Abstract
Background
Sports related concussions continue to be a public health concern and improving reporting behavior a focus of educational programs. While educational programs have addressed changes in knowledge of concussion symptoms, it has been challenging to design educational programs which have lasting effects on reporting behavior.
Aims
The current analysis describes an intervention in which thoughts about reporting behavior are actively written down in a worksheet exercise to “pre-arm” athletes with cognitions designed to enhance reporting behavior prior to the injury event.
Method
A total of 503 male and female college athletes participating in collision (football, field hockey, ice hockey, lacrosse, and soccer) and contact sports (baseball, basketball, and softball) from 7 colleges/universities competing across all three NCAA divisions provided data collected during a randomized trial of a peer concussion education program.
Results
Qualitative analysis revealed 10 themes that would improve reporting including short-term benefits, faster recover, safe and healthy return to play, reporting helps the team, reporting protects the brain, risk aversion, long-term benefits, coach will be supportive, teammates will be supportive and understanding, and academic performance will be affected.
Discussion
Athletes had awareness of key risks involved in concussions and understood both short- and long-term consequences.
Conclusion
These findings have important implications for understanding how to change athletes’ thoughts about reporting concussions.
Sports concussions are brain injuries caused by physical jolts or blows to the head or neck region (e.g., direct helmet to helmet contact) which lead to complex pathophysiological changes (McCrory et al., 2017). Estimates indicate that between 1.6 and 3.8 million sports-related concussions occur annually (Langlois et al., 2006). In addition, the incidence of concussion has been increasing among the approximately 500,000 college athletes who compete in National Collegiate Athletic Association (NCAA) sanctioned competition (Kerr et al., 2017). These findings have contributed to concussions being recognized as a public health concern (Wiebe et al., 2011).
While many concussions resolve within 2 weeks (McCrea et al., 2013), for some athletes symptoms may persist for much longer (Eisenberg et al., 2014). Risks for athletes who train or compete while symptomatic include increased risk for additional concussion, prolonged symptom course and/or greater symptom severity (McCrory et al., 2017). Continuing to play while symptomatic may lead to adverse impacts on academic, athletic, and interpersonal functioning (McCrea et al., 2010; Wasserman et al., 2016). Additional concerns with continued play while symptomatic is the risk of second impact syndrome due to affects to the brain while in a vulnerable state (McCrory & Berkovic, 1998).
With these health risks becoming more well-known, it is concerning that athletes do not report sports-related concussions. Torres et al. (2013) reported 43% of collegiate athletes intentionally hid their concussion symptoms in order to continue playing in a game. Additionally, up to 33% of former collegiate athletes have reported at least one sports related concussion in which they chose not to disclose a suspected concussion they sustained for various reasons including not wanting to leave a game or practice, not wanting to let their team down, not thinking it was serious enough or being unsure if they actually sustained a concussion (Kerr et al., 2014). Additionally pressure from teammates, coaches, parents, or a fan can affect reporting with 25% of collegiate athletes reporting pressure from one of these groups influenced them to continue to play even after a head impact and those who experienced pressure from more sources were less likely to report a suspected concussion in the future (Kroshus et al., 2015). Similar barriers to reporting have been found among high school athletes as well (Chrisman et al., 2013; McCrea et al., 2004; Register-Mihalik et al., 2013).
One approach to improving reporting behavior has been through educational programs, which have been shown to increase knowledge about the physiology, symptoms, and health consequences of concussion (Caron et al., 2015; Echlin et al., 2010). However, knowledge alone is unlikely to change behavior (Azjen et al., 2007), and increased concussion knowledge is only weakly associated with reporting behavior (Kroshus et al., 2014; Kroshus et al., 2015; Register-Mihalik et al., 2013). Changes in more proximal (i.e., intention to report) and intermediate indicators (i.e., attitudes, subjective norms, perceived behavioral control; Azjen et al., 2007) have been found to influence athletes’ reporting behavior (Kroshus et al., 2014; Kroshus et al., 2015; Register-Mihalik et al., 2013).
Educational programs have traditionally focused on addressing symptom identification. Several concussion educational programs have been shown to increase knowledge of symptom identification (Bagley et al., 2014; Kroshus et al., 2014; Kroshus et al., 2015; Register-Mihalik et al., 2013). Unfortunately, many of these educational programs have not found lasting effects (Anderson et al., 2016; Cournoyer & Tripp, 2014; Kroshus et al., 2014; Kroshus et al., 2015). Two recent interventions have been found to show promise in improving intentions to report with lasting effects (Kneavel et al., 2020; Schmidt et al., 2020). Both educational interventions utilized an active educational component with either a multimedia simulation (Schmidt et al., 2020) or a peer-education program (Ernst & Kneavel, 2020) and found the programs to be effective in leading to increased intention to report a concussion after a delay (1 year and 4 months, respectively).
However, educational programs which incorporate more than symptom identification alone are needed. Given the need for educational programs which engage students, the current investigation evaluated athletes’ responses to an interactive component of a Peer Concussion Education Program (PCEP; Ernst & Kneavel, 2020). The PCEP was based on the Theory of Reasoned Action/ Theory of Planned Behavior (TRA/TPB) which postulates changes in knowledge alone only weakly predict changes in behavior and in order to maximize effective change there must be accompanying alternations in attitudes and norms surrounding the behavior (Azjen et al., 2007). The PCEP had three unique design elements: peer-mediated, a cognitive-behavioral model of change foundation, and an interdisciplinary approach utilizing multiple stakeholders (Ernst & Kneavel, 2020). Consistent with the TRA/TPB, peer programs have been shown to be effective in the maintenance of attitudes, norms, and beliefs (Chia, 2006), as they have been shown to facilitate the relationship between knowledge and performance of a behavior (Azjen et al., 2007). Moreover, cognitive-behavioral models support the TRA/TPB whereby individuals can identify and modify cognitions and feeling states including attitudes which lead to changes in behavior and reductions in barriers to carrying out desired behaviors (Adefolalu, 2018). The worksheet activity described here were designed to address attitudes which influences thoughts about concussion reporting. Cognitive-behavioral models applied to health-related behavior adherence demonstrate that changes in cognitions are key to improving healthy behaviors whereas changing knowledge alone is insufficient (Adefolalu, 2018; Azjen et al., 2007). Studies demonstrating increases in concussion knowledge alone do not shown significant changes in reporting behavior (Kroshus et al., 2014; Kroshus et al., 2015; Register-Mihalik et al., 2013). Models employing both peer-mediated and cognitive-behavioral modification programs have been shown with a wide range of positive outcomes in diverse populations (Dart et al., 2014; Dawson et al., 2014). Cognitive-behavioral interventions have been employed to modify cognitions and feeling states, such as attitudes, leading to changes in behavior and reductions in barriers to desired behaviors (Dobson & Dozois, 2019). More specifically, cognitive-behavioral models applied to health-related behavior adherence demonstrate changes in cognitions are key to improving healthy behaviors, whereas changing knowledge alone is insufficient (Adefolalu, 2018; Azjen et al., 2007). Effectiveness for peer-mediated and cognitive-behavioral modification programs has been shown with a wide range of outcomes and diverse populations including school-aged students (Dart et al., 2014), college students (Bowman-Perrott et al., 2013; Dawson et al., 2014; Rohrbeck et al., 2003), and adult veterans (Beattie et al., 2013). The purpose of this article is to identify cognitions which athletes identified as supporting concussion reporting following a PCEP.
Method
Participants
A total of 503 male and female college athletes participating in collision (football, field hockey, ice hockey, lacrosse, and soccer) and contact sports (baseball, basketball, and softball) from seven colleges/universities competing across all three NCAA divisions provided data from worksheets collected during a randomized trial of a PCEP (see Kneavel et al., 2020, for detailed description of methods and quantitative results). Table 1 provides an overview of the universities, teams, sports, and gender of the athletes who provided data for this study. Overall, more males (n = 358) than females (n = 104) provided data because football roster sizes were larger (e.g., n = 128) than other team roster sizes (i.e., softball n = 24). This was data from a larger study of 1,614 college athletes across 10 colleges and universities providing a response rate of 31% (Kneavel et al., 2020). While it is unknown who among this sample of n = 503 athletes reported previous concussions, data from the larger, original study (n = 1,604), suggests that half (51.3%, n = 824) reported they had not previously had a concussion, 40.3% (n = 648) reported they had, and 8.6% (n = 138) were unsure as to whether they had previously sustained a concussion. The original, larger study (n = 1,604) included n = 1,103 males and n = 511 females which is a comparable ratio to the current study. The ethnicity of participants from the original larger study included 364 African American, 18 Asian, 1,206 European American, 50 Latino or Latina, 10 Native American, and 19 mixed or another identity; participants could indicate more than one ethnicity. To enhance the authenticity of the data and generate overall understanding of the phenomena of enhancing reporting of concussions in college athletes, no identifying information (gender, sport, or institutional) information were collected on the worksheets. Because the phenomenological question was to understand what enhances concussion reporting among college athletes, comparisons among groups (i.e., gender, sports, and divisions) was not recommended or possible with the data collected. Data were collected by coordinators on each study site and mailed to the researchers with no identifying information. Thus, the researchers were blinded to gender, sport, and any personally identifying information.
Participant Demographics.
Unaccounted worksheets came from schools and teams that were not clearly labeled or marked and could thus not be adequately categorized.
Measures
Data for this study were collected from a concussion reporting worksheet which required participants to list thoughts that prevent reporting concussion and develop replacement thoughts that might facilitate reporting (see Figure 1). The data analyzed for this article were from the second component of the worksheet: replacement thoughts. The instructions were in the second column, provide a replacement cognition that will facilitative reporting.
Worksheet for reporting cognitions.
Procedure
The concussion reporting worksheets were completed during a PCEP and the randomized control trial (RCT) of the PCEP (see Kneavel et al, 2020, for a description of the RCT; see also Ernst & Kneavel, 2020, for a description of the PCEP). The research was approved by the institutional review board of the researchers’ home institutions and the institutions where the research occurred. During the educational program, two peer concussion educators (known as PCE’s) delivered the PCEP to their teammates. The worksheet activity took place during Part 2 of a 2 part PCEP. Part 1 involved education about the signs and symptoms of concussion, the return to play protocol, and safety measures to reduce concussive incidents. Part 2 included a lecture describing the cognitive-behavioral model of change. During Part 2, the PCE’s led their teammates in the concussion reporting worksheet activity (see Figure 1 and the online manual with fully downloadable material, which can be accessed at https://www.chc.edu/peer-concussion-education/peer-concussion-education-program-manual; Ernst & Kneavel, 2016). The worksheet activity on which the current analysis was conducted was based on cognitive-behavioral theory and intervention which posits that changing cognitions underlies potential changes in behaviors (Beck, 1970; Ellis, 1962). It was designed to be an interactive and engaging activity rather than a passive learning event in which cognitions were actively generated by participants to “pre-arm” them with thoughts about concussion reporting prior to the event occurring to enhance reporting. Module 2 provides participants with an example cognition in the presentation and on the worksheet, “If I report my concussion, not only will I be protecting my brain, but I will return to play when I am at 100%, which will be helpful to my team.” In accordance with the PCEP’s implementation procedure, the lecture and the worksheets were completed without the presence of any researchers or staff to increase the likelihood of obtaining honest responses on the worksheets. To further enhance the authenticity of the data, the worksheets were completed anonymously. Consequently, no identifying information (name, gender, sport, or institution) was collected on the worksheets. Moreover, comparisons among groups (i.e., gender, sports, and divisions) were not considered relevant to the primary research question, which was to generate a broad understanding of cognitive barriers to reporting concussions in college athletes. After the worksheets were completed, they were gathered by the PCE’s and returned to each site research coordinator. Because of the nature of the team cohesion, it was expected that honest and frank answers would be elicited. In addition, athletes provided answers in an anonymous format, increasing the likelihood of open and trustworthy responses.
Data Analysis
Qualitative research considers the analysis of the subjective experiences of an individual’s experience with a given phenomenon as a legitimate form of data to be analyzed (Levitt et al., 2018). Phenomenological research focuses on the experiences of multiple individuals with respect to a given phenomenon to develop a contextual understanding of the essence of th
Results
Ninety-four significant statements were extracted and arranged into 10 themes. Participant quotes are reflected with participant numbers (i.e., P25 indicates Participant Number 25).
Theme 1: Short-Term Benefits Postconcussion
When asked to develop thoughts/cognitions which might increase concussion reporting, a number of participants mentioned benefits to their athletic performance. For example, one participant (P25) stated, “When I come back 100%, I will be able to play better and more alert.” Another participant (P37) stated, “I will perform better when I am 100%, rather than playing with a concussion.” Along this line, a participant (P249) stated, “If I take time to recover my brain’s health, my body will recover as well, making me better than before.”
Being mindful of a coach’s assessment was also considered. For instance, a participant (P220) stated, “If I report my concussion, I will be able to show coach my best skills.” Participants also indicated benefits associated with playing time and their standing on the team. For instance, one participant (P190) stated, “I will come back stronger and retain playing time.” Moreover, another participant (P274) indicated, “When I come back I will be 100% and able to earn my spot back.” A positive impact on teammates was also indicated as evidenced by a participant (P136) stating, “If I report it, it will make me perform at 100%, which will make me and my teammates better.”
Avoiding the possibility of diminished athletic performance due to playing with a concussion was also cited by participants as a thought/cognition which might increase reporting. For example, a participant (P105) reported, “If I’m good enough, I’ll play when I’m healthy and I won’t play well with a concussion anyway and might still lose playing time.” In addition, a participant (P147) wrote, “If I report the concussion, I will be less of a liability on the field, if I don’t feel right.” Another participant (P354) succinctly stated, “Not reporting may impair my performance.”
Theme 2: Faster Recovery
The vast majority of athletes playing at the collegiate level are likely to possess a strong motivation to play their sport and want to avoid missing opportunities to compete. Therefore, it is not surprising that an efficient return to play due to prompt reporting emerged as a theme which might increase concussion reporting. For example, one participant (P329) stated, “If I report, I will get the proper care I need to get on the field quicker.” Another (P171) stated, “If I report my concussion, I will recover faster and get back on the field faster.” Similarly, a participant (P465) reported, “If I report my concussion, I can get back to practice faster and healthier,” as a thought which might increase concussion reporting.
Theme 3: Safe and Healthy Return to Play
Other participants appeared to focus more on a safety as opposed to efficiency with respect to returning to play. For example, a participant (P445) mentioned, “If I report my concussion, I will lose playing time, but I will return healthy, safe, and better off to play.” Another participant (P21) stated, “If I allow time to heal, I’ll be 100%.”
Theme 4: Reporting Helps the Team
In this theme, participants appeared to associate concussion reporting with benefits to the team. Along this line, one participant (P500) stated, “If I report my concussion, I would come back healthier and perform better for my team.” Another participant (P434) stated, “I can’t help my team if I am not 100%.” One participant (P216) appeared to take a more altruistic perspective with respect to a thought which might increase reporting by stating, “Better for the team to get a healthy guy playing.” Other participants combined benefit to the team with their own health. For instance, a participant (P143) stated, “I may become more healthy and able to help my team.” Similarly, another participant (P236) wrote, “If I report, I will be protecting my health and not cost my team.”
Theme 5: Reporting Protects the Brain
Some participants associated possible increases in concussion reporting with protecting the brain and keeping it healthy. For example, one participant (P228) stated, “Protecting my brain will be my main reason to report. You only get one brain.” Another participant (P337) offered the following statement/thought which might increase concussion reporting, “If I report it, I will be protecting my brain.” One participant (P33) emphasized brain health over playing time by stating, “Losing playing time is better than losing brain cells.” Placing brain health over a possible negative reaction from teammates was also reported as evidenced by a participant (P224) stating, “My teammates will get over it, I may not get over my brain injury.”
Theme 6: Risk Aversion
Concerns ranging from relatively minor to catastrophic were reported by participants as those which might increase concussion reporting. With respect to relatively minor risks, a participant (P366) stated, “Play will suffer.” Other relatively minor risks stated by participants (P13) included, “It might not be a migraine,” and (P54) “Avoid pain.” Conversely, some participants indicated thoughts associated with catastrophic risks. For example, one participant (P233) succinctly stated, “I won’t die,” and another (P166) stated, “2nd impact syndrome”. Moreover, participants (P464) cited, “May never recover,” and (P138) “Don’t want to lose my mind.”
Theme 7: Long-Term Benefits
In this theme, several participants took a long-term perspective. In particular, some participants focused on concussion reporting as a means to mitigate future complications. For example, a participant (P394) stated, “If I report my concussion, I will protect myself from long-term damage.” Thoughts associated with mitigating future complications also included (P353), “I will save myself from future complications,” and (P491) “It is better to miss a game than to ruin your life.” Other participants focused more on functioning in the future. For example, one football player (P285) stated, “If I do report, I can assume a healthy life after football.” Another football player (P74) wrote, “Football is temporary, I need my brain forever.” Finally, a participant (P123) stated, “If I report my concussion, I will have a better chance of getting treatment and having a healthy life.”
Theme 8: Coach Will Support Me
Coaches typically are a major influence on team culture and those coaches who emphasize concussion safety are likely to increase concussion reporting. Along this line, participants identified a number of statements that might facilitate reporting. For example, one participant (P109) stated, “If I report my concussion, my coach will be proud that I take initiative and am protecting my health.” Another (P151) stated: “If I report my concussion, my coach will be understanding because I am protecting myself.” Moreover (P356), “If I report my concussion, my coach will be glad that I’m taking proper protocol,” and (P417) “My coach wants me to be healthy,” was cited by participants. In addition, some participants indicated a lack of consequences from coaches might influence reporting. For example, one participant (P360) stated, “My coach will not hold it against me,” and another (P125) wrote, “If I report, my coach will allow me to become healthy to compete for my spot.”
Theme 9: Teammates Will be Supportive and Understanding
In addition to the coach, participants indicated concussion reporting might be enhanced by the support and understanding of their teammates. For instance, one participant (P458) indicated, “My teammates care about my wellbeing and completely understand.” Another participant (P338) stated, “My team will understand and encourage me.” Other replacement thoughts that might increase reporting combined support from teammates with possible benefits to the team. For example, one participant (P225) stated, “If I report my concussion, my teammates will be happy I’m doing what it takes to get back to 100% as quickly as possible.”
Theme 10: Better Academic Performance
The final theme in this section underscored the academic advantages associated with concussion reporting. “If I report my concussion, my performance in school will be able to stay at a high level when I return,” (P369) was one replacement thought and another participant (P379) stated, “If I report my concussion, I will be protecting my brain and I will be able to attend class at 100%, which will be more helpful in my academics.” Another participant (364) stated, “I will help my academic success by staying healthy.” Cognitions associated with academic support were also indicated as possible facilitators of concussion reporting. For example, one participant (P155) stated, “If I report my concussion, I will get the help I need to not fall behind in class and my grades won’t suffer.” Finally, “My professors will help me as much as they can to help me catch up,” was cited by a participant (P188).
Discussion
For the most part, when concussion education programs have evaluated efficacy, they have assessed change in knowledge about concussion symptoms (Conaghan et al., 2020). More recent research suggests incorporation of the theory of planned behavior/theory of reasoned action (TRA/TBA) into concussion education programs can be effective (Kroshus et al., 2014; Register-Mihalik et al., 2013). A novel, peer cognitive-behavior based concussion education program was developed based in part on the (TRA/TPB). The PCEP includes an educational intervention based on a cognitive behavioral model of change which requires athletes to identify thoughts to prevent reporting and replace them with thoughts to facilitate reporting. Qualitative analysis was conducted to develop a broader and more contextualized understanding of modifications in thinking that might facilitate reporting. Ten themes emerged that clustered into four areas: (a) improving health and safety, (b) improving athletic performance, (c) generating a supportive culture for concussion reporting, and (d) supporting academic achievement.
College athletes who participated in the PCEP generated these cognitions to support reporting through an interactive peer-led educational process. The educational program consisted of two components, the first of which covered the pathophysiology of concussions, the reasons and steps in the return to play protocol, and some steps to minimize the impacts of concussions while playing and practicing (https://www.chc.edu/peer-concussion-education/peer-concussion-education-program-manual; Ernst & Kneavel, 2016). The second component was fully led by peer educators who explained the cognitive-behavioral change process and provided one concussion related example. Following this, the athletes generated their own examples. Athletes in this study generated a large number of diverse examples from their own experiences related to a wide number of areas, which college students are concerned including short and long-term health, athletic performance, the culture around them, and their academic life. The large number of areas that college athletes address in this exercise indicates that the interactive worksheet exercise worked as intended and that college athletes who experience concussion have a wide breadth of experiences which affect many aspects of their lives.
The themes associated with the health and safety cluster focused on short- and long-term health and included: safe and healthy return to play, protects the brain, long-term benefits, and risk aversion. Participants recognized the risks of playing with concussions such as being at an increased risk for more severe and persisting impairments. Other participants reported being concerned with catastrophic health consequences such as chronic traumatic encephalopathy. These themes suggest material covered in the first educational module of the PCEP which addresses symptoms, return to play protocol information, and safety, was understood and incorporated by some of the athletes during the concussion reporting module. Moreover, these themes suggest that many athletes are aware of the potential health consequences of concussion and that awareness might increase reporting, which may have been attributed to some extent with growing awareness of information related to concussions discussed in the news media and general public. While few studies exist on college athletes’ perceptions of risk, one study has evaluated Division I football players perception of risk and found that as many as 40% believed they are susceptible to a concussion and almost 10% recognized the risk of future long-term consequences such as dementia, Alzheimer’s disease, or chronic traumatic encephalopathy (Baugh et al., 2017). For those athletes who had sustained a concussion, their assessment of the risk of future long-term consequences was much higher than those athletes who had not sustained a previous concussion (Baugh et al., 2017). Sarmiento et al. (2019) also found that athletes recognized the potential consequences that concussions could have on both long-term brain health (i.e., permanent damage) as well as possible effects on future play. Bringing attention to the potential long-term risk through the PCEP model before the actual concussion incident and having athletes think through the risk may increase reporting behavior. In assessments of peer education models on risk assessment of drinking behavior, Cleveland et al. (2012) have found a peer intervention to be effective in preventing heavy drinking among college students. Furthermore, meta-analysis of studies of interventions with college students which challenge alcohol expectancies found, significant cognitive changes in beliefs about alcohol use and behavioral changes in alcohol use (Scott-Sheldon et al., 2012). Thus changing cognitions around risk behaviors are likely to lead to positive changes in behavior.
The second cluster was associated with athletic performance and in line with expectations given the competitive nature of athletes performing at the collegiate level. Within this cluster themes included faster recovery, safe and healthy return to play, and reporting helps my team. The replacement thoughts that constituted these themes are encouraging as they suggest that athletes may begin to realize that reporting is not only in the best interest of their health but also their athletic performance. This realization is likely to counteract common thoughts that lead to barriers to reporting such as losing playing time and one’s “spot” on the team. In particular, some athletes realized that playing with concussion symptoms is likely to decrease performance, which in turn might adversely affect playing time. These replacement thoughts may counteract barriers to reporting identified in a focus group of high school athletes by Chrisman et al. (2013), which included “you’re supposed to play injured,” “don’t want to let the team down,” and “concussions are dangerous.” Not wanting to lose playing time has been a barrier reported by several researchers across high school and collegiate athletes (Chrisman et al., 2013; Kerr et al., 2016; Kneavel et al., 2019; McCrea et al., 2004; Register-Mihalik et al., 2013; Torres et al., 2013). Additionally, barriers to reporting were greater in playoffs or championships conditions as athletes indicated they would be less likely to report a suspected concussion in those types of important game conditions (Kerr et al., 2016). The first step in recognizing that concussions are dangerous is now supported by recognition of safe and healthy return to play. Thoughts that one must play injured are counteracted with recognition that one will have a faster recovery if one reports and does a proper return to play protocol.
The third cluster was characterized by themes associated with a generating a supportive culture for reporting concussions. These included the themes of coach will support me and teammates will support me. These finding were encouraging as they were consistent with one of the primary goals of the PCEP, which was to use a peer mediated approach to transform the culture of concussion from within the team itself. These themes were consistent with the TRA/TRB, which theorizes in part that knowledge predicts behavior when the norms of the group support reporting (Azjen et al., 2007; Kroshus et al., 2014; Register-Mihalik et al., 2013). The themes within this cluster suggest that directly involving college athlete though a peer mediated intervention that includes an activity they perform as a team unit may result in changes in cognition that creates a team environment conducive to changes in concussion reporting behavior. Kroshus et al. (2016) have reported that athletes who believed their teammates were more supportive of concussion safety were more likely to encourage teammates to seek help or alert a medical professional about a suspected concussion. This has been supported by a recent study from Sarmiento et al. (2019) in which young athletes indicated that being part of a supportive team environment would enhance their ability to report their concussions. Similarly, this theme directly aligns with previous research which has suggested a barrier to reporting has been athletes did not want to let their teammates down which has been found at both the collegiate level (Kerr et al., 2016) and at the high school level (Chrisman et al, 2013; McCrea et al., 2004; Register-Mihalik et al., 2013). Chinn and Porter (2016) reported that athletes did not report concussions because they not only did not realize they had suffered one (they were “in the zone”) but were more likely to be concerned for the welfare of their teammates than themselves. Not wanting to let the team down has been shown to be one of six themes found in a systematic review of common barriers to reporting concussion (Craig et al., 2020). Chrisman et al. (2013) reported that teammates have generated negative reactions to reporting including name calling (being called a “faker”) and having perceptions of weakness projected onto the athlete. Additionally, Kneavel et al. (2019) reported that teammates were hesitant to report their teammate’s possible concussions because they did not feel it was their job to make that call. Thoughts associated with coaches being supportive of reporting is also important as they typically have a considerable influence on many aspects of team culture including those associated with safety. Recognition of the importance of the coach in concussion reporting is consistent with the socioecological framework, which suggests that concussion reporting is enhanced when multiple levels of influence including the coaches and other environmental factors support reporting behavior (Kerr et al., 2014). The importance of the coach was also found in the focus group of barriers to reporting among high school athletes (Chrisman et al., 2013). This was also found in a recent study from (Sarmiento et al., 2019) in which athletes indicated that having a supportive coach created a comfortable environment for reporting concussions. Engaging athletes in a process to recognize the importance of teammate and coach provides support for athlete reporting behavior.
Last, the college athletes in this study recognized the academic part of their identity and protecting their academic performance as a key factor to facilitate reporting. When college athletes were asked what they want from concussion education (Kroshus & Baugh, 2016), one identified area was more information about the effects of concussion on academic performance. Additionally, over 10% of sampled college football players in one study indicated they foresaw a risk to short or long-term problems in school or work functioning as a result of a concussion (Baugh et al., 2017). If the football players had a previous history of concussion, they were more likely to perceive a risk to academic work (Baugh et al., 2017). Our findings suggest college athletes are aware of the potential effects of concussions on academic performance and consider these as at least one reason to report their concussion.
Limitations
There are several limitations to this work. In particular, development of replacement cognitions alone does not automatically translate into behavioral action. The results of previous research on the effectiveness of the PCEP found that college athletes who participated in the PCEP program were more likely to discuss concussions with significant others (teammates, coaches, peer educators, and athletic trainers) and were more likely to report a suspected concussion in a teammate (Kneavel et al., 2020). Thus there is evidence that combining the worksheet exercise along with training about concussion knowledge has potential to lead to positive behavioral change. Additionally, there are a number of cognitive biases among college athletes which may have influenced the reported and nonreported thoughts. Another limitation is the restriction of generalizability to all sports. The aim of the approach presented in this study was to understand thoughts that would encourage reporting concussions in the aggregate across all sports and thus were not broken out by individual sports, gender, division, and so on. For this reason, not all cognitions and themes may be applicable to all sports, genders, and other subgroups.
The findings indicate that athletes recognize the important impact that reporting can have on both short and long-term health and well-being after the educational intervention. One of the goals of the educational intervention that was addressed by the worksheet activity was rooted in the cognitive-behavioral model of change. The activity required college athletes to list thoughts/cognitions that prevent reporting a concussion in self and then replace them with thoughts that increase reporting. As identified by Turner et al. (2019), concussion education that engages athletes to process information deeply is most effective. They specifically recommend interactive peer-mediated and interactive educational programs. Overall, the responses to this activity indicated that the college athletes utilized it as designed and developed replacement cognitions that might facilitate reporting. These thoughts clustered into areas of health and safety, athletic performance, creating a culture conducive to concussion reporting, and supporting academic achievement. Therefore, college athletes are likely to be equipped with thoughts that might increase reporting self prior to the occurrence of a concussion, which may make it more likely that they will counteract thoughts that prevent reporting when a concussion actually occurs.
Future Research
The themes from this study will be used to develop an evidence-based concussion reporting assessment for collegiate athletes. Specifically, the researchers plan to convert the themes identified from the current study into a quantitative assessment. In addition, thoughts that impede reporting obtained from a separate qualitative analysis of the responses to the first column of the worksheet (see Figure 1) will also be converted into a quantitative assessment to provide more comprehensive information on concussion reporting. The assessment will employ a Likert response format that will allow for the quantification of the degree to which a given thought impedes or facilitates concussion reporting. This will allow for quantitative determination of the relative influence of a given thought on reporting, which may then be used to develop more targeted educational interventions. Moreover, the assessment data can be used to better elucidate relevant variables that may influence aspects of concussion reporting including gender, sport, college year, and NCAA division. Additionally, understanding of these cognitions that support reporting in other populations including high school, middle school, and military personnel will be important. Finally, data obtained from a quantitative assessment of concussion reporting will be used to provide preliminary psychometric information to develop a concussion reporting scale, which ultimately may be used to assess the effectiveness of concussion education programs.
Next Steps
The information gained from the reported cognitions that support reporting will be combined with the gains from the overall PCEP and the barriers to reporting that college athletes reported to streamline a comprehensive educational program. A recent review of concussion educational programs (Craig et al., 2020) found most to be ineffective in providing lasting changes in concussion knowledge or reporting behaviors. However, the PCEP (Ernst & Kneavel, 2020), which engages college athletes in developing cognitions prior to their concussion injury, has been found to have effects last up to 1 month on identification of concussion signs and symptoms, intention to report, and other subjective norms (Kneavel et al., 2020). The development of a scale to assess the impact of these cognitions will be beneficial in elucidating the weight of influence of these cognitions as well as group differences.
The results from this study provide information about cognitions athletes can use to make decisions to support reporting concussions. These cognitions can be utilized in two important ways. The first is to further refine education programs for athletes as there is now a clearer understanding of cognitions, which support reporting behaviors. The second is the development of educational programs for health care professionals (e.g., athletic trainers) who can now continue to work with athletes with a clear list of cognitions which support reporting behaviors, which have been developed by the athletes themselves. Overall, these cognitions provide a starting point to have conversations about cognitions which support reporting behavior and enhance educational programs on concussion. The peer led cognitive behavioral educational intervention is a unique and effective team based activity designed to pre-arm athletes with cognitions which support reporting behavior.
Footnotes
Acknowledgements
The authors would like to acknowledge Sara Shuman, PhD, for completing an independent qualitative analysis of the data and helping to establish the dependability and credibility of themes.
Authors’ Note
The data will be available on request from the primary author.
Declaration of Conflicting Interest
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: This publication was made possible, in part, with support from the National Collegiate Athletic Association - U.S. Department of Defense Mind Matters Challenge
