A new study suggests that one of the best ways to combat the chronic underreporting of concussion by athletes may be to educate coaches on ways to create an environment where athletes feel safe reporting concussion symptoms. It adds to a growing body of evidence challenging the conventional wisdom that inadequate athlete concussion knowledge is the principal barrier to increased reporting, and that other ways need to be found to keep athletes safe, including enlisting coaches and parents in creating an environment in which concussion symptom reporting is encouraged.
Researchers at the Harvard School of Public Health and Boston University's Center for the Study of Traumatic Encephalopathy concluded, based on responses to questionnaires completed by male NCAA Division 1 hockey players, that the NCAA's general mandate that student-athletes be provided with "educational material on concussions" was ineffective.
Not only did such mandate fail to yield significant improvements in knowledge among the players after receiving written materials about concussion, but their receipt of such information did virtually nothing to change their intention to continue playing while experiencing symptoms of a concussion, which, studies show, puts athletes at increased risk of a longer concussion recovery time and adverse neurological consequences.
"Existing education programs for athletes have tended to focus on symptom identification and reporting protocol, with evaluation largely assessing change in concussion knowledge," writes lead author Emily Kroshus of the Department of Social and Behavioral Sciences at the Harvard School of Public Health, but "[g]iven that the goal of concussion education is to change player behavior (eg, ceasing play when symptoms are present), concussion knowledge may not be the best or only factor to target."
Instead, Kroshus and her colleagues recommend that concussion education focus more on the coach's critical role in facilitating concussive symptom reporting by communicating to athletes positive messages about concussion reporting, by fostering a "culture of safety," and by creating channels for reporting through a variety of formal and/or informal means.
Attitude: more important than knowledge?
Until recently, the conventional wisdom of concussion experts has been that the principal reasons for the chronic under-reporting by athletes of concussive symptoms is inadequate athlete concussion knowledge, and that increased concussion education - as is mandated by the NCAA and laws in almost every state - would likely remove the primary barrier to concussive symptom reporting.
As in the current study, a 2013 qualitative focus group study involving 50 athletes from three football, two boys' soccer, and four girls' soccer teams, researchers at Seattle Children's Hospital and the University of Washington found that athlete concussion knowledge was not the most important barrier to concussive symptom reporting.  Rather, wrote Sara P. Chrisman, M.D., M.P.H., the lead author of the Washington State study, it was that athletes were hesitant to report concussive symptoms out of concern as to how their reports would be received by their coach.
Most athletes, found Chrisman and her colleagues, "seemed to know a great deal about concussion. They could report a large number of signs and symptoms and they recognized the danger of concussion, mentioning risks of long term disability or death." (such high level of concussion knowledge may have been, Chrisman speculated, the result of the increased concussion education required under Washington State's groundbreaking Lydstedt Law). But nearly every one of the nine focus groups, she and her colleagues found, "came to the conclusion that they would keep playing when faced with a hypothetical scenario in which they were experiencing concussive symptoms ... after a collision."
Consistent with the result of the NCAA hockey study and a number of other studies over the past decade, as well as anecdotal evidence about concussion reporting attitudes gathered during MomsTEAM's filming of its high school football concussion documentary, "The Smartest Team," most athletes in the Washington State focus groups gave as reasons for choosing to continue playing while experiencing symptoms that:
- they did not want to stop playing or be pulled from the game;
- they questioned whether the symptoms, many of which are not specific to concussions (e.g. headache, dizziness, nausea), could have been caused by something other than concussion;
- it was not acceptable to leave the game for nonspecific symptoms of a concussion because if they were wrong, the coach might punish them for reporting by removing them a starting position, reducing future playing time, or inferring that reporting concussive symptoms made them "weak" (a sentiment expressed by both soccer and football players, male and female);
- they didn't want to let the team down; and
- they had received negative messages from coaches regarding injury reporting (although, to be fair, some reported having received positive messages from coaches regarding concussive symptom reporting).
The NCAA hockey study thus becomes just the latest in a series of recent studies [2-5] suggesting that one of the best ways to combat underreporting by athletes of concussion symptoms may be to shift the focus of educational efforts towards helping coaches facilitate concussion reporting, the theory being that athletes will be more likely to report concussion symptoms if they no longer think that they will be punished by the coach for reporting, such as by losing playing time or their starting position, perceived by their teammates as letting them down, or viewed by their coach as "weak," all of which have been documented in numerous studies over the past decade as reasons athletes are reluctant to report concussion symptoms.[2-9]
Its recommendations build on those made by Chrisman and her colleagues in their study in which they proposed that efforts to increase concussion reporting utilize the Theory of Planned Behavior (TPB) which, in the context of concussion reporting behavior, holds that such behavior is determined by the interplay of three factors:
- Attitudes: athletes' beliefs about the consequences of reporting concussion symptoms;
- Subjective norms: beliefs about what others (especially coaches, but also parents and eammates) expect the athlete to do; and
- Perceived behavioral control: beliefs about athletes' own abillity to report concussion symptoms (often called "self-efficacy").
Chrisman found that, contrary to the conventional wisdom, "athletes did not report concussive symptoms because of a lack of knowledge" [they found that high school soccer and football players seemed to know a great deal about concussions, could report a large number of signs and symptoms many of which they had personally experienced - and recognized the danger of concussion, mentioning risks of long term disability or death], but, rather because, despite understanding "the risk of playing with concussive symptoms (attitudes), they believed that [coaches] did not want them to report symptoms (subjective norms), and those norms had a greater influence on their behavior than their own perceived ability to report concussive symptoms.
"In other words," Chrisman concluded, "athletes' intentions to report concussive symptoms followed the norms for what was acceptable regarding concussive symptom reporting, even when these norms went against their own concussion knowledge. These norms, in turn, were based on athletes' perceptions of coach expectations regarding symptom reporting."
"The biggest barrier to concussive symptom reporting is that adolescents are designed to be risk takers," argues Chrisman. "Adolescents know concussions are dangerous, but they play anyway. The same has been found for cigarette smoking, alcohol use and driving while intoxicated. Adolescent risk-taking is not a new finding," she says, but, unfortunately, it "is also not susceptible to change."
"Our intent was to remind people that educating youth about the dangers of concussion is unlikely to improve concussion reporting. Instead, we must find other ways to make them safe. We focused on coaches because this is an area where change is possible. Coaches should be an ally in this discussion. Our experience has been that the vast majority of high school football and soccer coaches are very knowledgeable about concussion and willing to do all that is possible to ensure the safety of their athletes."
Behavior: hard to change
In the NCAA hockey study, Kroshus and her colleagues found support for viewing concussion reporting behavior in this way, viewing their findings among the players surveyed of a significant association among knowledge, attitude and subjective norms and concussion reporting intention as "reinforcing the importance of these cognitions as targets of concussion education and the potential appropriateness of TPB as a theory to inform the design and evaluation of programmes attempting to modify concussion reporting behavior."
Their study is the second to be published in the span of just over two months to support the use of TPB in guiding the development of concussion education programs, following the June 2013 publication of a qualitative attitude study  by researchers at WakeMed Health and Hospitals, Raleigh, NC, the University of North Carolina at Chapel Hill, and A.T. Still University in Mesa, Arizona, which found that, while the culture of sport (including influences from professional and other athletes), as well as the media and other outside sources play a role in the decision of student-athletes to report experiencing concussion symptoms, the three direct TPB factors (attitude, subjective norm, and perceived behavioral control) accounted for 53% of the intention to report concussions. The study found that it was coaches and teammates, along with parents, who have the strongest influence on the decision to report a concussion during sport participation.
The findings prompted lead author Johna Register-Mihalik, Ph.D, LAT, ATC, Senior Research Associate at WakeMed and Adjunct Assistant Professor at UNC-Chapel Hill, and her colleagues - apparently independently of the Chrisman and Kroshus groups - to recommend the need for "multi-level" concussion awareness programs, starting with the intra-personal (the individual) and moving through the inter-personal (relationships to the individual), the organizational level (team) [to] the policy level," with the intra-personal and inter-personal level targets "aimed at creating positive attitudes and beliefs towards concussion and concussion reporting," both among indidividuals as well as parents, coaches, and teammates, and towards "creating an environment that rewards positive concussion-care seeking behaviors such as reporting an injury or removing one's self from play when experiencing concussive symptoms."
While recommending that the emphasis of concussion education be changed, Register-Mihalik was unaware of any program thus far usinh the Theory of Planned Behavior in this way.
Study details and findings
To assess the concussion education provided to the hockey players in terms of content, delivery, and effectiveness in changing concussion-reporting behavior, Krosher and her colleagues asked players on six NCAA Division 1 male hockey teams to complete two surveys at the beginning of the 2012-2013 school year and prior the start of hockey season: one the day before, and one the day after receiving concussion education.
The type of education differed by team: four received written materials on concussions (three receiving individual hard copies of the handout, the members of one team having the handout left in their locker room for common perusal, and two teams receiving the materials by e-mail). Five of the six teams also received a lecture from their athletic trainer about concussions. Members of one team not only got individual handouts and received a lecture, but also watched a concussion video specifically targeting hockey players. 
Significantly, the video had the highest rate of recall across all teams and types of educational materials (92%), and in response to a prompt asking what changes would make their concussion education more effective, players on other teams most frequently reported wanting information delivered in video form, with testimonials from former athletes about the long-term conseqences of concussion. That concussion education in video form can be effective, at least in the short term, in increasing concussion knowledge, was also found among junior hockey players in Canada, although that study recommended that future concussion prevention efforts in hockey and other sports incorporate a variety of educational modalities, given the lack of evidence that any specific modality (e.g. educational videos, websites, seminars) is the best technique to employ.
Based on questionnaire responses by 146 hockey players, the Boston researchers found that:
- change in intention to continue playing with a minor concussion was significantly higher among athletes who reported remembering that they had received a lecture, and significantly lower among those who remembered that they had received an email;
- an athlete's baseline concussion knowledge had no influence on whether or not they accurately remembered the type of educatino they received;
- the team that watched the video had the greatest improvement in concussion knowledge, while two teams actually scored worse on the measure of concussion knowledge following education;
- 18.5% of participants reported being diagnosed with at least one concussion by a medical professional during the previous season,
- Many more participants saying they experienced symptoms after a head impact suggestive of concussion, with nearly half (45.9%) reporting they continued playing with a headache after being hit on the head, but with significant variability between teams (12.5-54.2%).
- Among athletes who suspected that they had a concussion during the previous season but did not report their injury:
- fully half (50.6%) stated that they did not report it because they did not know it was a concussion;
- 7 out of 10 (69.7%) because they did not think it was serious enough;
- close to half (48.3%) because they did not want to be pulled out of the game or practice; and
- a third (32.6%) because they did not want to let down their teammates.
1. Kroshus E, Daneshvar DH, Baugh CM, Nowinski CJ, Cantu RC. NCAA concussion education in ice hockey: an ineffective mandate. Br J Sports Med. 2013;doi:10.1136/bjsports-2013-092498 (epub. August 16, 2013)
2. Echlin PS, Skopelja EN, Worsley R et. al. A prospective study of physician-observed concussion during a varsity university ice hockey season: incidence and neuropsychological changes. Part 2 of 4. Neurosurg Focus 2012;33(6):E2
3. Chrisman SP, Quitiquit C, Rivara FP. Qualitative study of barriers to concussive symptom reporting in high school athletics. J Adolesc Health 2013;52:330-5 e3.
4. Register-Mihalik JK, Linnan LA, Marshall SW, Valovich McLeod TC, Mueller FO, Guskiewicz KM. Using theory to understand high school aged athletes' intentions to report sport-related concussion: Implications for concussion education initiatives. Brain Injury 2013;27(7-8):878-886.
5. Anderson B, Pomerantz W, Mann J, Gittelman M. "I Can't Miss the Big Game": High School (HS) Football Players' Knowledge and Attitudes about Concussions. Paper presented at the Annual meeting of the Pediatric Academic Societies, Washington, D.C. May 6, 2013.
6. Register-Mihalik JK, Guskiewicz KM, Valovich McLeod TC, Linnan LA, Meuller FO, Marshall SW. Knowledge, Attitude, and Concussion-Reporting Behaviors Among High School Athletes: A Preliminary Study. J Ath Tr. 2013;48(3):000-000. DOI:10.4085/1062-6050-48.3.20 (published online ahead of print)
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8. Dziemianowicz M, Kirschen MP, Pukenas BA, Laudano E, Balcer LJ, Galetta SL. Sport-Related Concussion Testing. Curr Neurol Neurosci Rep 2012 (published online July 13, 2012)(DOI:10.1007/s11910-012-0299-y).
9. McGrath N. Supporting the Student-Athlete's Return to the Classroom After a Sport-Related Concussion. J Ath. Tr. 2010:45(5):492-498.
10. Ajzen I. The theory of planned behavior. Organizational Behav Hum Dec Proc 1991;50:179-211.
11. NCAA. Concusion: a Fact Sheet for Student-Athletes. 2012. http://fs.ncaa.org/Docs/health_safety/ConFactSheetsa.pdf
13. Cusimano MD, Chimpman M, Donnelly P, et al. Effectiveness of an educational video on concussion knowledge in minor league hockey players: a cluster randomized controlled trial. Br J Sports Med 2013;doi:10.1136/bjsports-2012-091660)(e pub August 5, 2013) ( finding that concussion knowledge did not result in a change in attitudes or decrease aggressive play, which the authors speculated was likely "due to the fact that players at all levels in all age groups receive consistent cultural messaging that quite likely emanates from potentially aggressive parents, 'hard line' coaching styles, the media, television personalities and negative professional role models." They thus recommended that "the influence that define the culture of ice hockey and sport more generally need to be considered in prevention strategies because ignoring them will undermine and negate any attempt at prevention.")