Engaging Teammates in the Promotion of Concussion Help Seeking

Abstract

Concussion underreporting contributes to the substantial public health burden of concussions from sport. Teammates may be able to play an important role in encouraging injury identification and help seeking. This study assessed whether there was an association between beliefs about the consequences of continued play with a concussion and intentions to engage as a proactive bystander in facilitating or encouraging teammate help seeking for a possible concussion. Participants were 328 (male and female) members of 19 U.S. collegiate contact or collision sports teams. Athletes who believed that there were negative health or performance consequences of continued play with a concussion were significantly more likely than their peers to intend to encourage teammate help seeking, but not more likely to alert a coach or medical personnel. Additionally, athletes who believed that their teammates were more supportive of concussion safety were more likely to intend to engage as proactive bystanders in encouraging teammate help seeking. Exploring how to encourage bystander promotion of concussion safety is an important direction for future programming and evaluation research and may provide an opportunity to improve the effectiveness of concussion education.

Keywords

bystander concussion education norms sport

More than eight million high school and college athletes participate in organized interscholastic sport in the United States on an annual basis (National Collegiate Athletic Association [NCAA], 2013; National Federation of High School Sports, 2014). While there are many positive benefits of organized sport participation (Bailey, 2006; Fredricks & Eccles, 2006), there is also risk of harm from injury. In many sports that involve contact or collision, not just American football, concussions are among the most frequently sustained injuries (Hootman, Dick, & Agel, 2007). Most athletes who sustain a concussion will recover within 2 weeks and not experience lasting neurologic consequences (McCrea et al., 2013). However, athletes who sustain multiple concussions can face longer lasting symptoms (Chrisman, Rivara, Schiff, Zhou, & Comstock, 2013; Corwin et al., 2014; Eisenberg, Andrea, Meehan, & Mannix, 2013; Iverson, Echemendia, LaMarre, Brooks, & Gaetz, 2012) and potentially health difficulties later in life (Kerr, Evenson, et al., 2014; Kerr, Marshall, Harding, & Guskiewicz, 2012; Lehman, Hein, Baron, & Gersic, 2012; McCrory, Meeuwisse, Kutcher, Jordan, & Gardner, 2013). The incidence of repeat concussions does not appear to be randomly distributed: The brain is in a metabolically vulnerable state while recovering from the initial injury (Prins, Alexander, Giza, & Hovda, 2013), making it more likely that an athlete who experiences an additional impact during this period will sustain a concussion (Echlin, Tator, et al., 2010; Guskiewicz, Weaver, Padua, & Garrett, 2000; McCrea et al., 2009; Zemper, 2003).

Reducing the health burden of concussions is a multifactorial endeavor (Benson et al., 2013). The most certain approach is primary prevention: limiting exposure to the initial brain trauma. However, given the potential for increased harm as a result of additional impacts sustained while an athlete is symptomatic after their initial injury, secondary prevention—early identification and care provision—also plays a critical role in harm reduction (McCrory, Meeuwisse, Aubry, et al., 2013). Despite the importance of the secondary prevention, many athletes continue playing their sport while experiencing symptoms of a concussion. At the collegiate level, estimates suggest that at least half of all concussions are not diagnosed (Delaney, Lamfookon, Bloom, Al-Kashmiri, & Correa, 2015; Llewellyn, Burdette, Joyner, & Buckley, 2014; Torres et al., 2013).

Concussion education for athletes is one approach to reduce the incidence of continued play while symptomatic. Concussion education programs to date, evaluations of which have been conducted almost exclusively in samples of male athletes, have focused on increasing concussion knowledge and changing attitudes, with a goal of encouraging injured athletes to report their symptoms (Bagley et al., 2012; Cusimano, Chipman, Donnelly, & Hutchison, 2014; Echlin, Johnson, et al., 2010; Kroshus, Baugh, Hawrilenko, & Daneshvar, 2015; Kroshus, Daneshvar, Baugh, Nowinski, & Cantu, 2014; Manasse-Cohick & Shapley, 2013; Miyashita, Timpson, Frye, & Gloeckner, 2013). However, deliberative cognitions of the injured athlete only explain a relatively small fraction of variability in underreporting (Kroshus, Baugh, Daneshvar, & Viswanath, 2014; Kroshus, Kubzansky, Goldman, & Austin, 2014; Register-Mihalik et al., 2013). This may be because the injured athlete is in a state of heightened arousal due to exertion, the competitive situation, and their emotional response to injury (Tracey, 2003; Vast, Young, & Thomas, 2010), and decision making under these conditions tends to be nondeliberative and reactive (Figner, Mackinlay, Wilkening, & Weber, 2009; Reyna & Farley, 2006). Consequently, educational programming, framed by theories such as the Theory of Planned Behavior (Ajzen, 1991), which presume that the injured athlete is making deliberative expectancy value calculations, may be of limited relevance to on-field injury-reporting decisions. Another possible reason for the low explanatory power of expectancy value theories could be that an athlete who sustains brain trauma may not always be able to accurately appraise their situation: Symptoms of concussions can include cognitive issues such as confusion. Consequently, there may be a limit to the utility of educational approaches that focus solely on encouraging deliberative, rational behavior by the injured athlete.

Consistent with a more expansive social ecological approach to increasing concussion disclosure (Kerr, Register-Mihalik, et al., 2014), stakeholders on the sidelines—chiefly medical personnel, but in some cases coaches and parents—are now often provided with educational training to help identify potentially concussed athletes (Chrisman, Schiff, Chung, Herring, & Rivara, 2014). This is an important but insufficient solution to the problem of concussion underdiagnosis. Not all teams have an athletic trainer or physician present at games and practices (Pryor et al., 2015). Even if medical personnel are present, their attention is often split between multiple athletes or may be directed off the field of play as they manage another athlete’s injury. The attention of coaches is also understandably often directed elsewhere. To date, there has been no focus on the role that uninjured teammates can play in encouraging teammate help seeking for a suspected concussion. Relevant teammate bystander behaviors might include asking a teammate who just sustained an impact how they are doing, encouraging a teammate who appears symptomatic to get checked out by medical personnel, or letting a coach or clinician know that a teammate may be symptomatic.

Understanding what makes an athlete more or less likely to encourage or facilitate teammate help seeking can inform the development of targeted programming to increase this important behavior. Latane and Darley (1970) have provided a generalized five-step framework for understanding the likelihood that an individual intervenes as a bystander. The first two steps involve the individual noticing the situation and classifying it as problematic (Latane & Darley, 1970). Across a range of domains, individuals who are more aware of a problem tend to be more likely to help (Dovidio, Piliavin, Schroeder, & Penner, 2006). With respect to concussions, this could include identifying symptoms of a possible concussion, or identifying potentially dangerous impacts. The athlete must also believe that unreported concussions are harmful. Dimensions of harm could include how continued play while symptomatic could harm the team’s athletic performance or how it could harm the injured athlete’s health. Subsequently, individuals must decide that they are responsible for action, decide on an action, and then engage in that action. Collectively, these steps in the decisional process involve balancing the costs and benefits of intervening. The decisional balance between perceived costs and benefits is an important predictor of behavior, with intervention most likely in situations where perceived benefits exceed costs (Banyard & Moynihan, 2011; Bénabou & Tirole, 2005; Darley & Latane, 1968).

While these steps provide an organizing framework for thinking about bystander intervention, there are group-level modifiers that may be particularly relevant to the conceptualization of bystander intervention on sports teams. Intervention in groups is most likely to occur when the group considers the issue important and when there is a strong group norm in support of action (Frings, Abrams, Randsley de Moura, & Marques, 2010). Athletes who believe that their teammates would not report symptoms may believe that their team considers the issue of concussion reporting to be of relatively low importance. Perceived team reporting norms could thus influence the likelihood of bystander intervention by influencing the cost–benefit analysis that occurs during the decisional process (Latane & Darley, 1970): Intervening when others on your team do not support your action may carry with it the cost of being considered deviant within that context. Consistent with the Theory of Social Control (Chekroun & Brauer, 2002), perceived team norms of nonintervention could be further reinforced by observing teammate inaction when another team member sustains an impact that might warrant concern. The bystander effect, which has been tested across numerous domains, finds that the more individuals there are witnessing an event the less likely any one individual is to intervene (Darley & Latane, 1968). The structure of sports teams means that numerous people are necessarily proximate to the injured athlete if the injury occurs during a game or organized practice.

No research to date has addressed the role that teammates might play in the secondary prevention of concussions. Additionally, concussion-related research has tended to focus on the experience of male collegiate athletes in the sports of football and ice hockey at highly competitive levels; however, the majority of collegiate student-athletes at risk for concussion compete in other contact or collision sports and at levels other than the highest profile Division I teams (NCAA, 2013), and many are female. Consequently, the present study focused on the experience of male and female athletes competing in contact or collision sports other than ice hockey or football, and at institutions that are not a member of a “Power 5” conference, a designation given to what are typically the five most competitive NCAA Division I athletic conferences (NCAA, 2014b). The present study describes concussion-related bystander intentions of these collegiate athletes. It tests the hypotheses that athletes who perceive there to be a health or athletic performance threat of continued play with a concussion would be more likely to intend to intervene as bystanders—encouraging teammate help seeking or alerting the team’s coach or medical personnel. It also assesses whether the association between these beliefs about concussions and bystander intentions are moderated by perceived team concussion reporting norms. Characterizing the extent and predictors of bystander intervention among athletes can help inform the design of bystander-focused educational programming to help reduce the substantial public health burden of concussion underreporting.

Method

Sample and Procedure

Participants were male and female collegiate athletes who were current members of a contact or collision sports team at one of four colleges located in the northeast region of the United States. Institutions designated as a member of a “Power 5” athletic conference (NCAA, 2014b)were not included in the sampling frame. Twelve institutions were invited to participate in the study, and the institutional participation rate was 25%. There were no significant differences between the four participating and eight nonparticipating institutions in the number of athletic teams sponsored, division of athletic competition, undergraduate enrollment, mean test scores of entering undergraduate students, or whether the institution was funded publically or privately. At participating institutions, a total of 19 contact or collision teams took part in the research study, and the within-institution team participation rate was 54%. Teams were classified as contact or collision according to the listing in the NCAA Sports Medicine Handbook (NCAA, 2014a). Football and ice hockey teams were not included in the sampling frame. Sports included in the sample were soccer (six teams), lacrosse (three teams), basketball (three teams), baseball (three teams), field hockey (two teams), volleyball (one team), and softball (one team). The number of participants on each team ranged from 6 to 29 (M = 17, SD = 6). From these teams, there were a total of 328 participating athletes, and the within-team participation rate was 74%. The percentage of the sample from each participating school was 34.8%, 22.9%, 22.5%, and 19.8%, respectively. Across the full sample, 53% of participants were female, and 47% male.

The same individual met with each team in person, obtained informed consent, and administered an anonymous paper survey in a group setting. All surveys were completed between the months of January and April of 2014. The Harvard School of Public Health Institutional Review Board approved all research activities.

Measures

Beliefs About Continued Play While Symptomatic

Using items drawn from Rosenbaum and Arnett’s (2010) Concussion Knowledge Index, participants responded to two binary response questions about the health and athletic consequences of continued play while symptomatic: “There is a possible risk of death if a second concussion occurs before the first one has healed” (yes = 1, no = 0); and “Even if a player is experiencing the effects of a concussion, his performance on the field of play will be the same as it would be had he not suffered a concussion” (no = 1, yes = 0).

Bystander Intentions

Participants responded to two questions about their bystander intentions: “If I think a teammate has sustained a concussion, I intend to encourage them to tell our coach and/or sports medicine staff”; and “If I think a teammate has sustained a concussion, I intend to alert our coach and/or sports medicine staff.” These items were scored on 7-point Likert-type scales, with response options ranging from strongly disagree to strongly agree. Due to nonnormal distribution of both bystander intention variables, all responses indicating a lack of intention to engage in bystander behaviors (scores of 1, 2, 3, or 4 on the 7-point Likert scale) were collapsed into a single scale point. The resulting bystander variables were thus analyzed on a 4-point scale, with higher values indicating greater bystander intentions.

Team Concussion Reporting Norms

Participants responded to six concussion reporting scenarios provided in Rosenbaum and Arnett’s (2010) Concussion Attitude Index. One scenario read, “Player R suffers a concussion during a game. Coach A decides to keep Player R out of the game. Player R’s team loses the game.” Instead of indicating what “most athletes” would do, as was measured in the original items, respondents indicated what their “teammates” would do. For the aforementioned scenario, the response prompt read, “My teammates would feel that Coach A made the right decision to keep Player R out of the game.” Each item was scored on a 7-point Likert-type scale, with the six items summed for a maximum scale value of 42. Higher scores indicated safer perceived teammate concussion reporting norms. The internal consistency reliability of the measure was adequate (Cronbach’s α = .76).

Other Characteristics

Participants indicated the number of concussions they had ever had diagnosed by a medical professional, their sex, and their current year in school.

Analysis

Pairwise Pearson correlations, with Bonferroni corrections for multiple comparisons, were conducted with the bystander intention variables, concussion reporting belief variables, sex, year in school, and number of previously diagnosed concussions. Multivariable linear regression was used to separately assess the association between concussion reporting beliefs and bystander intentions. Within each model predicting the specific bystander intention, moderation of the association by perceived concussion norms was also assessed. The continuous norms variable was mean centered when creating interaction terms to reduce nonessential multicollinearity. Based on the results of the initial bivariate correlations, only the athletes’ sex was included as an additional independent variable in all multivariable regression models. All multivariable linear regression models used clustered robust standard errors to account for possible team-level nonindependence. An alpha level of <.05 was the threshold for statistical significance. All analyses were completed in STATA 12.1 (College Station, TX).

Results

Sample characteristics are reported in Table 1, and Pearson pairwise correlations are reported in Table 2. Most athletes (85%) indicated that they intend to encourage a teammate who they suspect has sustained a concussion to seek medical attention. Fewer athletes—around half (56%)—indicated that they intend to alert a coach or medical personnel about a teammate’s suspected concussion. There were significant differences in bystander intentions by the athlete’s sex and perceived team norms but not by their year in school or number of previously diagnosed concussions.

Table 1.

Descriptive Statistics.

Variable	% (n)
Sex
Female	53.05% (174)
Male	46.95% (154)
Year in school
First year	33.33% (109)
Second year	26.91% (88)
Third year	24.77% (81)
Fourth year	14.68% (48)
Diagnosed concussions
Zero	58.72% (192)
One or more	41.28% (135)
Belief—Performance^a	80.43% (264)
Belief—Health^b	86.85% (285)
	Mean (SD)
Bystander intention—Teammate^c	5.95 (1.30)
Bystander intention—Coach^d	5.33 (1.66)
Perceived team norm^e	32.54 (5.77)

Response to statement, “There is a possible risk of death if a second concussion occurs before the first one has healed” (1 = yes and 0 = no). ^bResponse to statement, “Even if a player is experiencing the effects of a concussion, his performance on the field of play will be the same as it would be had he not suffered a concussion” (1 = no and 0 = yes). ^cResponse to statement, “If I think a teammate has sustained a concussion, I intend to encourage them to tell our coach and/or sports medicine staff” (1 = strongly disagree to 7 = strongly agree). ^d“If I think a teammate has sustained a concussion, I intend to alert our coach and/or sports medicine staff” (1 = strongly disagree to 7 = strongly agree). ^ePerceived team concussion reporting norm, scale range of 7 to 42, with higher values indicating a greater belief that teammates would engage in safe concussion reporting behaviors.

Table 2.

Pairwise Correlation Tables (N = 328).

	Belief—Health	Belief—Performance	Team Norm	Year in School	Sex	Bystander Intention—Team	Bystander Intention—Coach
Belief—Health^a	1.00
Belief—Performance^b	−0.10	1.00
Team Norm^c	0.11	0.12	1.00
Year in School	0.10	0.01	0.02
Sex	0.02	−0.10	−0.24**	0.07	1.00
Bystander Intention—Team^d	0.11	0.18*	0.42***	0.07	−0.22*	1.00
Bystander Intention—Coach^e	0.04	0.09	0.38***	0.06	−0.03	0.67***	1.00
Diagnosed concussions^f	−0.02	0.09	0.03	0.07	−0.04	−0.05	−0.11

Response to statement, “There is a possible risk of death if a second concussion occurs before the first one has healed” (1 = yes and 0 = no). ^bResponse to statement, “Even if a player is experiencing the effects of a concussion, his performance on the field of play will be the same as it would be had he not suffered a concussion” (1 = no and 0 = yes). ^cPerceived team concussion reporting norm, scale range of 7 to 42, with higher values indicating a greater belief that teammates would engage in safe concussion reporting behaviors. ^dResponse to statement, “If I think a teammate has sustained a concussion, I intend to encourage them to tell our coach and/or sports medicine staff” (higher scores indicate greater intention). ^e“If I think a teammate has sustained a concussion, I intend to alert our coach and/or sports medicine staff” (higher scores indicate greater intention). ^fNumber of concussions diagnosed over the respondent’s lifetime.

p < .05. **p < 0.01. ***p < .001. Significance levels Bonferroni adjusted for multiple comparisons.

Results of multivariable linear regression describing the predictors of intention to encourage a teammate with a suspected concussion to seek medical attention are reported in Table 3. Beliefs about both the health and performance consequences of continued play were independently associated with bystander intention in models including the athlete’s sex and history of diagnosed concussion (Models 1.1 and 2.1). When adding perceived team reporting norms to the respective models, the association between beliefs about performance consequences of continued play while symptomatic, but not beliefs about health consequences, remained significantly associated with bystander intentions (Models 1.2 and 2.2). Norms were significantly associated with bystander intentions in all models tested. The interaction between beliefs about health consequences of continued play and perceived team reporting norms was significantly associated with bystander intentions (Model 1.3). This suggests that among athletes who believe that there is a health threat of continued play with a concussion, perceived team reporting norms and bystander intentions are less positively associated than among athletes who do not believe there is a health risk of continued play. The interaction between norms and belief about performance consequences of continued play was not significantly associated with intentions to encourage teammate help seeking (Model 2.3). Female athletes were more likely than males to intend to encourage teammate help seeking. This difference was no longer significant when perceived teammate reporting norms were added to the models.

Table 3.

Multivariable Linear Regression Predicting Bystander Intentions to Encourage a Teammate With a Suspected Concussion to Seek Medical Attention (N = 328).

Variable	Model 1.1, B (SE)	Model 1.2, B (SE)	Model 1.3, B (SE)	Model 2.1, B (SE)	Model 2.3, B (SE)	Model 2.3, B (SE)	Model 3.1, B (SE)	Model 3.2, B (SE)
Belief—Health^a	0.36 (0.17)*	0.23 (0.14)	0.19 (0.13)				0.41 (0.17)*	0.28 (0.14)
Belief—Performance^b				0.55 (0.22)*	0.48 (0.20)*	0.43 (0.20)*	0.60 (0.22)*	0.51 (0.20)*
Team norm^c		0.08 (0.01)***	0.12 (0.01)***		0.08 (0.01)***	0.11 (0.03)***		0.08 (0.01)***
Belief—Health × Team norm			−0.05 (0.02)**
Belief—Performance × Team norm						−0.03 (0.02)
Sex (ref = female)	−0.50 (0.19)*	−0.30 (0.16)	−0.32 (0.17)	−0.46 (0.19)*	−0.27 (0.16)	−0.27 (0.16)	−0.46 (0.19)*	−0.28 (0.17)
Concussion ever diagnosed (ref = zero)	−0.36 (0.10)*	−0.33 (0.09)***	−0.34 (0.08)***	−0.37 (0.10)**	−0.35 (0.09)	−0.35 (0.09)**	−0.38 (0.09)**	−0.36 (0.09)***
R ²	0.088	0.255	0.268	0.100	0.270	0.273	0.123	0.280

Note. Clustered robust standard errors used to account for potential team-level nonindependence. Models 1.1, 1.2, and 1.3 are multivariable linear regression including belief about health outcomes of continued play with a concussion as an independent variable; Models 2.1, 2.2, and 2.3 are multivariable linear regression including belief about performance outcomes of continued play with a concussion as an independent variables; Models 3.1 and 3.2 include both health and performance beliefs as independent variables. Bystander intention measured on a 4-point scale with higher scores indicating greater intentions to engage as a bystander.

p < .05. **p < .01. ***p < .001.

Table 4 reports the results of multivariable linear regression predicting intention to alert a coach or team medical personnel about a teammate’s suspected concussion. Beliefs about the health consequences or performance consequences of continued play with a concussion were not significantly associated with bystander intention in any of the models tested. Perceived team reporting norms were associated with bystander intentions in all models. The interaction between norms and beliefs about health consequences was not significantly associated with bystander intentions (Model 1.3). However, the interaction between perceived norms and performance beliefs was significantly associated with intentions to alert the team coach or medical personnel about a teammate’s suspected concussion (Model 2.3). This suggests that among athletes who consider there to be a performance cost of continued play with a concussion, team norms are less strongly associated with intentions than among athletes who do not believe there is a performance cost of continued play. There were no significant differences between male and female athletes in their intentions to alert the team coach or clinician about a teammate’s suspected concussion.

Table 4.

Multivariable Linear Regression Predicting Bystander Intentions to Alert Team Coach or Medical Personnel That a Teammate May Have Sustained a Concussion (N = 327).

Variable	Model 1.1, B (SE)	Model 1.2, B (SE)	Model 1.3, B (SE)	Model 2.1, B (SE)	Model 2.2, B (SE)	Model 2.3, B (SE)	Model 3.1, B (SE)	Model 3.2, B (SE)
Belief—Health^a	0.19 (0.17)	0.04 (0.16)	0.04 (0.15)				0.22 (0.18)	0.06 (0.16)
Belief—Performance^b				0.33 (0.20)	0.23 (0.16)	0.16 (0.16)	0.35 (0.20)	0.24 (0.16)
Team norm^c		0.09 (0.01)***	0.09 (0.02)***		0.09 (0.02)***	0.14 (0.02)***		0.09 (0.01)***
Belief—Health × Team norm			0.01 (0.02)
Belief—Performance × Team norm						−0.06 (0.02)*
Sex (ref = female)	−0.13 (0.17)	0.09 (0.15)	0.09 (0.15)	−0.11 (0.17)	0.10 (0.15)	0.10 (0.15)	0.11 (0.17)	0.10 (0.15)
Concussion ever diagnosed (ref = 0)	−0.46 (0.15)**	−0.45 (0.13)**	−0.45 (0.13)**	−0.47 (0.15)**	−0.46 (0.13)**	−0.45 (0.13)**	−0.47 (0.15)***	−0.46 (0.13)**
R ²	0.037	0.190	0.191	0.041	0.194	0.202	0.046	0.195

p < .05. **p < .01. ***p < .001.

Discussion

Encouraging teammates to serve as proactive bystanders expands the number of individuals engaged in the secondary prevention of harm from concussions. A bystander approach to concussion identification does not remove the need for individual honest disclosure as symptoms are not necessarily apparent to outside observers, and it does not mean that teammates should bear final responsibility for each other’s health behaviors. However, given the endemic nature of concussion underreporting, it may be an important step toward creating a culture of concussion safety on sports teams.

Consistent with a decisional balance approach to bystander intervention in which costs and benefits of intervention influence bystander behavior (Bénabou & Tirole, 2005; Latane & Darley, 1970), the present study found that athletes who believed that there were negative health or performance consequences of continued play with a concussion were significantly more likely to intend to encourage teammate help seeking than were their peers who did not hold these beliefs. However, the athletes’ beliefs about health or performance consequences of continued play were not associated with their intentions to alert a coach or medical personnel about a teammate’s suspected concussion. These results suggest that a different decisional calculus may be influencing cognitions about encouraging teammate help seeking as compared to alerting the team coach. Regardless of the possible harm of the injury, it is possible that the act of circumventing the injured teammate to tell the team coach or medical personnel could be viewed as compromising the injured athlete’s autonomy or of violating some implicit code of team membership, and may thus be perceived negatively by teammates.

Consistent with existing evidence about the role that group norms pertaining to help seeking play in influencing intervention in groups (Chekroun & Brauer, 2002; Frings et al., 2010), athletes who thought that teammates would be more likely to support reporting symptoms of a suspected concussion were more likely to intend to intervene as a bystander to encourage teammate help seeking or to alert a coach or medical personnel about a teammate’s suspected concussion. Perceived norms were less strongly associated with intentions to alert a coach or medical personnel when the athlete believed that there was a performance consequence of continued play with a concussion. This may reflect a belief that deviating from normative team behaviors is more acceptable if it is in support of another team goal, such as winning. Ensuring that all athletes and coaches are aware of the performance consequences of continued play while symptomatic after a concussion may thus be critical information to communicate in concussion education initiatives. It may also be important for coaches to communicate explicitly to their team that health and safety—and not just athletic performance—is valued.

At most levels of sport, athletes are currently required to receive preseason concussion education. Currently, this education tends to focus on the athlete’s own risk and help-seeking behaviors. Incorporating messaging into this education about how being a good teammate means saying something if you suspect a teammate may have sustained a concussion is a low-burden modification that could help increase bystander behaviors in support of concussion safety. Those designing new concussion education interventions should consider adding a bystander component to their programming and evaluating whether safety attitudes, norms, and behaviors are improved on teams that receive education with this approach as compared to those who receive similar programming that lacks a bystander component. However, it is critical to note that it is unlikely that a one-time concussion education program will be sufficient to change a team’s concussion reporting culture, whether or not it focuses solely on the athlete’s own reporting behaviors, or also includes content encouraging bystander intervention. Consequently, there is a need for program development and evaluation research to explore strategies for extending safety-oriented messaging across the season and building it naturalistically into the team’s discourse, rather than simply being something that is delivered prior to the start of the season by an outside authority. For example, coaches and team captains could be enlisted to reinforce safety messaging at discrete points in time throughout the season, supporting the perception that concussion safety is a valued team behavior.

There may also be opportunities to incorporate concussion-focused education into existing bystander programming that is not currently focused on concussion. The NCAA provides a bystander training program for collegiate athletes called Step UP! (Long, 2012), teaching team members to intervene to address a range of health and safety issues that their teammates might experience. Building a module about concussion-related bystander behaviors into this existing theory-driven programming structure is a feasible approach to disseminating bystander training for athletes in contact and collision collegiate sport.

Limitations

A primary limitation of this study is the focus on intended rather than actual behaviors. Prospective research is needed to understand the extent to which bystander intentions and cognitions about concussion safety are in fact related to bystander behavior over the course of a competitive season.

Additionally, the results of this study may not generalize to all sports, schools, or levels of competition. It is important to note that much of the existing research on concussions has focused on male ice hockey and football. The present study intentionally focused on lower profile male and female sports where concussions are also prevalent. Future research should include ice hockey and football, along with the sports sampled in this study, as well as athletes at different ages and levels of competition to get a better idea of how the present results generalize across different populations of athletes. Additionally, generalizability may be limited due to institutional and coach self-selection. Although there were no apparent differences between participating and nonparticipating institutions, it is possible that the institutions and coaches choosing to allow student-athletes to participate in the present study prioritize concussion safety differently than nonparticipating institutions.

The heterogeneity of the sample in terms of the sports represented by school may also limit generalizability to a specific sport context, and it is possible that teams with more participants disproportionately influenced the results despite the use of clustered robust standard errors to account for possible team-level nonindependence in all linear regression analyses. However, future research in a larger sample is encouraged to model sport and team-specific effects to understand whether there are sport and/or team-specific influences on concussion help-seeking behavior.

The single-item nature of the bystander intention questions themselves may also be a limitation. Using vignettes to make the bystander behavior more vivid and contextualized and describing bystander behavior in specific decisional settings may help increase the robustness of the measures. Future research is encouraged to build more comprehensive models of the cognitions predictive of bystander intervention, incorporating all stages of Latane and Darley’s (1970) framework for bystander intervention.

Conclusions

The present findings suggest that athletes who are more aware of the potential harms associated with continued play while symptomatic after a concussion are more likely to intervene as bystanders; however, this awareness appears to be more important for intentions to communicate with teammates rather than coaches or clinicians. Perhaps most critically, perceived team concussion reporting norms were found to be strongly associated with bystander intentions and to moderate the association between awareness of concussion reporting harms and bystander intentions. These findings provide a starting point for additional research and program development work to appropriately engage teammates as bystanders in the secondary prevention of harm from concussions.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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