Development of a Peer Education Program to Improve Concussion Knowledge and Reporting in Collegiate Athletes

An estimated 1.6 to 3.8 million concussions from sport- and recreation-related activities occur per year in the United States.¹ In addition, rates of concussion during athletic events, which include both competitions and practices, have increased for collegiate athletes from the late 1980s to the mid-2000s.² These rates vary by sport, with greater risks in sports such as football and wrestling for men and soccer and ice hockey for women.³ Rates of diagnosed concussions have also increased among high school athletes,⁴ and in a prospective 11-year study, researchers⁵ found increased concussion rates for male and female high school athletes in all 12 sports studied.

The increase in sport-related concussion rates is likely to be associated with several factors, including advances in evaluation and management.⁶ In addition, the proliferation of online education programs for athletes, parents, coaches, and sports officials, such as “Heads Up to Youth Sports” from the Centers for Disease Control and Prevention,⁷ may have led to greater awareness. Legislation such as the Lystedt law, which requires youth athletes with suspected concussions to be removed from play and cleared by a health care professional before returning as well as concussion education for athletes, parents, and coaches, may also be responsible for increased concussion rates.⁸ For example, the number of documented concussions in 10 public high schools in Seattle, Washington, more than doubled the year after the Lystedt law was passed.⁸ Finally, similar legislation has been passed in all 50 states_,⁸ which is likely to increase concussion identification rates nationwide.

Concussion identification is challenging and often relies in part on self-report.⁹ Facilitating prompt removal from play is crucial, as engaging in strenuous activities shortly after concussion adversely affected neurocognitive recovery¹⁰ and may increase the risk of repeat concussion.¹¹ Unfortunately, cultural aspects surrounding competitive athletics appear to create barriers to concussion reporting.¹² Collegiate student-athletes described pressure from multiple sources, including teammates, coaches, parents, and fans, to continue playing despite experiencing a head impact.¹³ These pressures, along with those internal to the athlete (eg, not wanting to lose playing time), are consistent with research findings^13–15 indicating that approximately one-third to one-half of collegiate athletes continued to play while experiencing symptoms of a possible concussion. Moreover, high school athletes reported only 40% of recalled concussive events to a coach or medical professional.¹⁶ A reluctance to report concussion symptoms and continuing to play while symptomatic are behaviors that appear to begin before collegiate competition, which suggests that factors inhibiting concussion reporting may persist for years and become entrenched.

Several concussion-education programs have been developed to enhance athlete safety. These programs typically consist of videos, fact sheets, or presentations by health care professionals.^7,17,18 Current education programs increased concussion knowledge; however, little evidence indicates that increasing knowledge alone changes behaviors to produce a culture of safety.¹² For example, a qualitative focus-group study¹⁹ of male and female high school athletes showed that even though participants demonstrated a solid understanding of concussive symptoms and possible adverse outcomes (eg, long-term disability), many would not report concussive symptoms due to factors such as wanting to keep playing and to avoid letting the team down. Additionally, investigators²⁰ suggested that knowledge about concussion symptoms alone failed to fully predict concussion-reporting behavior and that other attitudes influenced reporting behavior. However, a program involving a variety of formats, including slide presentations, videos, and case studies delivered by medical or health care student volunteers, improved both symptom knowledge and appropriate postconcussion responses in youth athletes immediately after the program.¹⁸

These findings support the need for a cultural change to enhance concussion safety, which has been promoted by several major research, health care, and athletic organizations, including the Institute of Medicine,¹² Centers for Disease Control and Prevention,²¹ National Collegiate Athletic Association (NCAA), and U.S. Department of Defense.²² For this cultural change to occur, additional approaches to concussion education are needed that not only increase concussion knowledge and awareness but also facilitate a change in attitudes and behavior that increase reporting and collaboration with health care personnel regarding a safe return to play.

Our aim was to describe the development and implementation of a novel peer concussion-education program (PCEP) designed to enhance concussion knowledge and reporting, with the ultimate goal of changing team norms to be more conducive to concussion safety. The PCEP's conceptual model was informed by the Theory of Reasoned Action and Planned Behavior (TRA-TPB), which has traditionally been applied to understanding attitudes and norms related to health behaviors.²³ The TRA-TPB posits that knowledge is a predictor of behavior only when group norms and other facilitating factors support the behavior.²³ The TRA-TPB has been used to explore the relationship among the intention to report concussion, an athlete's thoughts about how teammates perceive his or her behavior, and the effects of reporting on the team's performance.²⁴

The use of a peer-mediated approach to concussion education is further supported by studies demonstrating the effectiveness of peer-assisted learning and behavioral management in a range of populations, including school-aged children,²⁵ college students,²⁶ and Vietnam War veterans.²⁷ Moreover, in an anonymous survey,¹⁴ only 10% of collegiate athletes reported being unlikely or extremely unlikely to conceal symptoms of concussion from a teammate, leading the authors to suggest that including peers in concussion education might be valuable. Peer-mediated concussion education may also be beneficial for high school athletes. Among high school football players, most (76.7%) reported their concussions to a certified athletic trainer; however, a sizable minority (27.2%) disclosed the injury to a teammate.²⁸ The PCEP capitalizes on this tendency of student-athletes to be less likely to conceal a concussion from a teammate and perhaps more likely to entrust the information to a teammate. Given the PCEP's emphasis on changing team norms though a peer-mediated expectation that concussion reporting of self and teammates is a necessary and appropriate behavior, we anticipated that disclosure to teammates and possibly Peer Concussion Educators (PCEs) would, in turn, facilitate disclosure to health care professionals.

PROGRAM DESCRIPTION

Program Model and Rationale

The PCEP's conceptual model incorporates 3 components. The first component uses a peer-mediated approach to directly engage the primary constituents, student-athletes, in the change process. Most approaches to concussion education include educational videos and fact sheets that are essentially “top-down” approaches in which information is disseminated from an expert authority to student-athletes. Although these programs are portable and can be completed relatively quickly, changing the culture of concussion to one that supports reporting and safety is likely to require a multipronged approach. Therefore, concussion education is likely to be more effective when “top-down” approaches are combined with “bottom-up” or grassroots approaches such as peer education. The advantages of using a peer-mediated approach to concussion education are summarized in Table 1.

Table 1 Advantages of a Peer-Mediated Approach to Concussion Education

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The second component of the program uses a cognitive-behavioral model of change to identify thoughts that inhibit reporting concussions in oneself and teammates and to replace them with thoughts that facilitate reporting. Cognitive-behavioral therapy refers to psychological interventions developed by Albert Ellis²⁹ and Aaron Beck³⁰ with the basic premise that identifying and modifying cognitions leads to changes in behavior and a concomitant reduction in emotional distress. Researchers³¹ of behavioral change suggested that cognitively identifying barriers is a primary strategy for approaching behavioral change. An example of a cognition that inhibits self-reporting is “If I report my concussion, I will lose my spot.” An example of a replacement cognition that may increase reporting is “I can recover and be 100% and then play and have a better chance of keeping my spot than if I risk losing it with a concussion.” An example of a cognition that inhibits reporting a teammate is “My friend wants to keep playing, and he will be mad,” which can be replaced by “I am protecting him and he will be better when he comes back.” Consistent with the TRA-TPB, authors³² of a review of cognitive-behavioral theories and adherence to health-related behaviors found that changing the knowledge about a health condition alone was insufficient for altering behavior but changing cognitions associated with a specific health behavior was a key factor in improving healthy behaviors.

Finally, the third PCEP component uses an interdisciplinary approach to facilitate cultural change. Attempting to change the culture of concussion is a complex and challenging endeavor, as factors operating at multiple socioecological levels (eg, intrapersonal, interpersonal, and environmental) have the potential to undermine concussion safety.³³ Consequently, expertise shared by multiple professionals and resources from different departments across the college or university are likely to bring about the broadest and most significant change. Moreover, Knapp et al³⁴ asserted that interdisciplinary work can provide insights into complex problems, such as a culture that creates barriers to concussion safety. The PCEP uses an interdisciplinary team that can consist of faculty and staff from many departments, including athletics, academic affairs, and student life, to identify and support the PCEs and supervise the implementation of the program.

PROGRAM IMPLEMENTATION PROCEDURE

The PCEP is implemented using a 4-step procedure delineated in the online manual (https://www.chc.edu/peer-concussion-education/peer-concussion-education-program-manual) and summarized in Table 2. (An optional fifth step consists of a detailed process for assessing the program.) In the first step, an interdisciplinary team is formed to implement the PCEP. Ideally, an implementation team spanning multiple departments and consisting of professionals with varied areas of expertise is recommended; however, not all colleges or organizations may have access to a broad range of professionals with expertise in concussion or there may be logistical or organizational barriers (eg, a lack of collaborative relationships across departments) to involving professionals from different departments. At a minimum, the program-implementation team should consist of an athletic trainer, a coach from each participating team, and the director of athletics or an administrative designee.

Table 2 Steps of Peer Concussion-Education Program Implementation

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Next, 2 PCEs are selected from each team by a committee including a coach, athletic trainer, and administrator from the department of athletics. The candidates must be respected by most of the team. Individuals on the periphery with respect to social involvement or athletic prowess typically should not be selected. Also, a candidate should not be the coach's “favorite” unless the team also holds that individual in high regard. Additional criteria include leadership (both on and off the field), diplomacy, strong interpersonal skills and academic ability, and positive attitudes and behaviors toward health in general and dealing with concussion in particular. One PCE should be either a senior or junior and the other a sophomore or freshman to provide continuity after the graduation of the more senior student. The presence of 2 PCEs per team also allows for mutual support and allows team members to approach more than 1 PCE with concerns.

After being selected, the PCEs are trained by appropriate faculty or staff to provide Module 1 (“Enhancing Concussion Knowledge”) and then Module 2 (“Enhancing Concussion Reporting”). After completing the training, the PCEs meet with their respective teams and deliver Education Modules 1 and 2 to their teammates. Each module takes 20 to 30 minutes, and they are presented successively with a brief break in between. Because the information presented in Education Module 1 is at times technical and complex, an athletic trainer or other qualified faculty or staff member needs to be present. Conversely, faculty or staff are not present during Education Module 2 to emphasize the peer-mediated nature of the program, increasing the likelihood that the PCEs and their teammates will take ownership of the program and the candor of the responses.

Each team participates in the program annually. It is recommended that the program be implemented during preseason or after the student-athletes' return from summer break; however, each organization and team can determine the optimal time for implementation. More detailed information on the implementation procedure along with all of the materials needed to implement the PCEP is available in the online manual.

PROGRAM-DEVELOPMENT PROCESS

The preliminary concept and model for the PCEP came from the athletic and professional experiences of the authors, a consultation with an athletic trainer, and a review of the concussion-knowledge and -reporting literature. These sources of information were integrated, and the following conclusions were drawn. First, concussion knowledge alone, which is almost always obtained from sources outside the team, does not always translate into reporting.¹⁹ Therefore, an approach that consists of information presented by individuals from within the team that directly engages student-athletes in the educational process might increase the likelihood of translating concussion knowledge into reporting behavior. Next, student-athletes need more in-depth information on concussion, including the pathophysiological changes that occur in the brain, to appreciate its seriousness and the importance of allowing the brain to return to preinjury functioning before they return to play. Also, lesser known symptoms, such as sleep disturbance and affective changes,³⁵ should be emphasized to improve concussion identification. Including information on the RTP was also deemed important; we reasoned that if athletes had a greater understanding of the purpose of the RTP, they would be more likely to report their symptoms and collaborate with health care professionals. Finally, barriers to concussion reporting and strategies for mitigating those barriers needed to be identified by the student-athletes themselves to increase the relevance of concussion education. These conclusions informed the development of the program's educational modules.

Pilot Implementation and PCE Debriefing

After the modules were completed, we pilot tested the PCEP with the men's lacrosse and women's soccer teams. The concussion-reporting worksheets from Module 2 were collected, and sample cognitions were extracted and placed in separate tables for oneself and one's teammates (see Tables 3 and 4 for abbreviated lists). The tables were developed for use during the PCE training session to prepare the PCEs for the types of cognitions they might encounter when delivering Module 2 to their teammates. In addition, the tables were designed to allow the PCEs to compare cognitions generated by their teammates with those of a larger group during the presentation of Module 2 to facilitate awareness and discussion. Finally, the information in the tables provides the PCEs with a contingency in the event their teammates are reluctant or have difficulty discussing cognitions that inhibit or facilitate reporting.

Table 3 Exemplar Cognitions: Reporting Self

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Table 4 Exemplar Cognitions: Reporting Teammates

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After the pilot implementation, the 4 PCEs participated in a group debriefing and were asked to (1) describe their experiences serving as a PCE, (2) explain how the PCEP differed from traditional concussion-education programs, (3) discuss the characteristics of an effective PCE, and (4) provide recommendations for improving the PCEP (Tables 5 and 6). We read the transcript from the PCE debriefing multiple times, based on the recommendation of Creswell and Poth,³⁹ to develop an overall understanding of the phenomena before extracting meaning statements and themes. Recommendations from PCEs that we both deemed to be salient and feasible were selected. Those recommendations included implementing the program during the preseason or off-season and emphasizing interpersonal skills during the PCE selection process and were incorporated into the online manual. Simplifying and clarifying the terminology in Module 1 was also advised. We reviewed the Module 1 slide presentation with the PCEs and identified the changes to be implemented (eg, adding the term chemical messengers to explain neurotransmitters). Moreover, the slide presentation was shortened by condensing or omitting material (eg, abbreviating the slide describing the RTP and removing a slide of a magnetic resonance imaging scan depicting grey and white matter). The PCE debriefing was based on only 4 individuals. Consequently, information from a greater number of PCEs may result in further revisions to the PCEP.

Table 5 Peer Concussion Educators' Perceptions of the Peer Concussion-Education Program: Debriefing Statements

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Table 6 Recommendations from Peer Concussion Educators (PCEs) for Improving the Program and Its Education Modules

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The program-development process culminated in the completion of the online manual to allow broad dissemination of the PCEP. The online manual contains all of the necessary procedures and materials for implementing the PCEP, including a program overview, a description of the program's model and rationale, and a detailed 5-step process for implementing and assessing the PCEP. In addition, video excerpts from the faculty, staff, and student-athletes who participated in the pilot implementation are featured in the manual.

DISCUSSION

Sport-related concussions occur frequently,¹ and their rates are increasing among collegiate² and high school^4,5 athletes. These increased rates appear to be associated with advances in clinical assessment and management,⁶ greater availability of educational programs,⁷ and legislation mandating concussion management and education for youth athletes.⁸ Identification of concussion often depends in part on self-reports⁹; however, reporting has several barriers^12,13 operating at multiple socioecological levels, including intrapersonal, interpersonal, and environmental levels.³³ These barriers are likely to be associated with substantial rates of underreporting among collegiate^13–15 and high school¹⁶ athletes. Although several concussion-education programs are available and seem to increase knowledge, knowledge alone does not always increase reporting.¹⁹ In this article, we described the development of a novel PCEP designed to enhance concussion knowledge and reporting with the ultimate goal of changing team norms to be more conducive to concussion safety.

After a review of the literature, which provided preliminary information for the PCEP's conceptual model and content for its education modules, we conducted a focus group to better understand the culture surrounding concussion reporting, barriers to reporting, and factors that might facilitate reporting.³⁶ Barriers to reporting included uncertainty about symptoms and being less likely to report symptoms considered less severe. These knowledge-based barriers operate at the intrapersonal level³³ and supported the decision to provide comprehensive and in-depth information during Module 1 to augment the routine concussion education offered at an athlete's institution. In addition, these findings were incorporated into the PCE training by emphasizing that the PCEs should encourage teammates to report all suspected symptoms.

Barriers to reporting also included concerns about being removed from play, situational factors (eg, playoff game), and the expectation that both oneself and one's teammates should “push through” concussion and other injuries and play, regardless of the consequences. Pressure from teammates to continue playing after a head impact at the collegiate level has also been reported by previous authors.¹³ These barriers operate at both the intra- and interpersonal levels³³ and reinforced the decision to include a second education module focused on reporting by oneself and one's teammates. Moreover, when training the PCEs to deliver Module 2, we used the focus-group findings to provide contextualized examples of cognitions that inhibit reporting. The intra- and interpersonal barriers to concussion reporting identified by the focus-group participants and prior researchers also supported the rationale for developing and including the concussion-reporting worksheet activities, which are a key component of Module 2. These activities have the added advantage of directly engaging student-athletes in the education process. Moreover, the worksheet activities provide content for reflection throughout the season germane to student-athletes' intra- and interpersonal reporting barriers and modified cognitions to mitigate those barriers.

The pilot implementation allowed us to collect exemplar cognitions that inhibit and facilitate reporting. The exemplars were placed in tables that were used to train the PCEs to deliver Module 2. The PCE debriefing provided additional information used to refine Module 1, such as shortening its length and decreasing jargon. Finally, the PCE debriefing resulted in recommendations that included implementing the program during the preseason or off-season and emphasizing interpersonal skills during PCE selection.

Although coaches have been identified as a potential interpersonal barrier to concussion reporting,¹³ high school football players disclosed their concussions to coaches at a relatively high rate (38.8%).²⁸ These findings, along with the crucial role coaches play in establishing and maintaining team culture, warrant the inclusion of coaches in the concussion-education process. Although coaches do not receive or deliver either of the PCEP's education modules, they are still a key part of the program through their involvement in the PCE selection committee. Consequently, coaches are made aware of the program's objectives and, as a result, are in a position to strengthen the PCEP's goal of facilitating normative changes around concussion reporting and safety.

The environmental level of the socioecological framework is another important level of potential influence that may impede or facilitate concussion reporting.³³ The presence of athletic trainers and other health care professionals during practice and competition contributes to an environment that promotes safety. However, coverage at levels of competition below Division I is likely to be more variable, with a trend toward less coverage in Divisions II and III as well as in high school and club sports.³³ Although the PCEs have less knowledge than health care professionals, the information they acquire through the PCEP, along with the fact that they are embedded within their team throughout the year, places them in a position to be adjuncts to health care professionals with respect to facilitating safety changes at the environmental level.

CONCLUSIONS

The PCEP was developed based on the Theory of Reasoned Action and Planned Behavior and uses a peer-mediated, cognitive-behavioral, and interdisciplinary model to enhance concussion knowledge and reporting in collegiate student-athletes. The PCEP and its education modules were developed in a 3-step process. The first step involved integrating information from a literature review, consultation with an athletic trainer, and our own athletic experiences. The second and third steps consisted of a focus group and pilot implementation, respectively, which provided information for further refining the PCEP and its education modules. The development process culminated with an online manual designed to facilitate broad dissemination of the PCEP. The PCEP represents a unique contribution to concussion education in that 2 student-athletes per team are trained as PCEs to deliver the educational material directly to their teammates. Moreover, the PCEs lead their teammates in a concussion-reporting worksheet exercise in which cognitions that inhibit reporting are replaced with those that facilitate reporting for both oneself and one's teammates. This approach to concussion education attempts to change team norms associated with concussion reporting by directly engaging student-athletes in the education process and leveraging relationships among teammates to facilitate a change in the culture of concussion safety. Finally, unlike most concussion-education programs that are provided once per year, the PCEs are available to demonstrate safe behaviors and collaborate with their teammates and athletic trainers to reinforce the PCEP objectives throughout the year. The effectiveness of the PCEP was investigated during a national randomized controlled trial, and the results are reported in “Randomized Controlled Trial of a Novel Peer Concussion Education Program in Collegiate Athletes.⁴¹