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."