Concussion Bingo: Taking an active learning approach to concussion education with vulnerable populations

Abstract

Objective:

The ability of athletes in underserved communities to recognise sport-related concussion (SRC) may be complicated by the lack of a qualified professional, such as an athletic trainer, present. An active learning educational activity (Concussion Bingo) was developed to assist in SRC identification. This study examined learning outcomes following the use of this activity by athletes in two US Title I (low socioeconomic status) high schools.

Design:

Cross-sectional study.

Setting:

High school sports.

Methods:

Participants (n = 102 athletes) completed 10-minute SRC knowledge of concussion surveys before and after participating in a Concussion Bingo activity. The 45-question survey assessed SRC knowledge through questions about SRC signs/symptoms, general injury information relating to loss of consciousness, the injured anatomical structure, complications of multiple SRCs and premature return to play. Participants had to mark key SRC terms on a Bingo card as they appeared throughout an SRC presentation including content from published consensus/position statements. Descriptive and parametric statistics were used to analyse the data.

Results:

Analysis of covariance revealed significant differences between pre- and post-Concussion Bingo scores. Athletes had the greatest knowledge increase of fogginess (n = 30, 29.5%), mood changes (n = 29, 28.5%), nausea (n = 27; 26.5%) and sleep problems (n = 27, 29.5%). On questions pertaining to the injury itself, athletes had the greatest increase on ‘you have to be hit in the head to get a concussion’ (n = 51, 50%), ‘what kind of an injury is a concussion’ (n = 31, 40.2%) and a concussion only occurs if you ‘black out’ (n = 24, 23.4%).

Conclusion:

Concussion Bingo increased Title I high school athletes’ knowledge of SRCs, suggesting that it may be an effective active learning tool for increasing SRC knowledge.

Keywords

Active learning concussion education knowledge transfer sport-related concussion USA

On a global level, sport-related concussion (SRC) continues to be a notable injury in high school athletics, and although the literature on education, recognition, prevention and management continues to advance at a rapid rate, it appears that educational interventions are not leading to intended behaviour modifications (Wallace et al., 2017a, 2017b). In addition, over a 7-year span from 2005 to 2012 in high school athletes across all sports within the USA, the diagnosis of SRC increased from 2.3 to 5.1 SRCs per 10,000 athlete exposures (Rosenthal et al., 2014). In an effort to produce safer athletic environments in the USA, all 50 states have put in place concussion safety laws (Lowrey and Morain, 2014). Although these laws differ slightly state to state (e.g. inclusion of graduated return-to-play protocol, limitation of full-contact practices for impact sports, intramural sport coverage, mandatory baseline neurocognitive testing; Barton Straus, 2018), one common factor included in these laws is the mandatory SRC education of athletes, parents and coaches.

There is currently no standardised format for SRC education for high school athletics and both take-home information packets and online education programmes have become more common (Centers for Disease Control and Prevention [CDC], 2017; USA Football, 2018). The lack of a standardised SRC education format makes it unclear as to the depth of knowledge transfer that is occurring within the high school athlete population. Moreover, within high school athletics, the task of providing state-mandated SRC education and handling the accompanying paperwork is often times assigned to the athletic director, athletic trainer or other healthcare providers who are present in the secondary school setting. Furthermore, providing SRC education becomes challenging when there is not a full-time athletic trainer or other healthcare professional to rely upon, which may be the case for low-income, Title I schools in more urban areas where funding is limited. Students at Title I schools¹ are supported by the Federal Free and Reduced Lunch programme and many Title I schools in urban communities often serve low-income student-athletes of African American decent with limited access to healthcare (Watson, 1989). For high school athletes lacking access to an athletic trainer or healthcare professional, their medical care could be compromised should an athlete sustain an SRC; thus, alternative SRC education interventions that increase awareness and recognition are warranted.

The absence of standardised SRC education and access to medical care could be especially troublesome and negatively impact SRC identification and management in Title I high schools in which a large majority of athletes participate in SRC risk sports such as football. According to the National Federation of State High School Associations’ 2016–2017 participation statistics, 15,457 high schools across the USA offered tackle football and nearly 1.1 million boys participated in tackle football. In high school football, Black young men are 2.4 times more likely than White young men to play football (Goldsmith, 2003). Racial differences shape high school sport participation, and this is largely due to school resources, sports offered, student body socioeconomic status (SES) and neighbourhood geography (Goldsmith, 2003). Previous research on SRC health disparities found that SES differences could be noted among high school athletes and that high school athletes attending mid-upper-SES, suburban schools knew more about SRCs compared to those attending low-SES, urban schools (Wallace et al., 2017a). Furthermore, White high school athletes were more knowledgeable about SRCs compared to African American high school student-athletes (Wallace et al., 2018). Regardless of race or school resources, high school athletes without access to full-time athletic trainers were less knowledgeable about SRCs than those who did have access to full-time athletic trainers (Wallace et al., 2017a, 2017b, 2018).

Researchers have reported that Black youth, high school and college student-athletes have a greater chance of worse clinical outcomes and more significant neurocognitive deficiencies following a mild traumatic brain injury, compared to other ethnic groups (Haider et al., 2007; Kontos et al., 2010). In addition, young people from higher income families were significantly more likely than their counterparts from lower income families to receive concussion education or having learned what to do if they believe they sustained a concussion (Donnell et al., 2018). Without the watchful eye of a skilled healthcare provider, underserved high school sport participants and coaches are left to identify SRCs, make difficult removal from play decisions and potentially monitor the management of this already daunting injury. Students and coaches should not be charged with monitoring complex brain injuries, such as SRC, and it is imperative that underserved populations, such as low-income high school athletes, become a focused target for SRC education efforts.

It has been previously understood that one element to successful SRC knowledge transfer is dependent upon the adaptation of education strategies tailored to the specific learning needs of the target audience (Caron et al., 2015; Provvidenza and Johnston, 2009). In the era of digital technology, high school student-athletes can instantly access numerous websites with SRC education information. Although convenient, research has found that health and SRC information available via the Internet has high variability in the standard and accuracy of information that is delivered to the consumer (Ahmed et al., 2011; Purcell et al., 2002). Filtering through the mass amounts of SRC information may be especially difficult for high school student-athletes who may not possess the resources, such as access to the Internet, or previous SRC awareness to uncover reliable SRC information that is written in a way that they can connect and understand. This lead to the development of Concussion Bingo, a simple and dynamic form of SRC education tailored directly to the needs of this population. The game of bingo was chosen as the active learning vehicle for SRC education because it requires the participant to be engaged with the game administrator and it can address different learning styles by incorporating visual, auditory and textile stimuli. Games such as BINGO have been used in chemistry education (Bayir, 2014) and the benefits of using active learning strategies in the form of games are beneficial when the teacher aims to review and reinforce material, address multiple learning styles, provide learners with immediate feedback and increase positive learning outcomes (Leach and Sugarman, 2005).

Active learning, in a science context, is based on the student-centred learning approach, which includes creating learning environments where teachers help facilitate knowledge transfer by stimulating internal inquiries through hands-on activities focused on connecting students to material in a tangible way rather than traditional methods of lecture and memorisation (Marx et al., 2004; Taraban et al., 2007). In science disciplines, the average test scores have been shown to improve by approximately 6% in classrooms that use active learning strategies and students in traditional lecturing classrooms were 1.5 times more likely to fail than those in classes that incorporated active learning (Freeman et al., 2014). Concussion Bingo was developed using active learning principles packaged in a game format that is familiar to high school student-athletes. Game-based learning strives to motivate consumers to engage in educational materials in a playful and dynamic way through competition, incentives and knowledge feedback loops (Trybus, 2014).

Concussion Bingo was created by the principal investigator (J.W.) and was used as a resource tool to educate youth and high school athletes in urban communities about SRCs. The health education principles used to develop Concussion Bingo are not novel, however contemporary, and the game was piloted with six Title I high schools in metro-Detroit as part of a community service initiative, gaining positive feedback from school administrators, coaches and athletes. Over the past decade, concussion education has been a large public health focus and multiple educational interventions have been introduced to various communities. Concussion Bingo provides an alternative platform to the programmes that have already elicited a positive result. Other methods of concussion education have included video platforms, the Sports Legacy Institute Community Educators (SLICE) curriculum and web-based programmes. The SLICE curriculum has been shown to improve recognition response on a concussion evaluation following a presentation given to youth athletes (Bagley et al., 2012). Furthermore, a standardised concussion video script overlaying the multiple aspects of concussion has been shown to increase high school athletes’ ability to identify signs and symptoms of a concussion (Hunt, 2015). Using technology tools and providing education via presentations is critical to achieving a knowledge transfer; however, not all interventions are appropriate for every community. Concussion Bingo is a new tool that has not been widely disseminated, however, and it could be an easy and useful tool to deliver SRC concussion information to physical education and extracurricular athletic programmes.

Making SRC education more active and tailoring it to specific populations will allow the receiver to engage in the material being presented in order to build cognitive pathways for information retention, thus achieving successful knowledge transfer. By providing underserved high school student-athletes with a greater understanding of SRCs, they may be able to understand more clearly the seriousness of the injury in order to make more informed decisions regarding their cognitive health and sport participation status. If effective in increasing SRC knowledge, the approach trialled in this study may provide a user-friendly, cost-effective model for medical personnel and administrators at Title I, urban schools to use when educating their student-athletes about SRCs. Against this background, the purpose of this study was to examine the acute learning outcomes following an SRC education active learning activity in underserved high school student-athletes at Title I, urban schools.

Methods

Participants

Study participants included 102 high school student-athletes from two Title I high schools in an urban community in Northeast Ohio. At the time of the study (September–October 2016), football, volleyball and women’s basketball were in season, and thus data were only collected on athletes participating in these three sports.

Instrumentation

The knowledge of concussion instrument used for this cross-sectional study was originally developed by Register-Mihalik et al. (2013). The knowledge of concussion instrument was pre-tested for face validity by content experts and for reliability Cronbach’s α calculated for the knowledge of concussion construct was .72 (Register-Mihalik et al., 2013). To reflect the most recent scientific information since the origination of the instrument, a few evidence-based additions and slight modifications were made. These changes included the addition of eight signs and symptoms (i.e. fogginess, changes in mood) and two true or false questions pertaining to the nature of a concussion injury. The same instrument was used for pre- and post-knowledge of concussion assessment.

The instrument was separated into three sections that included athlete demographics, knowledge of concussion items and two questions assessing the athlete’s self-understanding of concussion. The five demographic questions used in the survey included age, sex, grade in school, race/ethnicity and sport. Demographic questions were not used for any knowledge of concussion scoring. Knowledge of concussion was assessed using a sequence of 45 questions. Student-athletes were instructed to identify SRC-related signs and symptoms listed among distractors. Participants also answered questions related to loss of consciousness associated with concussion, identify the anatomical structure (brain, skull, face, etc.) injured from a concussion, identify the nature of the injury (structural vs functional) and identify complications related to multiple concussions and premature return to play. Total knowledge was calculated by summing the number of correct answers out of the 45 questions. Score totals could range from 0 to 45. Scores closer to 45 represented a greater degree of concussion knowledge.

Data collection procedures

Study approval was granted by Youngstown State University’s Institutional Review Board prior to the start of data collection. This study was granted exempt approval status because no personal identification information was collected. Because no personally identifying information was collected, each pre-test instrument had a number written on the right-hand corner and also had a sticker stapled to it with the same corresponding number for the athlete to place on their clothing.

The instrument was administered in the supervised cafeteria using a standardised script and all the participants received uniform instructions. Participation in the study was voluntary and participants were not excluded for any pre-existing learning disabilities, attention deficit disorder (ADD)/attention deficit hyperactivity disorder (ADHD) or any previous history of concussion. The pre-test instrument was a one-time administered paper and pencil survey that took participants 10 minutes to complete. Participants were allowed to skip questions and were able to withdraw at any time.

Following completion of the pre-test instrument, athletes participated in an active learning activity called Concussion Bingo. Each athlete was given his or her own Concussion Bingo card and bingo markers. The principal investigator created over 100 different variations in Concussion Bingo cards so that each athlete was given a different card. On the Concussion Bingo cards were key terms associated with concussions, including common signs and symptoms, uncommon signs and symptoms, terms related to the concussion pathology, terms related to injury characteristics, terms related to complications from concussions, terms related to return to play and terms related to care associated with concussion.

Concussion Bingo was presented using Microsoft PowerPoint. Information resourced from the US CDC (2017) Heads Up in Sport, in addition to material within medical community consensus statements, was referenced to create Concussion Bingo. In addition, among the PowerPoint content and important concussion-related terminology were photos to provide visuals representing the nature of a concussion injury, photos to explain characteristics of common and uncommon signs and symptoms, and videos. Athletes could only mark a term on their Concussion Bingo card if it was listed on a PowerPoint slide. The interactive Concussion Bingo game platform initiated discussion between the principal investigator and athlete participants. The Concussion Bingo game took approximately 30 minutes to complete.

Following the Concussion Bingo activity, each athlete was given the post-test with the same number corresponding to his or her pre-test. Athletes were asked to complete the same knowledge of concussion instrument in order to compare pre- and post-knowledge of concussion scores. The post-test took athletes 10 minutes to complete.

Data analysis

General descriptive (i.e. means, standard deviation, frequencies) statistics were used to summarise demographic data, pre- and post-knowledge of concussion total scores, and to conduct an item analysis for each knowledge of concussion question on both pre- and post-test. Pre- and post-knowledge of concussion scores were determined by summing the total number of correct responses to the 45 questions. Each correct response equalled 1 point and a higher score indicated greater SRC knowledge with a maximum score of 45. To determine if differences in pre- and post-knowledge of concussion scores existed following the Concussion Bingo intervention, an analysis of covariance (ANCOVA) was conducted. To control for any potential racial differences, race served as the covariate. The level of significance was set a priori at p ⩽ .05.

Results

A total of 102 high school athletes volunteered to participate in the study, consisting of 81 (79.4%) young men and 21(20.6%) young women. High school athletes ranged in age from 13 to 18 years (mean 16.02 ± 1.22). The highest percentage of athletes were in grade 10 (31.4%), followed by grade 11 (25.5%). In regard to race and ethnicity, 80 (78.4%) athletes were African American. Moreover, most of the athletes were football players (79.4%). See Table 1 for a breakdown of participant demographics.

Table 1.

Demographic information.

	n (%)
Grade in school
Freshman	24 (23.5)
Sophomore	32 (31.4)
Junior	26 (25.5)
Senior	20 (19.6)
Race/ethnicity
African American	80 (78.4)
Caucasian	13 (12.7)
American Indian	1 (1.0)
Hispanic/Latino	1 (1.0)
Asian	1 (1.0)
Other	6 (5.9)
Sex
Male	81 (79.4)
Female	21 (20.6)
Sport
Football	81 (79.4)
Girl’s basketball	18 (17.6)
Volleyball	3 (3.0)

Athletes were asked to indicate from a list which signs and symptoms of an SRC were true and false. Following the Concussion Bingo education session, athletes demonstrated the greatest increase in knowledge of lesser common signs and symptoms, including a 29.5% increase in fogginess, followed by a 28.5% increase in changes in mood, a 26.5% increase in nausea and a 29.5% increase in sleep problems. When asked true and false questions pertaining to the injury itself, athletes had the greatest increase in knowledge on ‘you have to be hit in the head to get a concussion’ (50% increase), ‘what kind of an injury a concussion is’ (40.2% increase) and a concussion only occurs if you lose consciousness ‘black out’ (23.4% increase). Finally, when asked questions pertaining to complications of having multiple concussions and returning to play while symptomatic, athletes had the greatest increase in knowledge understanding that multiple concussion increases the risk of having another concussion (11.7% increase). See Tables 2 to 4 for an item analysis and frequency breakdown of correct responses to each question on the pre- and post-knowledge of concussion instrument.

Table 2.

Pre- and post-sign and symptom recognition.

Sign/symptom	Pre-test correct, n (%)	Post-test correct, n (%)
Photophobia	84 (82.4)	82 (80.4)
Abnormal taste	91 (89.2)	94 (92.2)
Sleep problems	57 (55.9)	84 (82.4)
Blurred vision	93 (91.2)	95 (93.1)
Loss of consciousness	77 (75.5)	85 (83.3)
Tinnitus	64 (62.7)	56 (54.9)
Difficulty breathing	87 (85.3)	92 (90.2)
Headache	99 (97.1)	99 (97.1)
Bleeding from mouth	96 (94.1)	97 (95.1)
Abnormal smell	92 (90.2)	94 (92.2)
Bleeding from ear	88 (86.3)	91 (89.2)
Sharp pains in neck	78 (76.5)	86 (84.3)
Weakness in neck muscles	67 (65.7)	80 (78.4)
Confusion	90 (88.2)	92 (90.2)
Fogginess	64 (62.7)	94 (92.2)
Numbness and tingling	82 (80.4)	85 (83.3)
Joint stiffness	92 (90.2)	92 (90.2)
Changes in mood	34 (33.3)	63 (61.8)
Nausea	65 (63.7)	92 (90.2)
Black eye	97 (95.1)	96 (94.1)
Nose bleed	89 (87.3)	96 (94.1)
Memory loss	84 (82.4)	87 (85.3)
Dizziness	88 (86.3)	95 (93.1)
Chest pain	98 (96.1)	95 (93.1)
Stiff back	90 (88.2)	93 (91.2)
Fever	90 (88.2)	93 (91.2)
Skin rash	100 (98)	100 (98.0)

Shaded rows demonstrate statistically significant changes in knowledge pre- and post-test.

Table 3.

Pre- and post-percentages correct on true/false and multiple choice questions.

Question	Pre-total correct, n (%)	Post-total correct, n (%)
You have to be hit in the head to get a concussion. (False)	29 (28.4)	80 (78.4)
A concussion only occurs if you lose consciousness ‘black out’. (False)	57 (55.9)	81 (79.5)
If you are experiencing any sign or symptom of a concussion following a blow to the head or sudden movement of the body, you should not return to play. (True)	77 (75.5)	81 (79.4)
A concussion is an injury to the: (brain)	89 (87.3)	97 (95.1)
What kind of injury is a concussion? (Functional)	51 (50.0)	92 (90.2)

Note: The shaded rows allowed readers to see where the greatest knowledge gains were at a statistically significant level.

Table 4.

Pre- and post-total correct on questions related to complications of having multiple concussions and returning to play while symptomatic.

Question	Pre-total correct, n (%)	Post-total correct, n (%)
Of the following, what are possible complications of having multiple concussion? (check all that apply)
No complications exist (false)	95 (93.1)	98 (96.1)
Increased risk of further injury (true)	63 (61.8)	75 (73.5)
Brain damage (true)	96 (94.1)	98 (96.1)
Chronic traumatic encephalopathy (CTE) (true)	44 (43.1)	40 (39.2)
Joint problems (false)	85 (83.3)	85 (83.3)
Memory problems (true)	89 (87.3)	93 (91.2)
I don’t know (false)	97 (95.1)	101 (99.0)
Of the following, what are possible complications of returning to sporting activity while still experiencing possible concussion symptoms? (check all that apply)
No complications exist (false)	97 (95.1)	95 (93.1)
Increased risk of further injury (true)	79 (77.5)	88 (86.3)
Paralysis (false)	57 (55.9)	60 (58.8)
Brain damage (true)	84 (82.4)	96 (94.1)
Joint problems (false)	83 (81.4)	86 (84.3)
I don’t know (false)	85 (83.3)	99 (97.1)

Note: The shaded rows allowed readers to see where the greatest knowledge gains were at a statistically significant level.

Results from the ANCOVA showed significant differences between pre-test knowledge of concussion and post-test knowledge of concussion scores (F_{(1, 100)} = 35.38, p < .001, d = .42). The effect size associated with the change in knowledge of concussion scores was moderate, suggesting that the changes in pre- and post-scores are likely to be attributable to the Concussion Bingo intervention. Pre-test knowledge of concussion scores ranged from 19 to 44 with a mean of 35.23 ± 4.54. Post-test knowledge of concussion scores ranged from 25 to 45 with a mean of 38.73 ± 4.40. Following the Concussion Bingo intervention, the minimum knowledge of concussion score increased by 6 points or 8%. The mean percentage correct on the pre-test was 78.3% and the mean percentage correct on the post-test was 86.1% demonstrating that the Concussion Bingo intervention was an effective tool in creating a positive increase in concussion knowledge among high school athletes.

Discussion

This study examined the acute learning outcomes of an SRC active learning activity in underserved high school student-athletes at Title I, urban schools. Results indicated that high school student-athletes’ knowledge of an SRC increased after engaging in Concussion Bingo. Specifically, student-athletes’ post-knowledge of SRC scores increased by 6 points or 8%, suggesting that the Concussion Bingo intervention was an effective tool in creating a positive knowledge transfer. More importantly, when examining individual components of the survey, student-athletes demonstrated an increase in symptom knowledge by nearly 30% in fogginess, changes in mood, nausea and sleep. Student-athletes also reported an increased understanding that not being hit in the head can also result in an SRC and you do not need to lose consciousness or ‘black out’ to sustain an SRC. Finally, student-athletes also increased their knowledge in understanding that multiple SRCs can increase the risk of sustaining another SRC.

The findings of this study indicated that student-athletes who participate in Concussion Bingo can increase their knowledge on the signs and symptoms of SRC, the dangers of playing with an SRC and complications related to multiple SRCs. These results are similar to other studies that also used an alternative educational intervention to increase SRC knowledge. Specifically, Bagley et al. (2012) administered an educational intervention to students between the ages of 9 and 18 years and found a 22% increase in overall scores pre- to post-intervention. More recently, Glang et al. (2015) used a randomised control trial of high school student-athletes who received the Brain 101: The Concussion Playbook (a web-based intervention) compared to a control group and found that the educational intervention group performed significantly better on the post-test, after adjusting for pre-test differences (Glang et al., 2015). Finally, Parker et al. (2015) examined high school students who did the National Federation of High School/CDC Concussion in Sports: What You Need to Know online course and found that there was a 32% increase in correct answer response from pre-test to post-test. However, a limitation to this study is that it only included five post-test questions. Moreover, the aforementioned studies required access to the Internet which may limit feasibility to communities lacking access to Internet and/or communities of lower SES.

The results of this study also found an increase in recognition of the signs and symptoms of a SRC. Overall, the student-athletes had a 10% overall increase in SRC signs and symptoms. However, there were significant increases in the symptoms of fogginess, changes in mood, nausea and sleep disturbances, all of which are signs and symptoms that have less frequently been recognised by high school athletes (Wallace et al., 2017a, 2017b, 2018). These findings are similar to previous research that reported a 12.6% increase in SRC symptom identification following a 9-minute concussion video script (Hunt, 2015). There are several possible reasons why this study had a significant increase in the recognition of SRC symptoms of fogginess, nausea, changes in mood and sleep problems. First, it may be due to the interactive nature of the Concussion Bingo game. Concussion Bingo uses active learning principles that cater to multiple learning styles while creating a fun learning environment for student-athletes. Second, Concussion Bingo incorporates hands-on activities that connect participants to the SRC material in a tangible way while still using traditional methods of didactic presentation. The game-based learning strategy using bingo was fundamentally designed around specific SRC learning outcomes that incorporated procedural and strategic SRC knowledge. Finally, Concussion Bingo keeps students engaged through competition among their teammates and facilitates discussion among participants and the teacher. Because Concussion Bingo requires participation and dialogue, this educational strategy may be a more advantageous educational platform than videos or web-based activities that are often completed individually.

One of the other benefits of Concussion Bingo is that it is a cost-effective educational tool for school districts and athletic programmes that may be lacking sufficient funding. Characteristically, schools that are deemed Title I schools serve the most socioeconomically disadvantaged communities. The vast majority of students attending Title I schools qualify for the Federal Free and Reduced Lunch programme (United States Department of Education Institute of Education Sciences, 2017). Often, Title I schools face problems inherent in poverty and funding for resources can be a challenge. Only 36% of high schools in the USA have access to a full-time athletic trainer and, unfortunately, Title I schools often do not have the funding to employ a full-time athletic trainer (Pryor et al., 2015). For Title I programmes, in addition to other sport programmes being mindful of funding, Concussion Bingo can be a cheaper alternative to deliver required concussion information. It requires access to a copier and presentation technology.

This study’s primary population of focus was urban, low-income schools; however, Concussion Bingo may be an effective educational tool for any athletic programmes lacking access to healthcare professionals such as athletic trainers, and alternatively any athletic programme aiming to provide an educational platform that actively involves the learner with the material. Concussion Bingo is easy to implement and execute with high school athletes. Delivery of Concussion Bingo can be completed by school administrators, coaches and other stakeholders using a script and can be done with both small and large groups. Concussion Bingo incorporates photos, graphics and lay terms to describe a SRC and teaches participants what to do should they believe they sustained an SRC.

Although any educational intervention should increase knowledge, the ultimate objective of any intervention is change in health behaviours. Changing health behaviours is complex, and concussion researchers are comparatively new to studying reporting behaviour change. Therefore, there is a need for programmes that foster knowledge and awareness, which may lead to improvements in SRC reporting behaviours or the intention to report a SRC. Knowledge is an important predictor of behaviour (Kroshus et al., 2014b; Register-Mihalik et al., 2013), but the assumption that the underreporting of concussion by athletes is solely due to a lack of knowledge should not be the primary focus of SRC educational programmes, because intention has been shown to be a better predictor of behaviour (Kroshus et al., 2014a). Motivational aspects of reporting that include psychosocial theories of health behaviours should be incorporated into the development of educational strategies (Kroshus et al., 2014b).

Reporting of a SRC and the intention to report have been studied by Kroshus et al. (2014a), and nested within constructs of reporting and the intention to report are the theory of planned behavior (TPB; Ajzen, 1991) and the Integrated Behavioral Model (Glanz et al., 2008). Using the TPB may help produce more effective educational programming that yields behaviour changes because it aims to address the specific psychoeducational concerns of a population (Ajzen, 1991; Kroshus et al., 2014b). Concussion Bingo was produced using TPB constructs because it was created to address the specific needs of disadvantaged high school athletes discovered in previous knowledge of concussion research (Wallace et al., 2018). Furthermore, approaching education by focusing on population-specific beliefs regarding the consequences of reporting, and using the Integrated Behavior Model to address environmental and team-specific constraints, could lead to an increase in athletes’ reporting of a SRC (Kroshus et al., 2014a, 2014b). A unique benefit of Concussion Bingo is that it is disseminated with the entire team and the programme creates an interactive environment between athletes, coaches, administrators and researchers in which the dangers of not reporting a concussion are discussed and a ‘buddy system’ of reporting can be established. This game-based, ‘team’ environment of concussion education could potentially be used to mitigate the perceived negative consequences of reporting at both the individual and team levels.

Thus, future research should examine the Concussion Bingo intervention pre-season and then post-season to see if this interactive intervention increases a student-athlete’s reporting of a SRC or intention to report. Future research should also focus on long-term knowledge retention to determine if Concussion Bingo maintains an athlete’s change in SRC knowledge following a sport season or year of sport participation. In addition, it would be valuable to investigate age differences to see if this Concussion Bingo game can be used with athletes under the age of 12.

Limitations

As with all studies, this study is not without its limitations. First, the knowledge of concussion instrument used in this study did not undergo rigorous psychometric testing to be defined a validated knowledge of concussion measure. Although the calculated Cronbach’s alpha for the knowledge of concussion construct was strong at .72, the calculated results should be prudently interpreted. Second, the study had a relatively small sample size and the majority of these student-athletes were male, African American football players; therefore, results cannot be generalised to other races or ethnicities, nor female athletes. Furthermore, this intervention only assessed short-term learning outcomes that included an immediate recall following the intervention. In addition, there was also a ceiling effect with respect to knowledge of more familiar symptoms of concussion, such as headache, in which 99% of the participants correctly identified on the pre-test. Finally, student-athletes completed the pre-test prior to eating a meal, and thus lower scores on the pre-test could be due to student-athletes rushing to complete the survey so they could get to the team meal faster. However, all student-athletes were asked to remain seated until everyone was finished with their survey and student-athletes took the same amount of time to complete the pre-survey as they did the post-survey.

Conclusion

Concussion education interventions should be co-created with community stakeholders and the community at stake in mind. Concussion Bingo was created to serve the fundamental needs of low-income, Title I communities that may be lacking access to an athletic trainer and lacking sufficient funding for resources to adequately inform athletes, parents and coaches about the seriousness of concussion. Student-athletes attending urban, Title I high schools and African American athletes lacking access to an athletic trainer have been shown to have a decreased understanding of concussion (Wallace et al., 2017a, 2018). Athletes from low-income families have been shown to be less likely to have received concussion education than athletes from more affluent families, and thus this population in need could benefit from interactive educational platforms (Donnell et al., 2018). Sending print materials home for athletes and parents to read and sign may not be the most appropriate educational tool for these communities. A lack of knowledge and understanding could be one of the driving factors limiting reporting in high school athletes. Game-based, active learning formats could assist in the transfer of concussion knowledge in underserved communities that may ultimately lead to reporting behaviour modifications.

Footnotes

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

Notes

ORCID iD

Jessica Wallace

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