Abstract
Despite state laws requiring concussion education for youth sport stakeholders and a proliferation of educational programs, there has been little demonstrated impact on concussion reporting behaviors. We propose that this is because of four key limitations to existing approaches to concussion education: (1) deliberative decision making by the injured athlete is assumed, (2) interventions are often targeted at individuals rather than social systems, (3) education occurs once during preseason and is forgotten, and (4) dissemination challenges exacerbate health inequalities. Addressing these limitations, we propose a novel theoretic framework that situates individual behavior within a sport system’s culture and their broader structural context. Concussion education programs should seek to facilitate safety-supportive interpersonal communication within and between stakeholder groups and influence attributes of groups that drive behavior, including shared values. Addressing the limitations outlined and drawing on the proposed conceptual framework, we describe a novel approach to concussion education: pregame safety huddles.
Keywords
Every year, more than one million youth (age ≤18 years) are diagnosed with a concussion as a result of their participation in sport or recreational activities (Bryan, Rowhani-Rahbar, Comstock, Rivara, & Seattle Sports Concussion Research Collaborative, 2016). Sports that involve routine contact and collision, such as football, soccer, ice hockey, and wrestling, pose the greatest risk for concussion (Marshall, Guskiewicz, Shankar, McCrea, & Cantu, 2015). The Institute of Medicine report on concussions in youth sport (Graham, Rivara, Ford, & Spicer, 2013) identified an urgent need to decrease the health burden of concussion by reducing the incidence of injury and ensuring that when concussions do occur, athletes are immediately removed from play. Athletes who delay care seeking tend to have a longer recovery time (Asken et al., 2016). Moreover, during the symptomatic period postconcussion, the brain is in a vulnerable state during which an additional impact could have magnified neurologic consequences (Cantu, 1998). All states now have laws requiring athletes with a suspected concussion be removed from play. However, because symptoms of concussion (e.g., headache or difficulty concentrating) are not observable, early identification often relies on disclosure of symptoms to a referee, coach, or parent. As a result, estimates suggest that up to 50% of concussions go unreported and undiagnosed (Kroshus, Baugh, Stein, Austin, & Calzo, 2017; Llewellyn, Burdette, Joyner, & Buckley, 2014; Meehan, Mannix, OʼBrien, & Collins, 2013; Register-Mihalik, McLeod, Linnan, Guskiewicz, & Marshall, 2017).
Increased public awareness of the risk for concussion in youth sports in response to concussion research, legislation, lawsuits, and the media has fueled the development of multiple interventions aimed at decreasing concussion risk. However, concussions continue to occur, and concussion underreporting continues to be endemic (Llewellyn et al., 2014; Meehan et al., 2013; Register-Mihalik et al., 2017). Grounded in a social ecological model, Emery, Hagel, and Morrongiello (2006) proposed that the focus of risk reduction efforts in youth sport should be on rule changes oriented toward primary prevention. Such efforts should be a central focus of work to reduce the health burden of concussion. Nonetheless, education is still a focal element of state-level concussion policies, and it is one of the few ways to affect secondary prevention. Thus, we believe that existing educational paradigms should be revisited. We describe below four key limitations to existing concussion education approaches. We then propose a novel theoretic framework and approach to concussion education to address these limitations.
Limitation 1: Deliberative Decision Making by the Injured Athlete Is Assumed
A recent scoping review of concussion education programs with published evaluations (Caron, Bloom, Falcão, & Sweet, 2015) described content as inclusive of factual information related to injury prevention (e.g., risk-reducing techniques), injury recognition (e.g., mechanisms of injury, signs and symptoms), and injury management (e.g., return-to-play guidelines). Such education presumes that if athletes are aware of these important facts, they will make a rational decision to remove themselves from play if a concussion is suspected. However, what individuals intend to do, as mentally constructed while sitting quietly in a classroom or at home, may look very different from what they actually do in the middle of an important game. Intervention approaches that presume rationality do not capture the reactive and emotional processes that are at work when decisions are made under stress or physiologically arousing conditions (e.g., the middle of a sports game). In such conditions, decisions are less likely to be made deliberatively and more likely to be made using associative processes and in response to the immediate context (Figner & Voelki, 2004, Reyna & Farley, 2006; Vast, Young, & Thomas, 2010). This has been described by Kahneman (2003) as “System I” to distinguish it from slower rational thinking “System II.” In such decisional environments, contextual cues and an individual’s self-concept have a powerful influence on their willingness to engage in target behaviors (Gerrard, Gibbons, Houlihan, Stock, & Pomery, 2008). In addition to these challenges to rational and deliberative decision making, we must also remember that athletes who are experiencing significant cognitive impairment due to injury may not be best positioned to report symptoms. Thus, it is essential that coaches, athletes, and parents are all aware of the symptoms of concussion and the risk of continuing to play and are empowered to speak up if they think that someone else has sustained a concussion (i.e., “bystander” reporting; Kroshus, Garnett, Baugh, & Calzo, 2016). Athletes play a particularly important role in this regard, as they are both the most familiar with and the most proximate to their teammates on the field. However, at present no evaluated educational programming for athletes has demonstrated effectiveness in supporting this bystander role. Further program development and evaluation work is also needed to support coaches as prosocial bystanders. Caron et al.’s (2015) scoping review only found one coach concussion education program with published evaluation data that met their inclusion criteria; however, many sports organization (e.g., USA Football) provide education to their coaches about concussion (Kerr, Kroshus, Lee, Yeargin, & Dompier, 2018). Further program evaluation work is needed in all youth sport stakeholder group to ensure that the programming being delivered is effective in supporting concussion safety–related behaviors and in particular the role of prosocial bystanders in facilitating concussion identification and early care seeking.
Limitation 2: Interventions Are Targeted at Individuals Rather Than Social Systems
Some of the strongest drivers of behavior related to concussion safety are the product of the web of interconnected interpersonal interactions between youth sport stakeholders (Baugh, Kroshus, Daneshvar, & Stern, 2014; Kerr et al., 2014; Kroshus, Baugh, Daneshvar, & Viswanath, 2014; Kroshus, Garnett, Baugh & Calzo, 2016; Kroshus, Garnett, Hawrilenko, Baugh, & Calzo, 2015; Register-Mihalik et al., 2013). There is thus a critical need to intervene at a systems level to address the behaviors between and within different stakeholder groups that shape the culture of youth sport. These stakeholders include, but are not limited to, athletes, coaches, parents, and referees/officials (Kroshus, Parsons, & Hainline, 2017). Across all of the concussion education programs included in Caron et al.’s (2015) scoping review, athletes and coaches were educated in silos (e.g., not integrated with other stakeholder groups). This review did not find any published evaluation of education for referees/officials or parents. The win-at-all-costs mentality that characterizes professional sport is present in many youth sport contexts (Fenoglio & Taylor, 2014). Behaviors that reinforce the value of winning over the value of safety, such as playing through injury, have been identified as a threat to healthy youth sport participation among both boys and girls (DiFiori et al., 2014). Youth sport is influenced by broader cultural messages about what it means to be an athlete, and the culture of a team or youth sport organization is the product of the values, norms, and interpersonal interactions in that unique context (Bandura, 2001; Ostroff, Kinicki, & Tamkins, 2003; Schein, 1990). Team values do not necessarily reflect the values of all team members, but they provide a guide for the types of actions viewed as desirable by the group (Shier, Khodyakov, Cohen, Zimmerman, & Saliba, 2014; Verplanken & Holland, 2002). Although teams can espouse certain values, they only influence behavior if they are substantiated by actions consistent with those values. For example, a youth football organization may state that they value fun and safety; however, if rules related to safety (e.g., outlawing spearing or other dangerous collisions) are not enforced, or if coaches and teammates discourage athletes from reporting concussion symptoms, the stated organizational “value” will be undermined and another value (e.g., winning at all costs) will be assumed. Team values and norms influence behavior by providing information about the potential social costs or benefits of performing specific behaviors (Boer & Fischer, 2013; Cialdini & Trost, 1998). If an athlete thinks that their teammates and coach care about safety (value) and would want them to speak up if they think that they or a teammate have a concussion (norm), they are more likely to speak up. Values must be salient to influence behavior. During a game, teams can hold simultaneous and potentially competing values (i.e., safety vs. winning), and the more strongly the value of safety is activated, the more likely it will influence behavior (Rohan, 2000; Verplanken & Holland, 2002). Appraisals about the salience of a value often occur through a reactive or emotional process (System I). Amid intense game play, athletes are unlikely to make deliberative (System II) decisions, and instead are likely responding out of emotion and habit (Kahneman, 2003). Reinforcing values of safety repeatedly throughout the season with all key stakeholders and ensuring that interpersonal interactions are supportive of safety should make all involved more likely to behave in a safe manner.
Limitation 3: Education Occurs Once During Preseason and Is Forgotten
All of the concussion education programs included in Caron et al.’s (2015) scoping review were delivered during the preseason or at one point in time during the season. Across a range of domains, psychosocial-educational programming conducted at one time point rarely results in sustainable behavior change (Fleig, Pomp, Schwarzer, & Lippke, 2013). Reinforcing messaging at intervals sufficiently spaced apart can solidify learning for behaviors that are enacted through deliberative cognitive processes (Kowash, Pinfield, Smith, & Curzon, 2000; McBride, 2003). Timing and frequency of interventions also matter for changing behaviors that are enacted through reactive or emotional processes. Practicing a behavior frequently helps it become more automatic (Bandura, 1986; Montano & Kasprzyk, 2008). Providing “cues” or reminders about core intervention components throughout the athletic season has the potential to cognitively activate these core components and thus facilitate action (Montano & Kasprzyk, 2008). Message brevity will be critical for making more frequent educational messaging feasible and acceptable within sport settings. This may also help with athlete attention and recall of messages (Kroshus, Baugh, Hawrilenko, & Daneshvar, 2015), as brief and frequent messaging is being increasingly trialed as a health education strategy for adolescents in other domains (Jones, Eathington, Baldwin, & Sipsma, 2014).
Limitation 4: Dissemination Challenges Exacerbate Health Inequalities
A fundamental challenge to interventions across disciplines is sustaining programming at the end of a period of funding and external researcher engagement. Developing a complex psychosocial-educational intervention that requires substantial resources and programmatic support is not a strategy for sustainable change (Greenhalgh, Robert, Macfarlane, Bate, & Kyriakidou, 2004) and may exacerbate health inequities (Bernard et al., 2007; Frohlich & Potvin, 2008). There is some evidence to suggest that this may be the case with concussion. For example, in youth football, USA Football leagues located in lower socioeconomic status communities tend to have a lower percentage of coaches complete online concussion education training (Kroshus, Kerr, & Lee, 2017). A first step in addressing these challenges is engaging members of diverse communities in the intervention and dissemination planning process (Gustafson et al., 2003; Rogers, 2003). Interventions must also be flexible and adaptable to local challenges, organizational structures, and resources (Gustafson et al., 2003; Rogers, 2003). Designing interventions that are locally adaptable (while still maintaining fidelity of core intervention components) can help facilitate change and sustainability by providing ownership and buy-in among stakeholders involved in program adoption and implementation. Dissemination and implementation is rarely explicitly addressed in concussion education research or program development work, a limitation that has been observed in sport-setting educational research more broadly (Finch, 2011).
A New Conceptual Framework
We propose a new conceptual framework for understanding the relationship between context, culture, and athlete behavior related to concussion safety (Figure 1). This framework is an adaptation of the integrated behavioral model (Montano & Kasprzyk, 2008) and proposes two pathways through which individuals make decisions about whether or not to engage in a specific safety-related behavior: a reactive or emotional pathway (System I) and a deliberative pathway that involves rational expectancy value calculations (System II; Kahneman, 2003). As depicted, individual actions both produce and are the product of the social and structural contexts in which they are embedded (Bandura, 2001, 2002).
Conceptual framework describing influences on athlete concussion reporting behavior.
A New Approach to Education
Addressing the limitations outlined above, there is a critical need to intervene at a systems level to address the behaviors between and within different stakeholder groups that shape the culture of youth sport. Such an approach should be frequently reinforced throughout the season and be sufficiently low resource so as to be sustainably implemented across a range of youth sport settings. There are examples of successful approaches in other domains that can inform thinking about such intervention in the sports setting. For example, the most successful bullying prevention program for elementary and middle school students (the Olweus Bullying Prevention Program) uses a systems-level approach that engages all school stakeholders, addressing school values and normative interpersonal interactions supportive of those values (Olweus & Limber, 2010). In the medical context, there are often brief meetings of personnel prior to complex medical events (the start of a clinic day, prior to surgery), with a goal of ensuring that all members of the team are sensitized to safety priorities. These “huddles” have been found to improve the sense of teamwork (Shunk, Dulay, Chou, Janson, & O’Brien, 2014), increase desired outcomes, and significantly decrease medical errors (Glymph et al., 2015). The Institute for Healthcare Improvement has recommended the huddle as a means for improving efficiency of care and decreasing negative outcomes. Qualitative data suggest medical safety huddles achieve changes in safety culture by (1) creating time and space for communication, (2) reaffirming shared values, and (3) strengthening relationships (Provost, Lanham, Leykum, McDaniel, & Pugh, 2015).
Pregame Safety Huddles
Building on the model currently utilized in many medical settings, we propose that safety huddles be reappropriated to the sports field as a means for shaping cultures of concussion safety. Such huddles could bring together athletes and coaches from both teams, referees, medical personnel, and potentially parents prior to every game. Following the model of huddles implemented in the medical setting, these huddles would need to be brief in order to be sustainably implemented. Messaging within the huddles could be aimed at affirming values related to concussion safety and providing a public commitment to engage in behaviors during the game supportive of those values (e.g., making sure that no athlete continues playing while experiencing concussion symptoms). Huddles have the potential to influence both deliberate (System II) and reactive (System I) decision making. The act of engaging positively with the other stakeholders while affirming shared values regarding safe sport should theoretically help shape safety-supportive norms and provide contextual cues about concussion safety. This means that if stakeholders are engaged in a reactive or emotional decision-making process during the game, the decisional context should theoretically be perceived as supportive of concussion safety. We hypothesize that this will then be reinforced by referees’ behavior, as they will be more likely to call injury timeouts for the evaluation of potential concussions when given the explicit support of key stakeholders (particularly coaches and parents; Kroshus, Parsons, & Hainline, 2017). While pregame safety huddles make theoretic sense and address the limitations of existing approaches to concussion education, they must now be evaluated to determine their utility in reducing concussion underreporting. Dissemination and implementation must also be evaluated to determine whether the low resource nature of the intervention and simple structure allows for widespread reach and sustainable impact.
Implications for Research and Practice
A new approach is required to ensure that concussion education increases concussion reporting behavior. The conceptual framework described herein should be used as a guide for future efforts. We propose that sports organizations and individuals seeking to design concussion education consider the following:
Interventions should be conducted in settings that closely simulate those in which target behaviors will be enacted (e.g., on the field proximate to game or practice exertion as opposed to in a classroom setting or at home).
Interventions should facilitate safety-supportive interpersonal communication within and between stakeholder groups and seek to change attributes of groups that drive behavior, including shared values, norms, and relational expectancies.
Interventions should be short and delivered throughout the season, providing opportunities for frequent reminders and cues of core intervention components.
Stakeholders from a diversity of communities should be involved in intervention and dissemination planning.
Interventions should be flexible and adaptable to the challenges of local contexts.
Interventions should be simple and require minimal resources for implementation.
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 disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: CDC U01, RFA-CD-17-002 Development and Evaluation of Sports Concussion Research Strategies (co–Principal Investigators: Kroshus & Chrisman).
