malingering, and the return to play protocol being too long. Conclusion: Factors ranging from intrinsic to more distal cultural and environmental factors appear to influence reporting concussions. Student-athletes identified factors unique to the college athlete environment.

An Examination of Perceived Pressure From Stakeholders on Concussion Reporting Intentions and Behavior in Ice Hockey Athletes

OBJECTIVE

We aimed to assess whether perceived pressure predicts concussion reporting intentions and behavior in youth, high school, and collegiate ice hockey athletes, and, secondarily, whether perceived pressure from stakeholders differed between sex or level of play.

SETTING

Online survey.

PARTICIPANTS

One hundred fifty-two ice hockey athletes (males: n = 96, 63.2%; females: n = 55, 36.2%; missing: n = 1, 0.7%; age = 14.04 ± 3.6 years).

DESIGN

Cross-sectional.

MAIN MEASURES

Respondents answered a survey that elicited information about demography, perceived pressure from 6 stakeholders, and concussion reporting intentions and behavior. For the first aim, we used a generalized linear model to determine whether perceived pressure from any stakeholder predicted intention (symptom reporting, concussion reporting, and intention beliefs) or behavior ("all concussions," "not obvious concussions"; α < .05) while controlling for level of play. To determine whether pressure from any stakeholder predicted symptom reporting behavior, we used logistic regression while controlling for level of play. For the second aim, to examine sex differences in perceived pressure from each stakeholder, we employed Mann-Whitney tests and to examine level of play differences, we used Kruskal-Wallis tests.

RESULTS

Controlling for level of play, a 1-point increase in perceived pressure from parents and athletic administrators decreased concussion reporting intentions by 0.92 (P = .004) and 1.09 (P = .005) points, respectively. Perceived pressure from a sports medicine professional decreased intention beliefs by 0.17 (P = .029) points. Perceived pressure from stakeholders did not predict symptom reporting (P = .440) or "not obvious concussion" reporting (P = .655) behavior. We observed no difference in perceived pressure across stakeholders (all P values >.05); however, collegiate ice hockey respondents perceived greater pressure from coaches than youth or high school athletes (P < .001). We noted no other differences in perceived pressure across levels of play (all P values >.05).

CONCLUSIONS

Concussion reporting intentions were negatively influenced by perceived pressure from parents, athletic administrators, and sports medicine professionals, but these findings did not translate to reporting behavior.

Factors Associated With Concussion Nondisclosure in Collegiate Student-Athletes

CONTEXT

Mandated concussion education has aimed to improve student-athlete knowledge; however, some collegiate student-athletes continue to not disclose concussion. Concussion knowledge may not be the only factor influencing reporting, as student-athlete sex, sport, and pressure from external stakeholders (eg, coaches, teammates, fans, parents or family) have all been documented as influencing collegiate concussion-reporting behavior.

OBJECTIVE

To examine factors associated with concussion nondisclosure in collegiate student-athletes.

DESIGN

Cross-sectional study.

SETTING

Four National Collegiate Athletic Association Division I and two Division II universities.

PATIENTS OR OTHER PARTICIPANTS

A total of 1125 collegiate student-athletes completed the survey, and 741 provided viable responses and were included for data analysis.

MAIN OUTCOME MEASURE(S)

We used a 10- to 15-minute electronic or paper-and-pencil survey that asked about personal and sport demographics, diagnosed concussions and nondisclosed concussion history, concussion knowledge, and level of agreement regarding pressure to play after a head impact experienced during collegiate sport participation. Significant univariable factors were entered into a multivariable logistic regression analysis.

RESULTS

Sex (P = .005), sport-risk type (P < .001), diagnosed concussion history (P < .001), concussion knowledge (P = .017), and pressure from coaches (P < .001), teammates (P < .001), fans (P = .024), and parents or family (P = .003) were factors associated with concussion nondisclosure in individual univariable logistic regressions. After we conducted multivariable analyses, male sex (P = .001), high concussion-risk sport participation (P = .048), diagnosed concussion history (P < .001), increased concussion knowledge (P = .013), and experiencing pressure from coaches to continue playing after sustaining a hit to the head (P = .002) were factors associated with concussion nondisclosure in collegiate student-athletes.

CONCLUSIONS

Our results suggest that concussion-education programs should go beyond the identification of signs and symptoms to include the dangers of continuing to play, long-term consequences, and transparency about concussion protocols. Comprehensive concussion-education programs should involve coaches and athletes to improve the reporting culture.

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.

Concussion-reporting behaviors among high school athletes in Ireland: Applying the theory of planned behavior

Background

Sport-related concussion is a significant public health issue, especially among children and adolescents. A growing body of evidence suggests that athletes who do not immediately report concussion and continue to play while concussed take longer to recover than their counterparts. Yet, many child and adolescent athletes do not immediately report concussion symptoms to a responsible adult.

Aim

This study examined the utility of the Theory of Planned Behavior (TPB) in predicting concussion reporting intentions and in-season reporting behaviors among high school, Gaelic Athletic Association (GAA) athletes in the Republic of Ireland.

Methods

High school GAA athletes aged 12-18 years completed surveys at baseline and at three-month follow-up. Concussion-related perceived behavioral control (PBC), attitudes, subjective norms, and reporting intentions were assessed at baseline. In-season concussion reporting behaviors were assessed at three-month follow-up. Hierarchical linear regression models were used to examine the relationship between the constructs of the TPB and baseline reporting intentions. Logistic regression models were used to examine the relationship between the constructs of the TPB and in-season reporting behaviors. All data were collected during the 2016–2017 academic year.

Results

A total of 153 adolescent athletes were included (n = 102 [66.7%] females; Mage = 14.4 years, [SD = 1.6]). Consistent with the TPB, results revealed that PBC and reporting intentions contributed to the prediction of in-season reporting behaviors. Reporting intentions, in turn, were strongly influenced by PBC, attitudes, and subjective norms. PBC was the strongest predictor of concussion reporting intentions and in-season reporting behaviors; the stronger the athletes’ PBC, the stronger their reporting intentions and the more likely they were to have reported concussion symptoms during the current season.

Conclusion

Although the findings from the current study must be interpreted cautiously given the small sample size, the findings suggest that the TPB has some utility in the prediction of concussion reporting intentions and reporting behaviors. However, our findings suggest that the TPB should not be used in isolation; other models that incorporate personal factors and environmental constraints may be needed to better our understanding of concussion reporting intentions and behaviors among high school athletes. Concussion education programs that include strategies to enhance PBC over concussion reporting may help improve concussion reporting behaviors among high school athletes.

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.

Accuracy of US College Football Players' Estimates of Their Risk of Concussion or Injury

IMPORTANCE

Despite increased concern about the health consequences of contact sports, little is known about athletes' understanding of their own risk of sports-related injury.

OBJECTIVE

To assess whether college football players accurately estimate their risk of concussion and nonconcussion injury and to identify characteristics of athletes who misestimate their injury risk.

DESIGN, SETTING, AND PARTICIPANTS

In this survey study, questionnaires were given to 296 current college football players on 4 teams from the 3 of the 5 most competitive conferences of the US National Collegiate Athletic Association. Surveys were conducted between February and May 2017. Data were analyzed from June 2017 through July 2020.

MAIN OUTCOMES AND MEASURES

Multiple approaches were taken to compare athlete perceptions of their risks of concussion and nonconcussion injury with individual probabilities of these risks, which were modeled using logistic regression.

RESULTS

Of 296 male college-aged athletes from 4 football teams who participated in the survey, 265 (89%) answered all questions relevant for this study. Participating teams were similar to nonparticipating teams across nearly all measured characteristics. One hundred athletes (34%) had sustained 1 or more concussions, and 197 (68% of the 289 who responded to the question) had sustained 1 or more injuries in the previous football season. Logistic regression models of single-season injury and concussion had reasonably good fit (area under the curve, 0.75 and 0.73, respectively). Of the 265 participants for whom all relevant data were available, 111 (42%) underestimated their risk of concussion (χ2 = 98.6; P = .003). A similar proportion of athletes (113 [43%]) underestimated their risk of injury, although this was not statistically significant (χ2 = 34.0; P = .09). An alternative analytic strategy suggested that 241 athletes (91%) underestimated their risk of injury (Wilcoxon statistic, 7865; P < .001) and 167 (63%) underestimated their risk of concussion (Wilcoxon statistic, 26 768; P < .001).

CONCLUSIONS AND RELEVANCE

The findings of this survey study suggest that college football players may underestimate their risk of injury and concussion. The implications for informed participation in sport are unclear given that people generally underestimate health risks. It is necessary to consider whether athletes are sufficiently informed and how much risk is acceptable for an athlete to participate in a sport.

Using the health belief model to predict concussion-reporting intentions and behaviour

PURPOSE

To determine whether Health Belief Model (HBM) factors predict concussion-reporting intentions and behaviour. Methods: Participants completed a cross-sectional survey to measure the HBM constructs of concussion knowledge, perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and cues to action. We also asked participants to indicate their concussion-reporting intentions and behaviourfor symptom and concussion reporting. Four separate multivariable regressions were conducted to predict concussion-reporting intentions and behaviour based on HBM constructs. Results: Cues to action (β = 0.25, p= .016) predicted symptom reporting intentions (F_7,318 = 4.44, p< .001, R² = 0.089), while perceived benefits (β = 0.12, p= .018), perceived barriers (β = -0.11, p= .034) and cues to action (β = 0.29, p< .001) predicted concussion-reporting intentions (F_7,318 = 11.34, p < .001, R² = 0.200). The HBM did not predict symptom or concussion-reporting behavior (symptom: Χ² = 5.51, p= .138, Nagelkerke R² = 0.096; concussion: Χ² = 5.20, p= .157, Nagelkerke R² = 0.159). Conclusions: Strategies to reduce perceived barriers and increase benefits of reporting concussion symptoms may improve reporting intentions. This may include cues to action in sharing a positive view toward long-term health and dispelling that reporting a concussion would let down teammates. .

Concussion Knowledge, Attitudes, and Self-Reporting Intentions in Youth Athletes

CONTEXT

Although it has been suggested that developmental and sociological factors play a role in concussion reporting, the empirical evidence related to this is limited.

OBJECTIVE

To examine the influences of sex, school level, school location, concussion-reporting history, and socioeconomic status on concussion-related knowledge, attitudes, and reporting intentions among middle school and high school athletes.

DESIGN

Cross-sectional study.

SETTING

Master students and High School athletes attending pre-participation examinations (PPEs) were asked to complete paper-based surveys.

PATIENTS OR OTHER PARTICIPANTS

Overall, 541 athletes representing 18 sports returned fully completed surveys.

MAIN OUTCOME MEASURE(S)

Outcomes were concussion-related knowledge, perceived seriousness, positive feelings about reporting, and self-reporting intentions. We examined group differences in these outcomes across levels of the explanatory variables of sex, school level (middle school versus high school), school location (urban versus rural), concussion self-reporting history (yes or no), and socioeconomic status (free or reduced-price lunch versus no free or reduced-price lunch) using Wilcoxon rank sum tests. Then we used multivariable ordinal logistic regression models to identify predictors of higher score levels for each outcome. Odds ratio (OR) estimates with 95% confidence intervals (CIs) excluding 1.00 were deemed significant.

RESULTS

Odds of higher levels of knowledge were higher in urban versus rural school student-athletes (ORAdjusted = 1.81; 95% CI = 1.03, 3.17), and lower in student-athletes on free or reduced-price lunch versus those not on free or reduced-price lunch (ORAdjusted = 0.52; 95% CI = 0.36, 0.77). Similarly, odds of higher levels of seriousness were lower in male versus female student-athletes (ORAdjusted = 0.48; 95% CI = 0.32, 0.72). Further, odds of higher levels of self-reporting intentions were lower among male versus female student-athletes (ORAdjusted = 0.53; 95% CI = 0.37, 0.75).

CONCLUSIONS

Developmental and sociological factors were differentially associated with concussion-related knowledge, attitudes, and self-reporting intentions. These results can inform medical providers, parents, and coaches with regard to context-specific clinical assessments of concussion symptoms.

Factors Influencing Concussion Reporting Intention in Adolescent Athletes

Clinical Scenario: Concussions are severely underreported, with only 47.3% of high school athletes reporting their concussion. The belief was that athletes who were better educated on the signs and symptoms and potential dangers of concussion would be more likely to report. However, literature has shown inconsistent evidence on the efficacy of concussion education, improving reporting behaviors. Factors such as an athlete's attitude, subjective norms, and perceived behavioral control have shown promise in predicting intention to report concussions in athletes. Focused Clinical Question: Do attitudes, subjective norms, and perceived behavioral control influence adolescent athletes' intention to report? Summary of Key Findings: Three studies (1 randomized control and 2 cross-sectional surveys) were included. Across the 3 studies, attitudes, subjective norms, and perceived behavioral control positively influenced athletes' reporting intention. The studies found that attitude toward concussion reporting and perceived behavioral control were the most influential predictors of reporting intention. Clinical Bottom Line: There is moderate evidence to suggest that positive attitudes, supportive subjective norms, and increased perceived behavioral control influence reporting intention in secondary school athletes. Strength of Recommendation: Grade B evidence exists that positive attitudes, supportive subjective norms, and increased perceived behavioral control positively influence concussion reporting intention in secondary school athletes.