Athletic Training and Sports Health Care

Original Research 

Concussion Disclosure: Fears Presented by Football Student-Athletes

Debbie I. Craig, PhD, ATC, LAT; Monica R. Lininger, PhD, ATC, LAT; Taylor Lane, MA

Abstract

Purpose:

To investigate football student-athletes' fears about concussion disclosure.

Methods:

The mixed-methods design surveyed 205 collegiate football student-athletes from three NCAA Division I institutions.

Results:

Student-athletes feared losing playing time (51.9%), being considered weak (16.3%), and hearing about potential health impacts (11.3%) or that their football career may be over (7.5%). In comparison with similar questions in Kroshus et al's 2014 study, the current study's results indicate a positive increase in thinking that their teammates will think they made the right decision if they disclose a concussion (47% agree) and that they will be better off in the long run (59% agree).

Conclusions:

The results indicate that team norms around concussion reporting may be shifting toward a more positive trend.

[Athletic Training & Sports Health Care. 20XX;XX(X):XX–XX.]

Abstract

Purpose:

To investigate football student-athletes' fears about concussion disclosure.

Methods:

The mixed-methods design surveyed 205 collegiate football student-athletes from three NCAA Division I institutions.

Results:

Student-athletes feared losing playing time (51.9%), being considered weak (16.3%), and hearing about potential health impacts (11.3%) or that their football career may be over (7.5%). In comparison with similar questions in Kroshus et al's 2014 study, the current study's results indicate a positive increase in thinking that their teammates will think they made the right decision if they disclose a concussion (47% agree) and that they will be better off in the long run (59% agree).

Conclusions:

The results indicate that team norms around concussion reporting may be shifting toward a more positive trend.

[Athletic Training & Sports Health Care. 20XX;XX(X):XX–XX.]

Concussion disclosure in sports is currently being studied in various ways around the globe. Many of these investigations involve quantitative items that delve into reporting intention,1–3 team norms about reporting,4,5 concussion knowledge,6,7 and reasons for not disclosing a possible sports-related concussion.2,8,9 Each of these areas are critical for sports medicine clinicians to understand when working with student-athletes to improve healthy, efficacious concussion-reporting behaviors. Although we now have evidence that high levels of concussion knowledge alone will not consistently improve concussion-reporting behaviors,2,6,7,10 emerging results suggest the use of other methods to improve reporting behaviors. This includes student-athletes gaining a better understanding of healthy team norms,2,4 a focus on how early disclosure can decrease missed playing time,11,12 and how early disclosure can decrease the risk of subsequent lower extremity injury when playing with a concussion.13

Previous research studies asking student-athletes to identify the reasons why they may not disclose a potential sports-related concussion have most commonly involved closed-ended questionnaire items, which were then quantitatively analyzed.8,9,14 Although these types of questionnaire items are easy to implement and analyze, the closed-ended nature may limit respondents' ability to provide their own perspective. What is less common in this literature are the student-athletes' own words regarding why they may choose to not disclose their potential sports-related concussion and/or their perspective on why the act of hiding a potential sports-related concussion persists. Intentions to report sports-related concussion have also been investigated qualitatively, although these methods are conducted less often. Studies using qualitative methodology allow the use of open-ended interview questions to develop new questionnaire items3 or to query student-athletes about their experiences with concussion disclosure.15 This study is unique in its qualitative design in that all participants (N = 205) had the ability to answer open-ended questions about concussion disclosure, rather than a select few.

Therefore, the purpose of this research study was to use both qualitative analytic procedures and quantitative methods to determine the reasons why football student-athletes choose not to disclose a potential sports-related concussion, their fears about disclosure, and how those responses may illustrate shifting team norms. Learning more about why student-athletes may not disclose a sports-related concussion, in their own words, will allow clinicians to positively affect concussion-reporting behaviors by addressing specific team norms.

Methods

Design

A cross-sectional study design was used to assess the reasons why student-athletes may not disclose a potential sports-related concussion. This is a portion of the results from a larger study that investigated many aspects of concussion-reporting behaviors at three National Collegiate Athletic Association (NCAA) Division I institutions.16 Student-athletes completed a paper and pencil questionnaire that included both closed- and open-ended items, with data collection occurring following the 2017 football season. Prior to data collection, institutional review board approval was granted for all procedures.

Participants

Two hundred five football student-athletes (age: 19.8 ± 1.3 years) at three NCAA Division I institutions (1 Football Bowl Subdivision and 2 Football Championship Subdivision institutions different NCAA conferences) were recruited through the head athletic trainer at each site, with support from the athletics administration and football coaching staffs. Informed consent procedures were followed, and participants signed paper consent forms prior to completing the survey. The criterion for inclusion was being on one of the three participating NCAA Division I football teams, regardless of class, position, or redshirt. Athletes who were not present for team-related activities on the day of measurement were excluded

Instrument Development

Demographic information were collected, including age, race/ethnicity, year in college, and previous experience playing football. The full instrument used in the larger study mentioned previously was 5 pages in length and previously validated.16 The current study analyzed and presented three items that focused on student-athletes' fears of concussion reporting, whereas the full questionnaire included more questions that were not specifically focused on their reporting fears. Two of the three items included for analysis had an open-ended structure (“What is your biggest fear about reporting a possible concussion?” and “What other information do you think the researchers should consider concerning concussion reporting”). The third item included for analysis was from the previously validated construct of perceived outcomes of reporting developed by Kroshus et al.17 This item included eight options answering the question, “If I report what I suspect might be a concussion, then. . . .” All items were rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree), with an internal consistency of 0.62 following reverse coding of appropriate items.

Procedures

After providing consent, student-athletes completed the initial survey with the larger questionnaire in a group setting during a 1-hour period. The full questionnaire was five pages in length. Student-athletes were instructed to fill out the questionnaire independently. They were instructed to select their best answer or write in comment boxes for open-ended questions, with no wrong answers or consequences for how they answered. They were informed that all responses would be kept confidential with an assigned ID not connected to their name, and results would only be presented in aggregate form. Researchers were present during administration of the questionnaire to ensure there were no conversations between participants. No coaches were present during the administration of the instrument. Qualitative and quantitative data from the questionnaires were entered into the computer by research staff members who were absent during data collection.

Data Analysis

Demographic variables were analyzed with frequencies and percentages, because all were categorical except age, where a mean and standard deviation are presented. For the Likert scale data (perceived outcomes of reporting), frequencies and percentages were calculated. All quantitative analyses were performed in SPSS software (version 25; IBM, Inc). For the qualitative analytical portion of this study, the three members of the research team followed previous methods suggested by Creswell.18 Each of the three researchers had previous experience with qualitative studies. Data from the open-ended question (“What is your biggest fear about reporting a possible concussion?”) were scanned independently first by each investigator to determine general themes. Then, collectively, common themes were agreed on. Following theme agreement, investigators revisited the data independently to code participant responses. Following the independent coding, the research team met to discuss coding discrepancies/disagreement. These were resolved when two of the three investigators agreed on a common code.

Results

In this sample, the majority of participants self-identified as Black (42%) or White (46%), were underclassmen (60%), had approximately 10 to 14 years of playing experience (60%), and were currently on a football scholarship (75%) (Table 1). On average, student-athletes started playing football at 9.2 ± 2.8 years.

Demographic Variables (N = 205)a

Table 1:

Demographic Variables (N = 205)

The scale assessing perceived outcomes of reporting requested participants to rate each of eight endings to the sentence that began with, “If I report what I suspect might be a concussion, then. . . .” Table 2 presents the results for each of the eight items. Most of the responses to the eight items occurred in the middle of the 5-point Likert scale as neither “agree” nor “disagree.” For the negatively phrased items (“I will hurt my team's performance,” “I will be held out of upcoming games even if it's not a concussion,” “I will not be allowed to start playing or practicing when I think I'm ready,” “I will lose my spot in the lineup,” and “My teammates will think less of me”), 34.2% of responses neither agreed nor disagreed, 23.6% disagreed, and 28.4% agreed. For the positively phrased items (“My teammates will think I made the right decision,” “I will lose fewer days of playing if I report right away,” and “I will be better off in the long run”), 35.7% of responses neither agreed nor disagreed, 10.7% disagreed, and 36.7% agreed.

Frequency (%) for Question: “If I Report What I Suspect Might be a Concussion, Then…”a

Table 2:

Frequency (%) for Question: “If I Report What I Suspect Might be a Concussion, Then…”

The open-ended question, “What is your biggest fear about reporting a possible concussion,” was posed at the end of the questionnaire. Table 3 shows the six themes that the three researchers agreed on prior to coding. Some responses included more than one theme and were included accordingly. More than 50% of the respondents stated that missed playing time was their biggest fear (eg, “not playing” or “losing my spot”). Being seen as weak (eg, “shame from coaches or players”) and the theme of no fear (eg, “I have no fear” or “I have none–I care about my health”) each were reported between 15% and 17% of the responses. Not wanting to know the health impacts (eg, “afraid of brain damage” or “hearing that I will die”) was reported by 11%, whereas letting people down (eg, “letting teammates down”) and future career being over (eg, “not playing football again”) fell between 7% and 9% of responses, respectively (Table 3).

Frequency of Comments on Each Theme for the Questiona: “What is Your Biggest Fear About Reporting a Possible Concussion?”

Table 3:

Frequency of Comments on Each Theme for the Question: “What is Your Biggest Fear About Reporting a Possible Concussion?”

The final open-ended question asked participants, “What other information do you think the researchers should consider concerning concussion reporting?” Table 4 illustrates the five themes that the three researchers agreed on, prior to coding. Because the responses to this item varied a great deal and were de- pendent on the full array of questionnaire items in the instrument, the results in Table 4 are presented as representative quotations without frequencies for each theme. These data are insightful and relevant for future research investigations.

Representative Quotations for the Question: “What Other Information Do You Think the Researchers Should Consider Concerning Concussion Reporting?”

Table 4:

Representative Quotations for the Question: “What Other Information Do You Think the Researchers Should Consider Concerning Concussion Reporting?”

Discussion

The purpose of this study was to investigate reasons collegiate football student-athletes may not disclose or fears they have about disclosing a potential sports-related concussion, using both closed- and open-ended questionnaire items. Some of the first data collected from student-athletes about why they may choose to not disclose a potential sports-related concussion was published by McCrea in 2004.9 The 1,532 high school varsity football student-athletes who participated completed a questionnaire item where they could select one or more from a list of reasons for not disclosing, including: didn't think it was serious enough (66.4%), didn't know it was a concussion (36.1%), didn't want to be pulled out of the game or practice (41%), didn't want to let down teammates (22.1%), or another reason (9.8%).

After that study, subsequent investigations into why student-athletes say they may choose to not disclose a potential sports-related concussion used these same questionnaire response options.8,14 In 2016, Kerr et al8 conducted a study with 797 former collegiate student-athletes that used the same question responses as the study by McCrea et al.9 The most common reason found in the Kerr study was “did not want to leave the game/practice” (78.9%), followed by “did not want to let the team down” (71.8%), whereas “did not know it was a concussion” and “did not think it was serious enough” were tied for the next highest percentage (70.4%). All three percentages were dramatically higher than those reported in the McCrea et al study 12 years earlier.

Similarly, Register-Mihalik et al14 conducted a study with 167 high school student-athletes using McCrea et al's response items and found that “did not think it was serious enough” was the most common reason why student-athletes did not report concussion (70.2%). Two responses (“did not want to be removed from a game” [36.5%] and “did not want to let down teammates” [27%]) were also similar to McCrea et al's results. However, the response “did not know it was a concussion” (14.9%) was far lower than McCrea et al's results. This may indicate greater awareness of concussion symptoms by student-athletes.

Our outcomes are similar to these studies when analyzing the reason of not wanting to miss playing time, with 51.9% in the current study and 41% in McCrea et al's study; and with not wanting to let teammates down (22.1% McCrea et al; 8.8% current study). An important difference between the participant answers in McCrea et al's study and the current study is that participants were asked what their greatest fear was, rather than choosing from predetermined reason(s) they did not disclose a potential sports-related concussion. Thus, none of the student-athlete responses in our questionnaire were related to the top reason in McCrea et al's study of “didn't think it was serious enough” (66.4%), because that response does not address actual fears of disclosing. Comparing the results of the McCrea et al, Kerr et al, and Register-Mihalik et al with the current study illustrates that many of the predetermined choices in prior studies did produce similar results when athletes were provided open-ended comment boxes to answer similar questions in their own words.

The unique approach of allowing participants to record their reasons for not disclosing a potential sports-related concussion in their own words adds to the literature by illuminating other, less commonly cited reasons for non-disclosure, including not wanting to be seen as weak (16.3%), not wanting to know the potential health impacts (11.3%), and not wanting to hear that their football career could be over (7.5%). This is clinically relevant and affects clinicians who are focused on improving sports-related concussion reporting rates. An additional contribution to the literature includes the percentage of student-athlete comments stating they did not feel any fear to report if they suspected a potential sports-related concussion (15.6%). To our knowledge, these data have never been collected previously. This could be an important metric for future investigations as a direct measure of how many student-athletes are truly comfortable disclosing potential sports-related concussions. Although 15.6% seems low, it is at least a point of reference for future studies. Further, researchers may be able to determine differences of “no fear of reporting” between level of play (high school, college, or professional) and type of sport (football, soccer, ice hockey, etc).

A mixed methods study by Chinn et al15 in 2016 quantitatively investigated reasons for not disclosing a potential sports-related concussion similar to the McCrea et al question (n = 986), and qualitatively analyzed interview responses regarding why participants did not realize a sports-related concussion might have been sustained (n = 9). The McCrea et al responses resulted in the following: “being into the practice/game and didn't realize I had a concussion (33.3%); knew I would be held out if I reported it (20.8%); didn't seem like a big deal (20%); and didn't know what a concussion was at the time (15.4%), as the top four responses.” These quantitative results are similar to the McCrea results described above.9

The qualitative analysis portion in the Chinn et al study is one of the only other qualitative studies regarding concussion non-disclosure. This revealed two themes that the 9 participants discussed for not realizing a sports-related concussion might have happened, specifically a “perceived physiological response precluding them from identifying the potential concussion” and “attitudes that mitigated their non-disclosure.”15 Sub-themes for physiological responses that precluded them from recognizing it may be a concussion included “adrenaline” and “being in the zone.” Sub-themes for attitudes that mitigated their reporting included “self-assessment,” “sense of duty and commitment to the team,” and “denial.” These outcomes warrant further investigations through either qualitative or quantitative methods to determine how much the degree of adrenaline and being “in the zone” truly may preclude student-athletes from either recognizing concussion symptoms and/or push them toward not disclosing the potential concussion. Of note, all of the student-athletes in the study by Chinn et al had received concussion education and felt well-versed on concussion knowledge.

Kroshus et al17 developed survey items designed to measure student-athletes' perceived consequences of disclosing a potential sports-related concussion. The investigation included 256 male ice hockey student-athletes who answered the question, “If I report what I suspect might be a concussion, then . . .”, followed by the same 8 sentence-ending statements we used in the current study (Table 2). Our results support the Kroshus et al results, specifically with the negatively phrased items of “I will not be allowed to start playing or practicing when I think I'm ready” (Kroshus et al: 27.3% scoring agreement/strong agreement; current study: 52% scoring agreement/strong agreement); and “I will lose my spot in the lineup” (Kroshus et al: 29.3% scoring agreement/strong agreement; current study: 41% scoring agreement/strong agreement). For the item asking, “my teammates will think I made the right decision,” Kroshus et al reported a low percentage of agreement/strong agreement (5.1%), whereas the current study found much greater agreement/strong agreement (41%). This indicates that student-athletes may be feeling more accepted by their teammates if they choose to report. In 2014, Kroshus et al reported 5.1% agreement/strong agreement for the item “I will be better off in the long run,” whereas the current study found agreement/strong agreement for 59% of the respondents, which is a remarkable and positive difference. It should be noted that the study by Kroshus et al included collegiate ice hockey players, whereas the current study included collegiate football players. Cultural differences between the sports may have played a role in the differing results.

These improved outcomes with positive personal statements are clinically meaningful and important when we consider efforts to improve team norms toward greater reporting. Specifically, when results demonstrate approximately 36% improvement in, “my teammates will think I made the right decision,” we can see that team norms are shifting toward players supporting each other to report potential sports-related concussion. Further, we can conclude that football athletes may be more focused on their own health as a reason for reporting, when results of, “I will be better off in the long run,” demonstrate approximately 54% improvement toward positive reporting behaviors between the 2014 study and this current study, a 5-year span. However, these positive results are somewhat conflicting with the continued negative result of, “I will not be allowed to start practicing when I think I'm ready,” which also increased by 25%.

Of note are the varied responses from the participants in our study for the question, “What other information do you think the researchers should consider regarding concussion reporting?” This allowed further free thinking for answers regarding why student-athletes continue to consider not disclosing potential sports-related concussion and illuminates potential future research areas. Strong sentiments were recorded for pressure from coaches to either not disclose or to return-to-play faster when diagnosed as having a sports-related concussion (Table 4). Many football student-athletes commented that there are a limited number of games in a season (typically 12), and they did not want to work as hard as they did to prepare for the season to sit out for a sports-related concussion (“All [of] the work I have done goes down the drain”). Interestingly, several student-athletes commented on not valuing their health as much as they value playing football, as a reason to not disclose, stating “everyone is concussed” and “everyone knows the risk of playing ball.”

Future research in concussion disclosure could include the impact of concussion education programs that focus on the current research illustrating that earlier reporting translates into less playing time missed and that playing with a concussion translates into greater risk of other lower extremity injuries. These topics change the focus from concussion signs and symptoms toward how to promote their individual performance at optimal levels regarding concussions. Additionally, research that investigates how to promote healthier team norms around valuing each student-athlete's health more than the game itself is gravely needed. This would involve a dramatic cultural shift in American football at all levels across the country.

Limitations

Limitations of the current study are that the full written questionnaire was lengthy (average time to complete was 45 minutes) and some participants may have experienced fatigue, especially because the two open-ended questions were at the end of the questionnaire. This potentially limited the depth and breadth of their answers on the questionnaire. Additionally, we included only football student-athletes at the NCAA Division I level. Results should therefore be expanded with caution to other levels of football and to other sports. Future studies should continue to investigate concussion disclosure using mixed methods to capture a richer level of detail from student-athletes' experiences, especially because the culture and influence on concussion-reporting evolves over time. It would be beneficial to expand the existing qualitative research into other high-impact sports (such as soccer, ice hockey, boxing, etc) to understand the differences between sports to create more tailored concussion disclosure protocols and identification methods.

Implications for Clinical Practice

The results highlight the importance of sports medicine clinicians' understanding of these complex influences on concussion-reporting. Understanding that only a small percentage of student-athletes (11%) reported specifically their future health was a consideration when potentially disclosing an sports-related concussion informs clinicians of what football athletes typically value. Conversely, when using the closed-ended item pertaining to better health in the long run, our results showed that more than half (59%) of the respondents strongly endorsed this item. Together this shows that student-athletes know the correct answer they believe they should provide, but ultimately, their future health is not really a fear for them. Clinicians who are cognizant of these complex influences might be able to better identify student-athletes who are influenced more heavily by missed playing time or being seen as weak, and work to mitigate those influences toward healthier norms. Healthier norms may include addressing concussion reporting within the framework of improving the student-athletes' sport performance, rather than relying on their sense of self-efficacy regarding their own future health. Further, our results indicate that 15.6% of the participants reported having no fear of reporting a potential concussion, which is a metric that will be valuable to measure change over time regarding the affect of our concussion education programs.

Conclusion

The results include novel data regarding the fears that football student-athletes have that may favor non-disclosure of potential sports-related concussions, in part due to the unique research approach of allowing participants to state in their own words why they may make these choices. From the student-athletes of three NCAA Division I football programs, we learned that not only are student-athletes concerned about losing playing time, but they are also concerned about being seen as weak, do not want to hear about the potential health impacts, and do not want to learn that their football career may be over. Further, in comparison with the Kroshus et al 2014 study, student-athletes demonstrated a dramatic and positive increase in thinking that their teammates will think they made the right decision if they disclose, and that they will be better off in the long run if they disclose. Important novel data indicated that 15.6% of the student-athletes had no fear of reporting. Future research efforts should investigate this particular construct to determine the effectiveness of concussion education programs. These are indications that team norms around concussion reporting may be shifting toward a more positive trend.

References

  1. Torres DM, Galetta KM, Phillips HW, et al. Sports-related concussion: anonymous survey of a collegiate cohort. Neurol Clin Pract. 2013;3(4):279–287.
  2. Register-Mihalik JK, Valovich McLeod TC, Linnan LA, Guskiewicz KM, Marshall SW. Relationship between concussion history and concussion knowledge, attitudes, and disclosure behavior in high school athletes. Clin J Sport Med. 2017;27(3):321–324.
  3. Kroshus E, Baugh CM, Daneshvar DH, Nowinski CJ, Cantu RC. Concussion reporting intention: a valuable metric for predicting reporting behavior and evaluating concussion education. Clin J Sport Med. 2015;25(3):243–247. doi:10.1097/JSM.0000000000000137 [CrossRef]
  4. Kroshus E, Kubzansky LD, Goldman RE, Austin SB. Norms, athletic identity, and concussion symptom under-reporting among male collegiate ice hockey players: a prospective cohort study. Ann Behav Med. 2015;49(1):95–103. doi:10.1007/s12160-014-9636-5 [CrossRef]
  5. Register-Mihalik JK, Linnan LA, Marshall SW, McLeod TCV, Mueller FO, Guskiewicz KM. Using theory to understand high school aged athletes' intentions to report sport-related concussion: implications for concussion education initiatives. Brain Inj. 2013;27(7/8):878–886 9p. doi:10.3109/02699052.2013.775508 [CrossRef]
  6. Kroshus E, Daneshvar DH, Baugh CM, Nowinski CJ, Cantu RC. NCAA concussion education in ice hockey: an ineffective mandate. Br J Sports Med. 2014;48(2):135–140. doi:10.1136/bjs-ports-2013-092498 [CrossRef]
  7. Kurowski B, Pomerantz WJ, Schaiper C, Gittelman MA. Factors that influence concussion knowledge and self-reported attitudes in high school athletes. J Trauma Acute Care Surg. 2014;77:S12–7 1p. doi:10.1097/TA.0000000000000316 [CrossRef]
  8. Kerr ZY, Register-Mihalik JK, Kroshus E, Baugh CM, Marshall SW. Motivations associated with non-disclosure of self-reported concussions in former collegiate athletes. Am J Sports Med. 2016;44(1):220–225.
  9. McCrea M, Hammeke T, Olsen G, Leo P, Guskiewicz K. Unreported concussion in high school football players: implications for prevention. Clin J Sport Med. 2004;14(1):13–17.
  10. Kroshus E, Baugh CM. Concussion education in U.S. collegiate sport: what is happening and what do athletes want?Health Educ Behav. 2016;43(2):182–190.
  11. Asken BM, McCrea MA. “Playing through it”: delayed reporting and removal from athletic activity after concussion predicts prolonged recovery. J Athl Train. 2016;51(4):329–335. doi:10.4085/1062-6050-51.5.02 [CrossRef]
  12. Asken BM, Bauer RM, Guskiewicz KM, McCrea MA, Schmidt JD, et al. Immediate removal from activity after sport-related concussion is associated with shorter clinical recovery and less severe symptoms in collegiate student-athletes. Am J Sports Med. 2018;46(6):1465–1474. doi:10.1177/0363546518757984 [CrossRef]
  13. Herman DC, Jones D, Harrison A, et al. Concussion may increase the risk of subsequent lower extremity musculoskeletal injury in collegiate athletes. Sports Med. 2017;47(5):1003–1010. doi:10.1007/s40279-016-0607-9 [CrossRef]
  14. Register-Mihalik JK, Guskiewicz KM, McLeod TCV, Linnan LA, Mueller FO, Marshall SW. Knowledge, attitude, and concussion-reporting behaviors among high school athletes: a preliminary study. J Athl Train. 2013;48(5):645–653. doi:10.4085/1062-6050-48.3.20 [CrossRef]
  15. Chinn NR, Porter P. Concussion reporting behaviours of community college student-athletes and limits of transferring concussion knowledge during the stress of competition. BMJ Open Sport Exerc Med. 2016;2:e000118. doi:10.1136/bmjsem-2016-000118 [CrossRef]
  16. Craig DI, Lininger MR, Wayment HA, Huffman AH. Investigation of strategies to improve concussion reporting in American football. Res Sports Med. 2020;28(2):181–193. doi:10.1080/15438627.2019.1586706 [CrossRef].
  17. Kroshus E, Baugh CM, Daneshvar DH, Viswanath K. Understanding concussion reporting using a model based on the theory of planned behavior. J Adolesc Health. 2014;54(3):269–274. doi:10.1016/j.jadohealth.2013.11.011 [CrossRef]
  18. Creswell JW. Educational Research: Planning, Conducting and Evaluating Quantitative and Qualitative Research, 3rd ed. Pearson Education, Inc; 2008.

Demographic Variables (N = 205)a

VariableFrequencyPercent
Race/ethnicity (n = 198)
  Black8342
  Asian11
  White9046
  Hispanic11
  Other2312
College year (n = 163)
  Freshman5735
  Sophomore4125
  Junior4930
  Senior138
  5th Year32
Years of previous football experience (n = 200)
  0 to 453
  5 to 95729
  10 to 1412060
  > 15189
Primary football position (n = 89)
  Offensive4854
  Defensive4146
Current football scholarship (n = 194)
  Yes14575
  No4925

Frequency (%) for Question: “If I Report What I Suspect Might be a Concussion, Then…”a

ResponseStrongly DisagreeDisagreeNeither Agree or DisagreeAgreeStrongly Agree
I will hurt my team's performance.10 (6%)51 (30%)45 (27%)56 (33%)8 (5%)
I will be held out of upcoming games even if it's not a concussion.5 (3%)45 (27%)57 (34%)47 (28%)16 (9%)
My teammates will think I made the right decision.8 (5%)17 (10%)75 (44%)58 (34%)12 (7%)
I will not be allowed to start playing or practicing when I think I'm ready.6 (4%)17 (10%)58 (34%)71 (41%)18 (11%)
I will lose fewer days of playing if I report right away.8 (5%)18 (11%)71 (42%)64 (38%)9 (5%)
I will lose my spot in the lineup.10 (6%)27 (16%)64 (38%)49 (29%)20 (12%)
I will be better off in the long run.2 (1%)19 (11%)36 (21%)78 (38%)35 (21%)
My teammates will think less of me.20 (12%)60 (35%)64 (38%)19 (11%)7 (4%)

Frequency of Comments on Each Theme for the Questiona: “What is Your Biggest Fear About Reporting a Possible Concussion?”

ThemesFrequencyPercent
Missed playing time8351.9
Being seen as weak2616.3
No fear/nothing2515.6
Knowing health impacts1811.3
Letting people down148.8
Future career over127.5

Representative Quotations for the Question: “What Other Information Do You Think the Researchers Should Consider Concerning Concussion Reporting?”

Losing playing time
  Our time as a football player is limited—reporting symptoms almost always reduces that time.
  When we get hurt we lose some of the very little time we have left to play the game we love.
  Because everyone's goal…is to play at the next level and if you get hurt and don't play, it limits their chances, so no one wants to report that.
  Players want to play and are more likely to not report symptoms if they are in competition for a spot or want to prove themselves.
  Trying to earn a scholarship.
Coach pressure
  Coaches may say we're faking.
  If their coaches LET them report.
  Fear of coaches rushing players back too fast and pressuring athletic trainers to clear the player.
  Coaches calling them weak.
Don't care about health in the moment.
  Everyone knows the risk of playing ball.
  Everyone is concussed.
  Some people value football more than they value their health.
  Some players love the game too much and need to play because they are the heart of the team, and are scared of being called a girl.
  Question more about self-awareness after playing football.
Pressure to win at all costs
  Worry more about the person, less about the game.
  Eliminate unnecessary practice.
  The pressure to play and WIN from coaches, fans, players. College football has become a business and coaches will do whatever to win.
  People get very pushy about getting an athlete back to playing.
Quotations about individual internal pressures
  Players' motives for playing the game.
  Pride, ego.
  How football got them out of a bad situation.
  Do I look down on those who spend extra time out because of a concussion? YES!
  How big the game is.
  Embarrassment of being “soft.”
  Fear of feeling like a failure.
  Sometimes a player doesn't know they have a concussion so they don't tell anyone.
Authors

From the Department of Physical Therapy and Athletic Training, Northern Arizona University, Flagstaff, Arizona.

The authors have no financial or proprietary interest in the materials presented herein.

Supported by the National Collegiate Athletic Association and U.S. Department of Defense programmatic research project investigating football programs' efforts to increase concussion-reporting behaviors (Mind Matters Challenge Grant Program).

Correspondence: Debbie I. Craig, PhD, ATC, LAT, Department of Physical Therapy and Athletic Training, Northern Arizona University, P.O. Box 15094, Flagstaff, AZ 86011. Email: Debbie.Craig@nau.edu

Received: October 15, 2019
Accepted: March 13, 2020
Posted Online: December 15, 2020

10.3928/19425864-20200424-02

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