Effectiveness of an Education Platform ( GoHuddle ) for Increasing Likelihood of Coach Concussion Communication with Athletes

Abstract

Research suggests coaches play a central role in establishing a context conducive to concussion reporting, particularly via direct verbal communication about concussion. Informed by qualitative interviews and stakeholder feedback, we developed a web-based concussion education platform for collegiate coaches (GoHuddle). The goal of GoHuddle is to encourage concussion safety-supportive coach communication using behavioral modeling and experiential learning. We then conducted a pre-post survey study to examine the impact of engaging with the platform on coach concussion communication, with outcomes of: (a) expected likelihood of communicating with athletes about concussive symptom reporting; (b) expected likelihood of pressuring medical staff to return athletes to play; and (c) belief in the usefulness of engaging in the communication described in a and b (i.e., response efficacy). We also assessed feasibility and acceptability of the platform in the collegiate sport context. The platform was sent to 435 coaches at five institutions, and 334 (77%) completed surveys (70% male, 37.8 years mean age). After completing GoHuddle, coaches had 2.5 greater odds of expecting to discuss concussion with their team (odds ratio [OR] 2.53, p < 0.001). Response efficacy for talking about concussion also increased significantly post-intervention (OR 3.78, p < 0.001). No significant change was seen in expectancies regarding pressure on medical staff to return athletes to play “as soon as possible.” A high proportion (82%) of coaches would recommend this platform for coach concussion education. In conclusion, this study suggests GoHuddle is a feasible and acceptable approach to coach concussion education, and use of this platform holds promise for shifting coach communication about concussion.

Introduction

Concussion is common in collegiate sports, affecting up to one in 12 student-athletes annually.^1,2 While most athletes with concussion recover, continuing to play while symptomatic is associated with risk of greater injury and prolonged recovery.^3,4 It is thus vital that athletes with potential concussion are appropriately removed from play. Estimates suggest, however, that up to 50% of athletes delay or never report potential concussive symptoms, making appropriate concussion management challenging.^5

–10 Previous studies indicate team norms can serve to encourage (or discourage) concussion care-seeking, with coaches playing a central role in shaping these norms.^5,6,11,12 In essence, athletes who believe their coach wants them to report concussive symptoms are more likely to report.^5,6,13,14

In competitive collegiate athletic departments, coaches develop an outsized influence on student-athlete health behaviors.^15
–17 While some coaches recognize such influence and seek to encourage health and wellness in their student-athletes, our qualitative work suggests that coaches at the collegiate level often defer to medical staff regarding concussion safety.¹⁸ Unfortunately, coaches who minimize the importance of their role in student-athlete concussion safety remain unaware of the potential positive influence they could have on athletes through explicit positive communication about safety-related behaviors.

Education for coaches has the potential to positively impact coach communication with athletes and medical staff. While multiple concussion education programs are available, at the collegiate level these programs tend to be aimed towards increasing knowledge, rather than changing behavior, and do not have coach communication as a behavioral target.¹⁹ Research suggests that coach attitudes regarding concussion—such as believing in negative outcomes of playing while concussed—are a more important determinant of coach concussion communication than knowledge.^{5,11,20
–22}

Our formative qualitative work with contact sport coaches in the National Collegiate Athletic Association (NCAA)¹⁸ found coaches were knowledgeable about concussion, having both experienced their own injuries and witnessed many occur on the field of play. Nearly all, however, were inclined to defer to medical staff regarding concussion communication because they discounted their influence on athlete concussion reporting behavior.

Informed by this work, and with iterative input from collegiate coaches and sports medicine staff, we developed an innovative coach concussion education platform: GoHuddle. We designed the GoHuddle platform to provide basic concussion knowledge in an interactive fashion, centered around a series of scenarios that utilize experiential learning and behavioral modeling to illustrate the potential outcomes of different approaches to concussion communication. The primary target of the GoHuddle platform is coach communication with athletes, with a goal of supporting coaches to discuss concussion reporting with their athletes by demonstrating positive and negative approaches to conversations about concussion with athletes.

As a secondary target, we focused on coach communication with medical staff. Our previous work²⁵ suggests that half of clinicians experience pressure (verbal and non-verbal) from coaches regarding accelerating return to play after a concussion. Such communication can influence providers to make decisions that go against clinical judgment, and/or suggest to athletes that medical providers' judgment is flawed or should be questioned. Coaches may not be conscious of applying such pressure or realize the impact of their communication on medical providers and student-athletes. One of the scenarios in the GoHuddle platform specifically addresses coach communication with medical staff, with a goal of improving coach communication in this context.

The goal of the current study was to collect preliminary data regarding efficacy of the GoHuddle platform for shifting coach behavioral expectancies and assess feasibility and acceptability of this approach to concussion education.

Methods

Overview

We conducted a pre-post study of the GoHuddle platform, with primary outcomes of expected coach communication with athletes and medical staff, and secondary outcomes of response efficacy and knowledge. Response efficacy was defined as coach perceived usefulness of communicating about concussion with athletes and medical staff. We hypothesized that increases in coach beliefs regarding the utility of talking to athletes about concussion (i.e., response efficacy) might mediate increases in likelihood of engaging in such communication.

We also examined the impact of demographic factors on all outcomes. We recruited five Pac-12 universities to utilize the GoHuddle platform during the 2018–2019 school year via contact with the medical staff. Medical staff at each institution then sent coaches a link to the platform to be completed as part of their annual concussion education. The survey was developed in Qualtrics (Qualtrics International Inc., Seattle, WA) and embedded in the GoHuddle platform to allowed for data collection before and after platform completion. We analyzed change in coach responses to survey questions. Coaches were provided an information sheet detailing risks and benefits of participation before completing survey questions, and documentation of consent was waived. All procedures were approved by the University of Washington Institutional Review Board.

Concussion education platform (GoHuddle)

GoHuddle is a web-based concussion education platform aimed at shifting the behavior of collegiate coaches to be more verbally supportive of concussion safety. The use of the word “Huddle” is intended to evoke images of repeated brief informal conversations led by the coach, underscoring the importance of coaches talking about health and safety with their team. The intervention is informed by the Extended Parallel Process Model,²³ addressing not only coach concussion knowledge, but also coach confidence that they will be able to communicate effectively about concussion (self-efficacy) and the belief doing so will be useful (response efficacy).

Drawing on Adult Learning Theory,²⁴ the platform provides opportunities for coaches to engage as self-directed learners, with content tailored closely to real-life situations that arise in collegiate athletics. The platform also includes information about key concussion topics (tailored for each sport) and opportunities for experiential learning using a “choose your own adventure” style scenario tool. It provides coaches space to reflect on their coaching style and legacy, helping coaches connect with their values regarding athlete well-being.

The platform has four sections: (1) Pre-Game, (2) Learn, (3) Apply, (4) Post-Game. The “Pre-Game” section includes a brief quiz to pull coaches into the platform (“What kind of coach are you?”). The “Learn” section covers concussion knowledge and beliefs (e.g., signs and symptoms of concussion, mechanisms, risks of continuing to play, and research regarding prevention).

The “Apply” section is the central feature of the platform and consists of four “choose your own adventure” scenarios each illustrating how coach communication influences athlete behavior. These scenarios are designed to cover the varied contexts in which concussion communication is most likely to occur, and the goal is to model how a coach can respond in a manner that would influence athletes to behave in a safe manner. The four scenarios include: (1) pre-season (i.e., talking about concussion before the start of the season); (2) suspected concussion; (3) return to play; and (4) retirement from sport. In each scenario, the participant plays the role of the coach and chooses a response (multiple choice) to statements made by either an athlete or medical staff member. After a few “waiting dots,” the responses from the athlete or medical staff member appear, similar to text responses. Participants can replay each scenario to experience different paths.

The “Postgame” section consists of a wrap-up slide encouraging coaches to communicate with athletes about concussion before the season starts, after a potential injury, and during recovery to support student athlete concussion safety.

Primary outcomes

Behavioral expectancies

Coaches indicated their likelihood of talking to athletes about concussion using the concussion communication behavioral expectancies scale (C-CBE), with a question asking: “How likely is it that you will talk to your team about reporting symptoms of a suspected concussion for the upcoming season?” Responses included not at all likely, likely, and very likely. They also indicated their likelihood of asking medical staff to return athletes to play rapidly using the return to play communication behavioral expectancies scale (RTP-CBE), with a question asking: “How likely is it that you will encourage team medical staff to get an athlete back to play as soon as possible after a concussion for the upcoming season?” Response options were the same as for C-CBE. Both scales have previously been used to evaluate collegiate coach concussion education.²⁵

Feasibility

We assessed feasibility via rates of platform completion, given that the platform was implemented in a manner that would be easily adaptable by a university athletic department (i.e., having medical or administrative staff at each institution send out the platform to coaches).

Acceptability

Coaches answered five questions regarding the likeability and acceptability of the GoHuddle platform, drawn from the previously published “Acceptability of intervention measure” or AIM.²⁶ Responses were elicited on 4-point Likert scale ranging from strongly disagree to strongly agree.

Covariates

Response efficacy

Coaches rated their beliefs that performing each of the behaviors (talking to athletes about concussion and pressuring medical staff to return an athlete prematurely) would result in desired outcomes, using the response efficacy for concussion communication (re-CC) and the response efficacy for concussion RTP (re-RTP), with responses of not at all useful, somewhat useful, and extremely useful. As with the behavioral expectations measure, these have been used previously to evaluate coach concussion education,²⁵ and the wording of these items is included in the supplement material.

Knowledge

Coaches answered seven questions regarding concussion knowledge, including questions regarding concussive symptoms, the potential negative outcomes of concussive injury, and risks of playing while injured with a concussion. These items were drawn from previous studies (Supplementary Table S1)^22,27 and selected specifically to provide variation (i.e., not all coaches answered them in the correct manner previously). Responses were limited to true and false and were combined to create an index with a possible range of 0–7, with higher scores indicating greater coach concussion knowledge.

Demographics and coaching experience

Coaches reported age, sex, coach role (i.e., head coach, assistant coach), sports coached, sex of athletes, and years coaching experience. Sport was later divided into contact/collision and limited contact using categories laid out in the NCAA Sports Medicine Handbook. ²⁸

Data analysis

All analyses were completed using SAS 9.2 PROC GENMOD (SAS/STAT, 2011). We used fixed effects growth modeling to assess potential change over time (i.e., pre-post training) for all outcomes: (a) coach concussion communication behavioral expectancies (C-CBE), (b) coach return to play communication behavioral expectancies (RTP-CBE), and (c) response efficacy for these two behaviors (defined as coach perceived usefulness for the two primary outcomes). We added predictors to these models separately, including previous season concussion communication behavior, sex of coach, sex concordance between coach and athletes, age of coach, years coached, coaching role, and contact nature of sport coached (contact/collision or limited contact/non-contact).

We also examined change in the number of concussion knowledge items correctly endorsed using Poisson regression with a log link. We controlled for missingness using multiple imputation with SAS PROC MI, utilizing study demographic characteristics and all pre-test and post-test outcomes to build the imputation model.

Results

A link to GoHuddle was e-mailed to 435 Pac-12 coaches at five universities via one of the medical staff from their athletic department, and 334 (77%) completed all parts of the platform and filled out pre- and post-platform surveys. The 334 coaches who completed surveys were on average 37.8 years old (standard deviation [SD] = 10.4), majority male (70%), and on average had coached at the collegiate level for 10.9 years (SD = 7.7, Table 1). Football was the most common sport coached (18%), followed by men's track and field (9%). Across all sports, 56% were categorized as contact/collision and 44% as limited contact or non-contact.

Table 1.

Demographic Information for Collegiate Coaches Completing Gohuddle, 2018–2019

	n	%
Age in years
21–30	95	28.4
31–40	109	32.6
41–50	72	21.6
51+	44	13.2
Prefer not to answer	14	4.2
Gender
Male	235	70.4
Female	91	27.2
Prefer not to answer	8	2.4
Years coached at the collegiate level
Less than 1	13	3.9
1 to 5	89	26.6
6 to 10	86	25.7
11 to 15	53	15.9
16+	89	26.6
Prefer not to answer	4	1.2
Coaching role
Head coach	69	20.7
Associate head coach	32	9.6
Assistant coach	131	39.2
Other	102	30.5
Sport(s) coached
Contact or collision	187	56.0
Limited contact or non-contact	147	44.0

Missingness

Rates of missing data because of item non-response at pre-test ranged from to 6–16%. Rates of missing data because of loss at follow-up and item non-response ranged from 4–12%.

Communication expectancies pre-post intervention

Descriptive data for the concussion communication expectancy items are shown in Table 2. Using fixed effects growth modeling, we noted a 2.53 times increase (p < 0.001) in the odds of endorsing a higher value (i.e., toward very likely) for the item, “How likely is it that you will talk to your team about reporting symptoms of a suspected concussion for the upcoming season” (C-CBE). There was no significant change for the other primary outcome, “How likely is it that you will encourage team medical staff to get an athlete back to play as soon as possible after a concussion for the upcoming season” (RTP-CBE). No variables were associated with greater likelihood of coaches talking to athletes about concussion reporting (C-CBE).

Table 2.

Coach Report of Pre- and Post-Training Concussion Behavioral Expectancy Items for the Gohuddle Evaluation, 2018–2019

How likely are you to do each of the following behaviors during the upcoming season?	Percent (%) reported
	Not at all likely	Somewhat likely	Very likely
Talk to your team about reporting symptoms of a suspected concussion.
Pre-training	6.3	17.1	76.6
Post-training	1.6	9.8	88.6
Encourage team medical staff to get an athlete back to play as soon as possible after a concussion.
Pre-training	82.8	9.1	8.1
Post-training	86.3	3.7	10.0

Coaches who had pressured medical staff about RTP in the past were approximately one-third less likely to shift in this behavior (RTP-CBE) from pre- to post-training. Details of these predictor × time interaction terms for the behavioral expectancy items are provided in Supplementary Tables S2, S3, and S4.

Response efficacy pre-post intervention

Descriptive data for the response efficacy items are shown in Table 3. We noted a 3.78 increased odds (p < 0.001) from pre- to post-training for endorsing a higher value (i.e., toward very useful) for the item, “How useful would it be for you to talk to your team about reporting symptoms of a suspected concussion for the upcoming season.” There was no significant change in the other response efficacy item, “How useful would it be for you to encourage team medical staff to get an athlete back to play as soon as possible after a concussion for the upcoming season.” No significant predictors of change were found for the response efficacy items (estimates provided in the supplement material).

Table 3.

Coach Report of Pre- and Post-Training Response Efficacy in the Gohuddle Evaluation, 2018–2019

How useful would it be for you to do each of the following behaviors during the upcoming season?	Percent (%) reported
	Not at all useful	Somewhat useful	Extremely useful
Talk to your team about reporting symptoms of a suspected concussion.
Pre-training	4.3	23.6	72.1
Post-training	0.0	9.8	90.2
Encourage team medical staff to get an athlete back to play as soon as possible after a concussion.
Pre-training	86.1	8.3	5.6
Post-training	87.4	5.1	7.5

Knowledge pre-post intervention

Descriptive data for the concussion knowledge items are shown in Table 4. Using Poisson regression, the number of items answered correctly significantly increased (p < 0.001) from pre- to post-training, with an increase of approximately 6.9% (about one-half of a question, given seven questions in the scale). No significant predictors of change were found for number of correct knowledge items endorsed (see supplement material).

Table 4.

Number of Concussion Knowledge Items Correctly Endorsed by Coaches in The Gohuddle Evaluation, 2018–2019

Total number correct	Percent (%)
Total number correct	Pre-training	Post-training
2	0.6	0.0
3	1.3	0.3
4	3.8	0.9
5	10.3	1.9
6	37.3	28.3
7	46.7	68.5

Feasibility

The GoHuddle platform was implemented via having one of the medical or administrative staff send a link to coaches without any additional incentives, an approach that could be carried out in most athletic departments. The completion rates of the platform (77%) thus suggest strong feasibility.

Acceptability and satisfaction with GoHuddle

Acceptability and satisfaction ratings for GoHuddle are shown in Table 5. Overall, there was a high level of satisfaction with the program, with 82% of coaches indicating agree or completely agree regarding recommending GoHuddle for their coach education and only 1.5% stating disagree or completely disagree.

Table 5.

Acceptability Ratings of the GoHuddle Program, 2018–2019

	Coaching staff (n = 334)
GoHuddle meets my approval
Completely disagree	1.2
Disagree	0.9
Neither agree nor disagree	7.7
Agree	50.3
Completely agree	39.0
Prefer not to answer	0.9
GoHuddle is appealing to me
Completely disagree	0.6
Disagree	1.5
Neither agree nor disagree	16.3
Agree	49.1
Completely agree	31.3
Prefer not to answer	1.2
I like GoHuddle
Completely disagree	0.9
Disagree	0.9
Neither agree nor disagree	16.0
Agree	51.2
Completely agree	29.8
Prefer not to answer	1.2
I welcome GoHuddle
Completely disagree	0.6
Disagree	0.6
Neither agree nor disagree	11.7
Agree	54.0
Completely agree	32.2
Prefer not to answer	0.9
I would recommend that my institution use GoHuddle platform to educate coaches
Completely disagree	0.6
Disagree	0.9
Neither agree nor disagree	14.4
Agree	50.6
Completely agree	31.6
Prefer not to answer	1.8

Discussion

We completed a pre-post trial of an online concussion education platform (GoHuddle), finding that the expected likelihood of talking to athletes about concussion safety increased significantly after completion of the platform. GoHuddle completion was also associated with significant improvement in the two theoretical mediators: response efficacy for communication with athletes and concussion knowledge. We also examined the effects of the platform on a negative coach behavior, intentions to encourage medical staff to return athletes to play “as soon as possible,” but found no shift in this item, potentially because of socially desirable responding and/or ceiling effects. A large majority (80%) of coaches found the platform appealing and recommended their institution utilize it for concussion education.

At present, there is only one concussion education approach for collegiate coaches that has a published evaluation, the use of a fact sheet about concussion from the NCAA.²⁹ Unlike GoHuddle, receipt of the NCAA's fact sheet was not associated with significant improvements in expected likelihood of talking to athletes about concussion safety. Potential reasons for this difference could have to do with GoHuddle's instructional approach, which employed scenario-based modeling and experiential learning, both of which are possible with an interactive web-based platform but not with a handout. The GoHuddle platform also provided coaches an opportunity to explore information about concussion at their own pace, with videos and graphics to illustrate each point, and links to original articles.

We were encouraged by the high feasibility and acceptability, suggesting that our process of iterative design and refinement was effective at generating an educational approach that appealed to coaches. Future iterations will need to continue to improve this further, but the current broad appeal will be important for future studies examining effectiveness of this platform on a larger scale.

Interestingly, exposure to the NCAA concussion fact sheet,²⁹ unlike GoHuddle, led to reduced likelihood of encouraging medical staff to return athletes to play as soon as possible. This discrepancy may be driven by ceiling effects and socially desirable responding because the NCAA fact sheet study had a larger proportion of coaches who reported a high likelihood of engaging in this behavior, allowing for more potential for shift.

In the NCAA fact sheet evaluation, the survey was sent to coaches directly from a researcher unconnected to their institution, whereas in the current study, the links to the GoHuddle platform and survey were sent by one of the medical staff from the institution. Despite assurances that medical staff members were not able to access study data, it is possible coaches may have believed their responses were not confidential. Future work is needed to explore this realm and identify factors influencing coach behavior with medical staff, given that such behaviors also play an essential role in facilitating athlete concussion safety.

We were encouraged to find that coach belief in the potential benefit of talking about concussion (i.e., response efficacy) also increased after completion of the GoHuddle platform as did concussion knowledge, in line with our hypotheses that change in these factors might mediate change in behavioral expectancies about concussion communication. In other words, engaging with GoHuddle not only affected coach likelihood of talking to athletes about concussion, but also coach knowledge of concussion and coach belief in the benefit of talking to athletes about concussion. Such findings support the validity of our results and provide additional targets for intervention.

We were interested in factors influencing the likelihood of coach communication with their team, and we explored multiple variables including sex, age, years coached, sport coached (contact/collision vs. limited contact), sex concordance between team and coach, and whether coaches had talked to athletes about concussion in the past, but none of these were significant. This is in contrast to previous findings that both sex of coach and sex concordance between coach and team influence concussion safety communication.²² We did include customizable content (videos of mechanism by sport and graphics of injury rate by sport), which may have ensured equivalent impact regardless of sport coached. We note, however, that while this study utilized a reasonable sized sample, examining the impact of potential moderators on intervention effectiveness requires greater power and should be studied with larger samples.

While this study had many strengths, particularly a moderate sized sample and very high response rates, it also had limitations. A convenience sample of five institutions was utilized, and responses may not generalize to other institutions. In addition, we utilized a pre-post trial, rather than a randomized controlled trial, and did not measure performed coach behavior given the complexity and timeline involved in such data collection. Finally, we assessed coaches immediately after their interactions with the platform and cannot extrapolate as to whether any impact on behavioral expectancies was still present weeks or months later. Further work is needed to better understand the ability of the GoHuddle platform to shift coach concussion communication and the impact of such a shift on athlete concussion safety behaviors (such as concussive symptom reporting).

Conclusions

A new online coach concussion education platform (GoHuddle) appears to be feasible and acceptable to a broad range of key stakeholders, and data suggest the platform effectively increases knowledge and improves expected coach concussion communication with their team about concussion reporting.

Footnotes

Authors' Contributions

Sara PD Chrisman was involved in formulating the idea for the study, pursuing funding, overseeing data collection and analysis, developing the draft, and finalizing the article with all author input. Emily Kroshus was involved in formulating the idea for the study, pursuing funding, overseeing data collection and analysis, reviewing initial drafts of the article, and approving the final version. Kimberly Garrett was involved in supporting data collection and analysis, reviewing initial drafts of the article, and approving the final version. Jeffrey Gau completed all data analysis, reviewed initial drafts of the article, and approved the final version. Kimberly Harmon and Ann Glang were involved in formulating the idea for the study, assisting with funding proposals, providing feedback regarding data collection and analysis, reviewing initial drafts of the article, and approving the final version. Dane Ramshaw developed the educational platform including data collection tools, supported data collection and analysis, reviewed initial drafts of the article, and approved the final version.

Funding Information

This work was made possible by a grant from the Pac-12 Student Athlete Health and Well-Being Initiative.

Author Disclosure Statement

No competing financial interests exist.

Supplementary Material

Supplementary Table S1

Supplementary Table S2

Supplementary Table S3

Supplementary Table S4

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