Clinical Journal of Sport Medicine

Among S-As, SRC knowledge levels varied by sex and sport-type, with females and C/C sport S-As demonstrating the highest SRC knowledge scores. Prior studies have shown conflicting results when comparing SRC knowledge levels between males and females at the high school and collegiate level.13,16–20 In gender-comparable sports, the incidence rate of concussion in females is higher than in males.^21,22 There may be other factors contributing to differences in SRC knowledge between sex, such as individualized learning style and gendered expectations, which are beyond the scope of this article. Higher SRC knowledge in collegiate C/C sport S-As has been noted by Tashima et al.²³ C/C sport S-As are known to be at higher risk of SRC and have a higher incidence of SRC, and, therefore, may have more opportunities to receive SRC education.^21,22,24

Interestingly, SRC knowledge scores did not differ significantly by year-in-college. One would assume that with higher year-in-college, S-As would have received more cumulative SRC education. It is also possible that SRC education received may have varied substantially between domestic and international, and transfer S-As before matriculating at this university.

Overall, SRC knowledge scores varied widely among S-As, pointing to deficiencies in the current method of providing SRC education, which includes the NCAA’s “Concussion: A Fact Sheet for Student Athletes.”²⁵ A number of studies have examined various SRC concussion education methodologies and their outcomes. Cusimano et al²⁶ found that in minor league hockey players, SRC knowledge increased immediately after watching an educational video but was not retained at 2-month follow-up. Oral presentations, online modules, and videos, and printed materials are common formats to provide SRC education.^27,28 Nonetheless, a qualitative review by Mrazik et al²⁸ found that SRC educational interventions may lead to improved knowledge in the short term but do not translate to long-term knowledge, behavioral, or attitude changes. The importance of knowledge transfer and exchange has been recognized as an important component of SRC education. This requires not only the educational media but also an interactive process, multidirectional and ongoing communications, and consideration of the individual user and context.²⁹ Printed materials seem to have limited efficacy when used alone.²⁹ Instead, SRC education can be enhanced with support groups facilitating peer-to-peer discussion to reinforce knowledge and promote a culture of safety.²⁹

As expected, SRC knowledge scores in ATs were significantly higher than those of S-As. Prior studies have noted higher SRC knowledge scores in ATs than in coaches.^30,31 Interestingly, Wallace et al¹⁹ found that high school S-As with access to an AT had higher SRC knowledge than S-As without an AT, though this did not result in better SRC reporting rates. Although continuing SRC education of stakeholders such as physicians, ATs, and coaches is justified, the higher SRC knowledge does not always equate to improved S-As safety. For S-As, there is not only a basic knowledge gap but also an SRC culture that needs to continue to shift.

Regarding SRC reporting in S-As, most of those who reported a history of SRC reported it to a medical/authority figure. Similar to prior studies done in collegiate S-As, males and C/C sport S-As were less likely to report SRC than females or LC/NC sport S-As, respectively.^5,7–9 Conformity to traditional “masculine norms” of risk taking, winning, and self-reliance and their relationship to SRC reporting has been explored, where higher conformity was associated with decreased SRC reporting intention in both males and females.³²

The trend toward not reporting SRC across year-in-college could perhaps be explained by S-As learning throughout their athletic career that being diagnosed with a SRC means loss of playing time while they are recovering. This might lead to development of a more negative attitude toward SRC reporting with time.

Interestingly, S-As who reported SRC did not differ in SRC knowledge scores compared with those who did not report SRC, suggesting that there were other factors besides lack of knowledge that would explain SRC nonreporting, including not wanting to lose playing time and internal pressure to not let the team down. Prior studies have had mixed results regarding the association between SRC knowledge and reporting behaviors, with some showing increased SRC reporting with better SRC knowledge while others have not.^4,5,8,17 The top reasons for not reporting SRC were not thinking the concussion was serious enough and not wanting to be withheld from games/practices, consistent with prior studies.^4,7,13,33 The various reasons for not reporting SRC, and the relative weight they carry, may also differ depending on sport-type, team versus individual sports, player position, starter versus bench player, practice versus game, and individual personality characteristics. In addition, the decision to report an SRC can also be affected by emotional or reactive decision making at the time of the event. Though relatively few S-As in our study cited pressure from teammates, coaches, parents, or fans as a reason for not reporting SRC, there is still work to be done to create a culture of safety for S-As and improved education for all those who interact with S-As.

Clearly, there are many factors influencing SRC reporting. The NCAA and Department of Defense issued a consensus statement on improving concussion education.³⁴ Cicero et al³⁵ suggested a basic framework of behavior analysis to understand SRC reporting behaviors, stating that educational interventions, attitudes on reporting, and socioecological models where an individual and their interactions with micro-, meso-, exo-, and macrosystems, when evaluated together, have not necessarily improved SRC reporting. Instead, Cicero uses behavior analytic theory—namely, operant behavior, reinforcement, punishment, and extinction—as a guide for interventions. For example, the negative punishment of removal from play after reporting SRC symptoms can be mitigated by actions such as verbally praising the S-A in front of teammates for reporting and refraining from requests to have the S-A continue to play through the game. This may represent a culture shift for some, though fortunately at our institution, most S-As reported their SRC to a medical/authority figure.

This study has several limitations. Given the design of the study, we relied on participants to recall their own history of medical provider-diagnosed or self-diagnosed concussions, introducing both recall bias and lack of confirmation of prior SRC diagnoses. Furthermore, we acknowledge that the questions used to assess SRC knowledge were limited and may overly simplify a complex topic, though given that most participants, aside from ATs, likely did not have extensive medical training in SRC, the level of complexity is likely suitable to the intended audience. To improve specificity and limit confusion, future surveys could incorporate wording to clarify timing of symptoms in relation to the SRC, whether symptoms are a direct or indirect result of SRC, or a free response section as well. For example, those who experience SRC may develop panic attacks that can manifest as chest pain and difficulty breathing, which technically are not direct signs and symptoms of SRC.

In addition, not all sports were represented equally, thus sports had to be grouped together by sport-type, based on contact level characteristics, to have sufficient numbers for analysis. Diving, which is considered a contact sport, could not be differentiated from swimming, an NC sport, because “swimming and diving” were grouped together in the original survey. Similarly, track and field was classified as an NC sport, and individual events were not differentiated in the original survey.

History of exposure to SRC curriculum was also not assessed. This information could have provided additional insight, for example, if there was a discrepancy with reported prior exposure to SRC curriculum and SRC knowledge scores.

Finally, the sample size for ATs was small and the overall study population was limited to 1 NCAA Division 1 school.

CONCLUSIONS

Collegiate S-As displayed highly variable levels of SRC knowledge, with females and C/C sport S-As scoring better. Athletic trainers had significantly higher SRC knowledge levels than S-As. Sports-related concussion reporting also differed based on sex, year-in-school, and sport-type, such that males, higher year-in-school, and C/C sports S-As were less likely to report SRC to a medical/authority figure. Although S-As who did not report SRC had similar knowledge scores compared with S-As who did report SRC, a gap in SRC knowledge and other internal and external motivating factors influence SRC reporting behaviors. This highlights the importance of continued efforts for improving SRC education, knowledge retention and transfer, and creating a culture of safety and positive attitudes toward SRC reporting.