Athletic Training and Sports Health Care

Systematic Review Supplemental Data

Concussion Reporting Behaviors of Athletes: A Systematic Review

Debbie I. Craig, PhD, ATC, LAT; Monica R. Lininger, PhD, ATC, LAT; Madison M. Vomacka, MS, ATC, LAT; Ryan Tiscareno, MS, ATC

Abstract

Purpose:

To summarize current evidence related to barriers pertaining to and strategies implemented to improve concussion reporting behaviors.

Methods:

CINAHAL, PubMed, and Web of Science databases were searched using the following terms: concussion reporting behaviors, sport-related concussion, reporting decision, and intention to report. Strengthening the Reporting of Observational Studies in Epidemiology checklist was followed to extract pertinent data.

Results:

Twenty studies met the inclusion criteria: articles published in English between 2000 and 2017, original or peer-reviewed research articles, and articles that investigated one or more of the clinical questions. Six studies included barriers to sport-related concussion reporting, and 15 articles described strategies implemented to improve reporting. General findings include that some barriers to reporting are still present, although there are numerous education interventions being implemented, with little evidence regarding the effectiveness of these educational efforts.

Conclusions:

Athletic trainers should include intention to report and norms adjustment to their knowledge of sport-related concussion.

[Athletic Training & Sports Health Care. 201X;X(X):XX–XX.]

Abstract

Purpose:

To summarize current evidence related to barriers pertaining to and strategies implemented to improve concussion reporting behaviors.

Methods:

CINAHAL, PubMed, and Web of Science databases were searched using the following terms: concussion reporting behaviors, sport-related concussion, reporting decision, and intention to report. Strengthening the Reporting of Observational Studies in Epidemiology checklist was followed to extract pertinent data.

Results:

Twenty studies met the inclusion criteria: articles published in English between 2000 and 2017, original or peer-reviewed research articles, and articles that investigated one or more of the clinical questions. Six studies included barriers to sport-related concussion reporting, and 15 articles described strategies implemented to improve reporting. General findings include that some barriers to reporting are still present, although there are numerous education interventions being implemented, with little evidence regarding the effectiveness of these educational efforts.

Conclusions:

Athletic trainers should include intention to report and norms adjustment to their knowledge of sport-related concussion.

[Athletic Training & Sports Health Care. 201X;X(X):XX–XX.]

Sport-related concussion research has grown exponentially in the past few years to understand the complexities and long-term effects of the injury.1 This research includes everything from an athlete reporting the concussion at the moment of injury to return to play. A majority of the research has investigated various components of the injury itself, including mechanisms of injury,2–5 evaluation,5–8 rehabilitation, and return-to-play criteria.1,9 However, research on the relationship between sport-related concussion and athletes' concussion reporting behaviors is growing.10–16

Across three landmark studies, it is estimated that 12% to 78% of potential sport-related concussions go unreported. Rivara et al.17 found that 69% of athletes in their sample reported playing while symptomatic and, of those with a sport-related concussion, 40% reported that their coach was not aware of their sport-related concussion. In a study including 469 athletes, 78.3% of the athletes with a sport-related concussion in the previous 12 months did not seek medical attention.13 More recently, a study of 438 high school athletes revealed the under-reporting of sport-related concussion could be as high as 55%.18 Each of these studies highlight the significant level of non-reporting, or non-disclosure, that is evident in American sporting culture. The consequences of not reporting these potential injuries range from affecting the athlete's sport performance to delayed recovery to more catastrophic permanent brain function alterations.7,9,10

Understanding what influences an athlete to either report or not report a potential sport-related concussion is a critical first step toward providing the best care possible and should be a priority for health care providers working directly with athletes during participation. We operationally define concussion reporting behavior as any behavior arising from an individual or organization that affects the potential concussion being brought to the attention of someone else (ie, a peer, coach, athletic trainer, or team physician). Examples of concussion reporting behaviors are when an athlete feels “not right” after a hit and goes to his or her athletic trainer to report the injury; when the same thing happens but the athlete chooses to hide the potential injury; when a teammate tells the athletic trainer that one of his or her peers is running a play incorrectly after sustaining a blow to the head; or when a coach observes odd behavior from an athlete and asks him or her to see the athletic trainer. There are multiple influences of reporting behavior. Although health care providers can offer suggestions as to why athletes may or may not report a sport-related concussion, the best evidence of these behaviors is derived from the athletes themselves. The need to understand reporting behaviors from an athlete's perspective has led to a mixture of quantitative and qualitative studies directly querying athletes.12,19,20

Sport-related concussion education is a common intervention strategy intended to improve reporting across a variety of settings. This education commonly includes the signs and symptoms of concussion, how to report the injury, and the potential long-term effects of repeated concussions. This traditional education has had mixed results.21 A majority of current evidence proposes that, although education is working to improve athlete knowledge of concussions, education alone is not an effective strategy to increase reporting rates.22–25 This implies that increasing athlete knowledge of sport-related concussion is not effectively increasing reporting.

Health care providers who have a better understanding of why an athlete may or may not choose to report a potential sport-related concussion can influence the culture of each team toward greater safety and long-term health.26,27 Therefore, the purpose of this study was to systematically review the available literature to answer the following clinical questions for an athletic population: (1) What are the most prevalent barriers to sport-related concussion reporting? and (2) What strategies have health care providers used to encourage sport-related concussion reporting?

Literature Review

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines,28 and used the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist29 to screen articles.

Data Sources and Searches

Electronic searches were performed in three databases: CINAHL, PubMed, and Web of Science. The search terms were: concussion report* AND behavior, self-report* AND concussion, athlete AND concussion report* behavior, concussion report*, concussion AND report* decision, concussion AND report* intention. Once the searches were completed, hand searches were performed for relevant articles from the reference lists of appropriate articles. All searches were conducted between January 10 and May 5, 2017.

Study Selection

Once articles were collected and duplicates removed, the initial screening of titles and abstracts was conducted independently by two authors (MMV, RT). Articles were then classified as either meeting inclusion, unsure, or not meeting inclusion by two authors (DIC, MRL) on the research team. The authors used the inclusion/exclusion criteria to obtain a consensus and discussed articles categorized as “unsure” further. If a consensus was not obtained or if the article did not meet the inclusion criteria, it was excluded from the study.

Articles met the inclusion criteria if they were: published in English between 2000 and 2017, original research and peer-reviewed, and investigated concussion reporting behaviors in athletics. The years of inclusion were specific to more recent years due to the amount of knowledge that has been gained through directed research activities regarding sport-related concussion injuries during this century.

Exclusionary criteria were: articles without full text, brain imaging studies, post-injury evaluation, qualitative method studies (due to inability to assign a level of evidence), review articles, abstracts, case studies, editorials, critically appraised topics, non-sport–related concussion, articles categorized by the Oxford Centre for Evidence-Based Medicine30 scale as below 4-level of evidence, and any investigations that did not address the clinical questions.

Data Extraction and Quality Assessment

The STROBE checklist29 was followed for data extraction from the articles that met the inclusion criteria. Data extracted from each article were the study design, participant sample description, data collection instruments, key results, and main conclusions. These data were entered into a data extraction form. Articles were then categorized in alignment with the clinical questions addressing the most prevalent sport-related concussion reporting barriers or strategies being used to encourage reporting. Any data or secondary outcomes that were not related to the clinical questions were not recorded. The 2011 Oxford Centre for Evidence-Based Medicine30 scale was used to assign a level of evidence to each included study.

Data Synthesis and Analysis

When assigning articles to clinical questions, if an article addressed more than one of the clinical questions, it was added to more than one clinical question, accordingly. Table A (available in the online version of this article) was created to summarize these results. Because many of the included articles were observational studies, a meta-analysis was not performed.

Summary of Studies Investigating Concussion Reporting BehaviorsSummary of Studies Investigating Concussion Reporting BehaviorsSummary of Studies Investigating Concussion Reporting Behaviors

Table A:

Summary of Studies Investigating Concussion Reporting Behaviors

Findings

Results of Search

The literature search resulted in 4,013 initial articles (Figure 1). After duplicates were removed, the remaining article titles and abstracts were screened using the inclusion criteria (n = 3,796). This screen produced 52 remaining articles. The reference lists from each article were reviewed. Twelve additional articles were retrieved from this search. A total of 64 articles were reviewed for exclusionary criteria and 44 were excluded. Twenty articles were included and the data were extracted for the results. The included articles were matched to the two clinical questions. Six articles reported barriers to sport-related concussion reporting, and 15 articles described strategies used by health care professionals to encourage sport-related concussion reporting. One article31 was used to answer both clinical questions.

Study selection process following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Figure 1.

Study selection process following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Barriers to Sport-Related Concussion Reporting

Six studies reported common barriers and/or reasons why athletes did not openly report sport-related concussions. The most commonly reported barriers or reasons were that the athlete did not think the injury was serious enough,10,13,18,20,31,32 did not know it was an sport-related concussion,20,31,32 did not want to be removed from play,10,18,20,31,32 and did not want to let the team down.13,18,20,31,32

McCrea et al.10 were among the first to report reasons for non-disclosure of a potential sport-related concussion in a study that included 1,532 high school varsity football players. The authors reported the primary non-disclosure reasons were that the athletes did not think the injury was serious enough (66.4%), did not want to be removed from play (41%), and did not know it was an sport-related concussion (36.1%). Italian soccer players stated they were reluctant to report a potential sport-related concussion because many believed the injury was not serious enough to warrant a medical examination (94.4%).32 The second most common reason for non-reporting was that the soccer athletes felt sport-related concussions were just part of the game (88.8%). Delaney et al.13 supported this perception in their study. Of the 19.6% of athletes who sustained a sport-related concussion (78.3% of whom did not report the sport-related concussion), the primary reason for not reporting was that the athletes did not feel the sport-related concussion was serious enough (59.8%).

Kerr et al.20 found similar results in their 2016 study with a sample of 797 former collegiate athletes. The main reason for not reporting a potential sport-related concussion was that athletes did not want to be removed from play (78.9%). This was followed closely with not wanting to let the team down (71.8%), did not know it was an sport-related concussion (70.4%), and did not think it was serious enough (70.4%).

Additionally, one article investigating sport-related concussion knowledge as a barrier to reporting found that sport-related concussion knowledge scores were not correlated with concussion reporting behaviors,18 meaning a lack of sport-related concussion knowledge is not a barrier to sport-related concussion reporting. In a study of 715 high school athletes, Wallace et al.18 found that athletes who indicated they had access to an athletic trainer were more knowledgeable about sport-related concussion, although this did not improve concussion reporting behaviors. This highlights the key concept that increasing athletes' knowledge of sport-related concussion alone is not an effective strategy to increase sport-related concussion reporting rates.

Strategies Used by Health Care Professionals to Improve Concussion Reporting Behaviors

Fifteen articles reported on various strategies that health care professionals used to improve concussion reporting behaviors. The following strategies were investigated: sport-related concussion education,22,23,25,33–40 coach support,41 intention to report,24,26,36 and state law mandates to report sport-related concussion.

Sport-related concussion education was the most common strategy employed to improve concussion reporting behaviors in the literature. Eleven of the 15 included studies used sport-related concussion education as a strategy to improve concussion reporting behaviors. Of the 11 articles that reported the efficacy of sport-related concussion education improving concussion reporting behaviors, only one article showed a positive outcome.34 In the current study of 60 high school soccer players, 72% of the athletes who received sport-related concussion education said they would always tell a coach of a suspected sport-related concussion, whereas only 36% of the athletes who did not receive education said that they would tell a coach. However, the current study did not provide actual sport-related concussion reporting rates through the season that followed the educational intervention.

Six articles reported that sport-related concussion education had no lasting effect on concussion reporting behaviors.22,23,33,35,39,40 Anderson et al.33 reported that, despite improved sport-related concussion knowledge scores after sport-related concussion education, athletes did not have improved sport-related concussion reporting attitudes, with 53% stating they would continue to play while symptomatic. In a study involving 334 high school varsity football players, Cournoyer and Tripp35 found that athletes did not have adequate knowledge of sport-related concussion symptoms or the consequences of playing while symptomatic, regardless of the varying quality of sport-related concussion education or delivery method.

In a study of 146 collegiate ice hockey players, Kroshus et al.22 concluded that the sport-related concussion education mandated by the National Collegiate Athletic Association (NCAA) varied greatly in delivery and was ineffective in improving knowledge scores or concussion reporting behaviors. Similarly, in 2014 Kurowski et al.23 found that improved knowledge was not predictive of concussion reporting behavior in a study of 496 athletes from various high school sports. One year later, Kurowski et al.40 studied sport-related concussion education by having a set of control schools that did not receive the education and a set of intervention schools that did receive the education. The authors concluded that, although sport-related concussion knowledge scores improved immediately after the education sessions, the improved scores dissipated toward the end of the season. Exactly what was included in the educational sessions was not delineated. McDonald et al.39 surveyed 77 female high school athletes regarding whether they received sport-related concussion education, sport-related concussion rates, and concussion reporting behaviors. Of the 77 athletes, 66% received the education and 32% did not report a sport-related concussion when it occurred. The authors did not report a correlation between the education group and concussion reporting behaviors differences with the non-education group.

Athlete intention to report a sport-related concussion is an emerging area of research that should be differentiated from sport-related concussion knowledge and actual reporting frequencies. Intention to report a sport-related concussion is a different measure from whether the athlete reports an sport-related concussion following a mechanism of injury. Intention to report is typically measured pre-season or post-season (either retrospectively or prospectively) and measures if an athlete intends (or intended) to report a concussion if such an injury should (or did) occur. By influencing intention within concussion education, researchers are using this as a strategy to improve reporting.

In a 2013 study of 167 high school athletes, Register-Mihalik et al.24 investigated contributing factors of intention to report sport-related concussion. Having a positive direct attitude about reporting, understanding the subjective team norms about sport-related concussion reporting, and the level of athlete direct perceived behavioral control were all positively associated with the athlete's intention to report. Furthermore, intention to report was associated with decreased levels of participating while symptomatic. However, intention was not associated with actual concussion reporting behaviors. Conversely, Kroshus et al.25 found that intention to report was associated with in-season actual concussion reporting behaviors, although pre-season sport-related concussion knowledge was not associated with in-season concussion reporting behaviors.

In 2014, Kroshus et al.36 investigated the Theory of Planned Behavior on its applicability to the intention to report sport-related concussions. The Theory of Planned Behavior was an appropriate model fit, with reporting attitudes, self-efficacy, and subjective norms all significantly positively associated with increased intention. In concussion reporting behaviors, self-efficacy is defined as an individual who purposefully acts to protect his or her health by seeking medical evaluation. Further, reporting outcomes related to the athlete's optimal athletic performance were most strongly associated with reporting intention. Therefore, the authors suggested that sport-related concussion education should incorporate these additional factors instead of knowledge alone.

The last included study31 investigating strategies to improve concussion reporting behaviors assessed the effect of state law that mandates sport-related concussion education. LaRoche et al.31 compared the results of a study conducted from 1999 to 2002 with those from a 2013 study, both in the state of Wisconsin. Results indicated that athletes were significantly more likely to report a sport-related concussion in 2013 (70.6%) than between 1999 and 2002 (47.3%). In 2013, the Wisconsin state sport-related concussion law of 2012 had only been in effect for 1 year. This is a dramatic increase within 1 year of a law being enacted.

Discussion

The main findings suggest that barriers to reporting are still largely present for athletes across sports, and that sport-related concussion education efforts, whether mandated or not, have improved athletes' knowledge of sport-related concussions but have had little to no impact on actual concussion reporting behaviors. Effective strategies are those that attempt to influence the intention to report sport-related concussions and outcomes that are connected to athlete performance, team beliefs of subjective norms, and athlete self-efficacy.

The results of this systematic review regarding barriers that athletes face when deciding whether or not to report potential sport-related concussion are that the athletes: (1) often did not believe the injury was serious enough to report to a medical professional; (2) did not know it was a concussion; (3) did not want to be removed from participation; and (4) did not want to let the team down. These barriers are still prominent 13 years later, despite first being reported in a 2004 research article by McCrea et al.10

In 2010, Broglio et al.32 reported that 94.4% of Italian soccer athletes in their study did not report a potential sport-related concussion at some point in their career because they believed the injury was not serious enough to warrant medical evaluation. Further, in that same season, 62% of concussive injuries were not reported. More recently, Kerr et al.20 found that 70.4% of participants had a potential sport-related concussion but did not report it because they did not think their potential sport-related concussion was serious enough to report; 78.9% did not report because they did not want to leave the game/practice. Each of these studies concur with the results of McCrea et al.10 one decade earlier. This is evidence that athletes continue to experience these barriers despite knowing more about the health effects of concussions. Thus, we suggest that these common barriers may be culturally engrained in various sports and/or individual teams, making change much more difficult.

To decrease these barriers and improve concussion reporting behaviors, various strategies have been implemented, most notably sport-related concussion education.22,23,25,33–40 The NCAA42 and all states now have laws31,43 requiring sport-related concussion education for most athletes and in some cases require sport-related concussion education for parents and coaches. Although recent literature demonstrates an increase in athletes' knowledge regarding sport-related concussion, this increase in knowledge is not necessarily affecting actual concussion reporting behaviors or attitudes toward the seriousness of sport-related concussion. In a study of 120 male high school football athletes from multiple schools, Anderson et al.33 reported no association between knowledge and attitude scores after sport-related concussion education, with 53% of athletes saying that they would continue to play when symptomatic from a concussive event. In 2014, Kroshus et al.22 concluded that the NCAA-mandated sport-related concussion education did not significantly change the constructs of sport-related concussion knowledge or reporting behaviors in their sample of 146 collegiate ice hockey players. Conversely, in 2012, Bramley et al.34 compared sport-related concussion reporting attitudes between groups that did and did not receive sport-related concussion education. This was one of the few studies that found significant results: 72% of the education group was willing to report their sport-related concussion injury in the future and 36% in the non-education group were not.

It would be interesting to determine if this influenced actual sport-related concussion reporting rates and/or behaviors between groups through the following season. The great variance in the mode of sport-related concussion education delivery, length of the education session, and content delivered make it difficult to compare educational methods that are effective with those that are not to determine any sort of causal relationship.

Despite little evidence of successful strategies to modify concussion reporting behaviors, some promising areas are those that influence factors such as intention to report, subjective norms, attitudes about sport-related concussion reporting, and direct perceived behavioral control.24,25,36,44 It is important to note that research demonstrating whether improved intention to report is directly correlated with concussion reporting behaviors is an area where more definitive research outcomes are needed.

Kroshus et al.25 found that pre-season sport-related concussion knowledge was not associated with within-season reporting behavior, but that intention to report was associated with in-season reporting behavior. However, Register-Mihalik et al.24 found that reporting intention may not always be an indicator of actual concussion reporting behavior, although reporting intention was associated with decreased prevalence of playing while symptomatic. To complicate this issue further, capturing accurate concussion reporting behaviors outcomes is challenging due to the barriers of sport-related concussion reporting as discussed in this article previously. Specific education focused on outcomes of optimal athletic performance and athlete self-efficacy, as opposed to only knowledge of signs and symptoms of sport-related concussion, may resonate better with student-athletes.36

In more recent research, Kroshus et al.25,45 investigated how pressure from various stakeholders affected athletes' concussion reporting behaviors, with pressure to not report being experienced by 26.5%. A greater likelihood of continuing to play while symptomatic was associated with greater risk-taking norm conformity. Thus, within this study, barriers to reporting include the team/cultural level of pressure to not report and the individual level of risk-taking conformity. This demonstrates the complexities of concussion reporting behaviors within a team setting. In a study of 167 high school athletes, Register-Mihalik et al.44 found that a greater number of previous sport-related concussions was associated with both a worse attitude toward sport-related concussion and more negative sport-related concussion disclosure attitudes

Currently, all 50 states in the United States of America have sport-related concussion education laws. LaRoche et al.31 found that the percentage of sport-related concussions reported to someone had increased significantly after the implementation of a state law mandating sport-related concussion education in Wisconsin, but this was one of the few reports that education has been effective. The difficulty is that the content and delivery of these educational sessions varies tremendously across the country. Many institutions only include sport-related concussion education topics on a handout, whereas others require athletes to watch videos or go through in-depth online training sessions on sport-related concussion topics. Some institutions have one-on-one meetings with each athlete, whereas others do mass group meetings where sport-related concussion topics are only a small portion of the information presented. However, a majority of the research evaluated in this review provided dismal evidence on the effectiveness of these sport-related concussion education programs to improve reporting.

The clinical relevance of our systematic review findings include that barriers athletes reported feeling in the initial 2004 study10 are still largely present, and they need to be addressed by medical teams assigned to sports directly. Further, until those barriers are decreased, educational strategies aimed to improve athlete knowledge of concussion likely will not be effective. However, educational strategies that address improved athlete performance by earlier reporting and adjusting the norms toward acceptance and support of reporting concussions on each team may prove helpful, although the evidence is currently inconclusive.

Further Research

Having synthesized the current literature on concussion reporting behaviors, there is a demonstrated need for further investigation. The finding that many athletes may choose to not report a potential sport-related concussion because they did not think it was serious enough is troubling, especially when combined with evidence that athletes are becoming more knowledgeable about sport-related concussion. Thus, although athletes are better informed of concussive signs and symptoms, they are choosing to not report a majority of these potential injuries. Future research should aim to define this disconnect. Future research should empirically compare whether an emphasis on athletes' sport-related concussion education aimed at changing their concussion reporting behavior is more efficacious than athlete education aimed at knowledge of sport-related concussion. Other areas of research should focus on measuring actual concussion reporting behaviors, rather than likelihood to report, sport-related concussion knowledge, and/or intention to report alone.

Limitations

A limitation of this systematic review is the limited number of articles per clinical question; however, this body of literature is new. We suggest that this systematic review topic be repeated in the next 5 years to include some of the current concussion reporting behavior outcome research being conducted that has not yet been published. A second limitation is that a majority of the included articles demonstrated a measurement of likelihood to report as opposed to actual concussion reporting behaviors. As the research and literature expands, so will assessments of true concussion reporting behaviors. Finally, the included articles used self-reported data, which may allow biases from participants.

Implications for Clinical Practice

As previously mentioned, consequences of not reporting potential sport-related concussions can include a wide range, from impacted athlete performance during activity to permanent brain function alterations.7,9,10 To prevent these negative consequences, understanding influencing factors on athletes' decisions to either report or conceal their potential for a sport-related concussion is critical. Improving clinician awareness of concussion-reporting barriers would not only help clinicians recognize these potential barriers, but also allow for clinical implication of their knowledge to improve educative communication between clinicians and athletes. Increasing athlete concussion-reporting is essential in aiding clinicians with early diagnosis and proper treatment of sport-related concussions, resulting in safer and more thorough care for athletes.

Conclusion

For practicing athletic trainers and physicians who work directly with athletes in any setting, understanding how to help athletes overcome various barriers to reporting sport-related concussions is imperative. This review systematically evaluated current evidence published between 2000 and 2017. Our findings indicate that concussion reporting barriers are present for athletes of all ages and in many sports. Although many forms of concussion education are being implemented to improve concussion reporting behaviors, there is limited evidence on the effectiveness of these educational strategies. Athletic trainers and school officials should review their sport-related concussion education content to focus on outcomes related to optimal athlete performance, relaying subjective norms that are accurate about concussion reporting, and encouraging athlete self-efficacy. Sport-related concussion reporting intention may be a more effective measure of future concussion reporting behaviors than the current focus on sport-related concussion knowledge alone, although researchers should also focus on actual concussion reporting behavior during sport seasons. Although all 50 states currently have laws mandating sport-related concussion education, the variability of the content and delivery of these educational sessions is not mandated and is proving ineffective. A greater focus on health outcomes of each institution's athletes should be primary, as opposed to concerns about athlete time commitments of attending these educational sessions.

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Summary of Studies Investigating Concussion Reporting Behaviors

StudyDesignSample SizeData Collection or InstrumentationKey ResultsConclusionsLevel of Evidence
Anderson et al.33 (2016)Cross-sectional survey120 male high school football players from multiple schoolsSurvey consisted of knowledge about concussions, and attitudes about playing sports after a concussion25% reported history of concussion; 70% reported receiving prior concussion education; 75% correctly recognized concussion symptoms asked; 92% recognized risk of serious injury if RTP too quickly; 54% would report symptoms to their coach; 53% would continue to play with symptoms; no association between knowledge and attitude scoresDespite having knowledge of symptoms and the dangers of concussions, many high school football players did not have a positive attitude toward reporting or abstaining from play3
Baugh et al.41 (2014)Multi-centered, cross-sectional survey717 collegiate football players from 10 NCAA FCS institutionsSurvey consisted of perceived concussion reporting support from peers and coaches, concussion frequency, and RTP with symptoms presentFreshmen agreed more than their older teammates that their coaches supported reporting; higher levels of coach support for reporting were associated with both fewer undiagnosed concussions and with RTP while symptomatic less oftenA coach's support of safe concussion reporting plays a critical role in a team's concussion safety behaviors3
Bramley et al.34 (2012)Cross-sectional survey60 high school boys and girls soccer players from multiple schoolsSurvey consisted of previous concussion education training (yes/no), attitudes about reporting during agame, and safety to keep playing when symptomatic72% of athletes with previous concussion education training indicated they would tell their coach or athletic trainer of a concussion, compared to 36% with no previous concussion educationHigh school soccer players who have received concussion education from any source reported being more likely to notify their coach or athletic trainer of a suspected concussion as compared to those with no previous education3
Broglio et al.32 (2010)Multi-centered, cross-sectional survey342 Italian soccer players, coaches, and medical staff from multiple teams (303, 27, 12, respectively)Athlete survey consisted of concussion knowledge, reporting frequencies, and reasons why potential concussions were or were not reported62% of concussive injuries were not reported during season; coaches were not good (38.9% correct) at identifying concussion symptoms; top 5 reasons why athletes didn't report were: did not think the injury was serious, concussions are part of game, did not know it was a concussion, did not want to be removed from game/practice, did not want to let team downThere is a clear need to educate both athletes and coaches about concussive signs and symptoms3
Cournoyer and Tripp35 (2014)Multi-centered, cross-sectional survey334 varsity football players from 11 high schoolsSurvey consisted of concussion symptom knowledge, concussion education history, and understanding of consequences of concussionsRelying on parents to discuss concussion awareness is ineffective; type of education did not correlate with knowledge scoresAthletes did not have appropriate knowledge of symptoms nor consequences of concussions, despite education. A better focus on the quality of education is critical3
Delaney et al.13 (2015)Retrospective survey469 male and female university athletes from various varsity teamsSurvey consisted of concussion frequencies for the previous 12 months, reasons why they reported or did not report, how often those reasons for not reporting occurred, and how important those reasons were in the reporting decision process19.6% had suffered a concussion; of those, 78.3% did not report; the most common reason (59.8% of concussion events) for not reporting was ‘did not feel the concussion was serious and felt like I could still play with little danger to self’; the reason for not reporting that was the most important to the athletes was ‘fear of letting team down by being removed from game’The dangers of non-reporting of concussions and continuing to play need to be heavily emphasized during concussion education sessions4
Kerr et al.20 (2016)Cross-sectional survey797 former collegiate athletesSurvey consisted of self-identified sports-related concussions from high school, college, or professional years; whether they disclosed those concussions, and motivations for non-disclosure26.9% suffered at least one concussion; of those, 33.2% did not report the concussion; non-disclosure was higher among males than females; the most common motivations for non-disclosure included: did not want to leave game/practice (78.9%), did not want to let team down (71.8%), did not know it was a concussion (70.4%), and did not think it was serious enough (70.4%)A substantial proportion of former athletes recall concussions that were not disclosed, with males being more likely than females to non-disclosure3
Kroshus et al.25 (2015)Prospective cohort study116 collegiate men's ice hockey playersSurvey consisted of concussion knowledge, attitudes, reporting/not reporting, and behavioral intentionPre-season concussion knowledge was not associated with in-season reporting behavior; intention to report was associated with in-season reporting behaviorConcussion reporting intention may be a stronger predictor of reporting behavior than concussion knowledge2
Kroshus et al.22 (2014)Prospective cohort study146 collegiate men's ice hockey playersSurvey consisted of concussion knowledge, attitudes, perceived norms, and reporting intention changes per the concussion education programConcussion education varied from team to team; no significant improvements in knowledge and a small decrease in intention to keep playing when symptomaticThe NCAA's concussion education mandate was delivered, but varied greatly. It did not significantly change the constructs of knowledge nor reporting behaviors2
Kroshus et al.36 (2014)Cross-sectional survey256 male ice hockey players (ages 18–21)Survey consisted of concussion symptom reporting behavior, intention to report, perceived norms, self-efficacy, and perceived outcomes of reporting and knowledgeTheory of planned behavior model was a good fit, with reporting attitudes, self-efficacy and subjective norms all significantly associated with behavioral intention; reporting outcomes related to athletic performance were most strongly associated with reporting intention.Perceived outcomes of reporting, perceived norms, and self-efficacy issues should be included in concussion education programs3
Kroshus et al.37 (2015)Cross-sectional survey328 male and female athletes in various collegiate sportsSurvey assessed perceived team reporting norms, individual reporting attitudes, objective team reporting norms, concussion reporting intention, and misperception of team normsTeam concussion reporting norms were misperceived, with 77.5% of the athletes believing they have safer attitudes about reporting than do their teammatesA social norms approach to concussion education, in which misperceived group norms are corrected and shifted in the direction of safety, may help increase the effectiveness of education programming3
Kroshus et al.38 (2015)Prospective cohort study116 collegiate men's ice hockey playersSurvey consisted of concussion knowledge, reporting attitudes, concussion history, athletic identity, and symptom reporting25.5% of the variance in non-reporting behavior was explained by having safer perceived reporting norms; 23.1% of the variance in non-reporting behavior was explained by considering both safer perceived reporting norms and the individual's own reporting attitudes; combined means of norms and athletic identity explained 37.7% of variance in non-reporting behaviors (i.e. the full model)Perceived reporting norms may be an important target of concussion education interventions aimed at reducing symptom under-reporting2
Kroshus et al.26 (2015)Cross-sectional survey328 male and female athletes in various collegiate sportsSurvey consisted of concussion diagnosis, reporting behavior, knowledge, subjective reports of pressure, and intention to report in the futureFewer than 10% sustained a concussion in that season; almost 50% continued playing while symptomatic after non-report; pressure from teammates to not report was experienced by 13.26%, from coaches was 13.68%, from parents was 9.42%, and from fans was 8.12%. 26.5% experienced pressure to not report from some sourceThese findings underscore the importance of designing interventions that address the system in which athletes make decisions about concussion reporting, including athletes' parents, rather than focusing solely on modifying the individual's reporting behaviors.3
Kurowski et al.23 (2014)Cross-sectional496 adolescent athletes in football, soccer, basketball, and wrestlingSurvey consisted of previous education, current knowledge, and self-reported attitudes, and behaviors about reporting concussionsImproved knowledge was not associated with improved self-reported behaviors; older athletes and female sex were associated with better knowledge; younger athletes, female sex, and soccer participation were associated with better self-reported behaviorsPrevious education was less predictive of knowledge about concussions when controlling for other factors3
Kurowski et al.40 (2015)Prospective cohort234 high school athletes (education school) and 262 high school athletes (control school) participating in football, soccer, wrestling, and basketballSurvey consisted of knowledge and attitudes at a control school and at a school that students received a lecture-based concussion education sessionTotal scores on the combined, knowledge-based, and behavioral-based questions showed improvement in the education group; scores peaked immediately post education, but dissipated at the end of the seasonThese results suggest that a didactic based pre-season concussion education likely has minimal long-term benefits2
LaRoche et al.31 (2016)RetrospectiveAthletes (N = 784) from high schools and collegesSurvey consisted of awareness of Wisconsin state law, its effect on reporting, concussion history, concussion incidence during the current season, whether incident concussions were reported, to whom concussions were reported, and reasons for not reporting. These results were compared with a previous survey (1999–2002)Rates of concussion in the 2013 season were comparable to findings from 1999–2002; athletes were significantly more likely to report their concussions in 2013; nearly 60% of the students were aware of the Wisconsin state law, with 55.1% stating the law would make them more likely to report a concussionRates of concussions for one sport season have not change significantly over the past 14 years (1999–2013). The percentage of concussions that are reported to someone has increased significantly4
McCrea et al.10 (2004)Retrospective1,532 varsity football players from 20 high schoolsSurvey consisted of number of concussions before current season, number during the current season and whether they were reported, to whom they were reported, and reasons for not reporting a possible concussion29.9% reported a previous concussion, 15.3% reported sustaining a concussion during the current season, of those 47.3% reported their injuryHigher prevalence of concussion in high school football players than previously reported in the literature4
McDonald et al.39 (2016)Cross-sectional77 female high school student athletes from 14 different sportsSurvey consisted of incidence of head injuries and concussion symptomsNearly half (31) of the athletes sustained a suspected concussion, with 10 of the 31 refraining from reporting symptoms; 66% reported receiving concussion education; education appeared to have no relationship with diagnosed concussion rates in athletes, removing athletes from play, or follow-up medical care after injuryFemale high school athletes underreport signs and symptoms of concussion3
Register-Mihalik et al.24 (2013)Cross-sectional167 high school athletes from multiple sportsSurvey consisted of Theory of Reasoned Action and Planned Behavior (TRA/TPB) constructs of attitude, subjective norms, perceived behavioral control, and intention to reportDirect attitudes, subjective norms, and direct perceived behavioral control were all associated with intention to report a concussion; intention was associated with decreased prevalence of participating while symptomaticFavorable attitudes toward reporting and social referents' beliefs have the greatest impact on intention to report concussion symptoms3
Wallace et al.18 (2017)Cross-sectional438 high school athletes with access to an AT and 277 without access to an ATA validated knowledge-of-concussion survey consisting of concussion history, knowledge, scenario questions, signs and symptoms of a concussion, and reasons why an athlete would not report a concussionThe underreporting of concussions among high school athletes was 55%; athletes with access to an AT had more knowledge of concussion than did athletes without access, although this did not demonstrate a higher percentage of reporting a concussionHigh school athletes with access to an AT had more concussion knowledge, but did not report suspected concussions more frequently2
Authors

From the Department of Physical Therapy and Athletic Training, Northern Arizona University, Flagstaff, Arizona (DIC, MRL); Tucson Orthopaedic Institute, Tucson, Arizona (MMV); and California State University–Monterey Bay, Monterey Bay, California (RT).

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

Correspondence: Debbie I. Craig, PhD, ATC, LAT, Northern Arizona University, P.O. Box 15094, Flagstaff, AZ 86011-5094. E-mail: Debbie.Craig@nau.edu

Received: December 14, 2017
Accepted: November 08, 2018
Posted Online: May 09, 2019

10.3928/19425864-20190322-01

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