Behavior: hard to change
In the NCAA hockey study, Kroshus and her colleagues found support for viewing concussion reporting behavior in this way, viewing their findings among the players surveyed of a significant association among knowledge, attitude and subjective norms and concussion reporting intention as "reinforcing the importance of these cognitions as targets of concussion education and the potential appropriateness of TPB as a theory to inform the design and evaluation of programmes attempting to modify concussion reporting behavior."
Their study is the second to be published in the span of just over two months to support the use of TPB in guiding the development of concussion education programs, following the June 2013 publication of a qualitative attitude study [4] by researchers at WakeMed Health and Hospitals, Raleigh, NC, the University of North Carolina at Chapel Hill, and A.T. Still University in Mesa, Arizona, which found that, while the culture of sport (including influences from professional and other athletes), as well as the media and other outside sources play a role in the decision of student-athletes to report experiencing concussion symptoms, the three direct TPB factors (attitude, subjective norm, and perceived behavioral control) accounted for 53% of the intention to report concussions. The study found that it was coaches and teammates, along with parents, who have the strongest influence on the decision to report a concussion during sport participation.
The findings prompted lead author Johna Register-Mihalik, Ph.D, LAT, ATC, Senior Research Associate at WakeMed and Adjunct Assistant Professor at UNC-Chapel Hill, and her colleagues - apparently independently of the Chrisman and Kroshus groups - to recommend the need for "multi-level" concussion awareness programs, starting with the intra-personal (the individual) and moving through the inter-personal (relationships to the individual), the organizational level (team) [to] the policy level," with the intra-personal and inter-personal level targets "aimed at creating positive attitudes and beliefs towards concussion and concussion reporting," both among indidividuals as well as parents, coaches, and teammates, and towards "creating an environment that rewards positive concussion-care seeking behaviors such as reporting an injury or removing one's self from play when experiencing concussive symptoms."
While recommending that the emphasis of concussion education be changed, Register-Mihalik was unaware of any program thus far using the Theory of Planned Behavior in this way.
Study details and findings
To assess the concussion education provided to the hockey players in terms of content, delivery, and effectiveness in changing concussion-reporting behavior, Krosher and her colleagues asked players on six NCAA Division 1 male hockey teams to complete two surveys at the beginning of the 2012-2013 school year and prior the start of hockey season: one the day before, and one the day after receiving concussion education.
The type of education differed by team: four received written materials on concussions[11] (three receiving individual hard copies of the handout, the members of one team having the handout left in their locker room for common perusal, and two teams receiving the materials by e-mail). Five of the six teams also received a lecture from their athletic trainer about concussions. Members of one team not only got individual handouts and received a lecture, but also watched a concussion video specifically targeting hockey players. [12]
Significantly, the video had the highest rate of recall across all teams and types of educational materials (92%), and in response to a prompt asking what changes would make their concussion education more effective, players on other teams most frequently reported wanting information delivered in video form, with testimonials from former athletes about the long-term conseqences of concussion. That concussion education in video form can be effective, at least in the short term, in increasing concussion knowledge, was also found among junior hockey players in Canada, although that study recommended that future concussion prevention efforts in hockey and other sports incorporate a variety of educational modalities, given the lack of evidence that any specific modality (e.g. educational videos, websites, seminars) is the best technique to employ.[13]
Based on questionnaire responses by 146 hockey players, the Boston researchers found that:
- change in intention to continue playing with a minor concussion was significantly higher among athletes who reported remembering that they had received a lecture, and significantly lower among those who remembered that they had received an email;
- an athlete's baseline concussion knowledge had no influence on whether or not they accurately remembered the type of educatino they received;
- the team that watched the video had the greatest improvement in concussion knowledge, while two teams actually scored worse on the measure of concussion knowledge following education;
- 18.5% of participants reported being diagnosed with at least one concussion by a medical professional during the previous season,
- Many more participants saying they experienced symptoms after a head impact suggestive of concussion, with nearly half (45.9%) reporting they continued playing with a headache after being hit on the head, but with significant variability between teams (12.5-54.2%).
- Among athletes who suspected that they had a concussion during the previous season but did not report their injury:
- fully half (50.6%) stated that they did not report it because they did not know it was a concussion;
- 7 out of 10 (69.7%) because they did not think it was serious enough;
- close to half (48.3%) because they did not want to be pulled out of the game or practice; and
- a third (32.6%) because they did not want to let down their teammates.
1. Kroshus E, Daneshvar DH, Baugh CM, Nowinski CJ, Cantu RC. NCAA concussion education in ice hockey: an ineffective mandate. Br J Sports Med. 2013;doi:10.1136/bjsports-2013-092498 (epub. August 16, 2013)
2. Echlin PS, Skopelja EN, Worsley R et. al. A prospective study of physician-observed concussion during a varsity university ice hockey season: incidence and neuropsychological changes. Part 2 of 4. Neurosurg Focus 2012;33(6):E2
3. Chrisman SP, Quitiquit C, Rivara FP. Qualitative study of barriers to concussive symptom reporting in high school athletics. J Adolesc Health 2013;52:330-5 e3.
4. Register-Mihalik JK, Linnan LA, Marshall SW, Valovich McLeod TC, Mueller FO, Guskiewicz KM. Using theory to understand high school aged athletes' intentions to report sport-related concussion: Implications for concussion education initiatives. Brain Injury 2013;27(7-8):878-886.
5. Anderson B, Pomerantz W, Mann J, Gittelman M. "I Can't Miss the Big Game": High School (HS) Football Players' Knowledge and Attitudes about Concussions. Paper presented at the Annual meeting of the Pediatric Academic Societies, Washington, D.C. May 6, 2013.
6. Register-Mihalik JK, Guskiewicz KM, Valovich McLeod TC, Linnan LA, Meuller FO, Marshall SW. Knowledge, Attitude, and Concussion-Reporting Behaviors Among High School Athletes: A Preliminary Study. J Ath Tr. 2013;48(3):000-000. DOI:10.4085/1062-6050-48.3.20 (published online ahead of print)
7. McCrea M, Hammeke T, Olsen G, et. al. Unreported concussion in high school football players: implications for prevention. Clin J. Sport Med 2004;14:13-17.
8. Dziemianowicz M, Kirschen MP, Pukenas BA, Laudano E, Balcer LJ, Galetta SL. Sport-Related Concussion Testing. Curr Neurol Neurosci Rep 2012 (published online July 13, 2012)(DOI:10.1007/s11910-012-0299-y).
9. McGrath N. Supporting the Student-Athlete's Return to the Classroom After a Sport-Related Concussion. J Ath. Tr. 2010:45(5):492-498.
10. Ajzen I. The theory of planned behavior. Organizational Behav Hum Dec Proc 1991;50:179-211.
11. NCAA. Concusion: a Fact Sheet for Student-Athletes. 2012. http://fs.ncaa.org/Docs/health_safety/ConFactSheetsa.pdf
12. https://http://www.nanonline.org/NAN/_Research_Publications/Concussions_....
13. Cusimano MD, Chimpman M, Donnelly P, et al. Effectiveness of an educational video on concussion knowledge in minor league hockey players: a cluster randomized controlled trial. Br J Sports Med 2013;doi:10.1136/bjsports-2012-091660)(e pub August 5, 2013) ( finding that concussion knowledge did not result in a change in attitudes or decrease aggressive play, which the authors speculated was likely "due to the fact that players at all levels in all age groups receive consistent cultural messaging that quite likely emanates from potentially aggressive parents, 'hard line' coaching styles, the media, television personalities and negative professional role models." They thus recommended that "the influence that define the culture of ice hockey and sport more generally need to be considered in prevention strategies because ignoring them will undermine and negate any attempt at prevention.")
