Although it is commonly estimated that between 1.1 million and 1.9 million sports-related concussions occur in U.S. youth each year, many of these are not reported (Bryan, Rowhani-Rahbar, Comstock, Rivara, & Seattle Sports Concussion Research Collaborative, 2016). Accurate and prompt reporting behavior is imperative, as a diagnosis is largely dependent on self-reported symptoms. Symptoms may vary in their quality and severity but frequently include headache, confusion, reduced coordination, dizziness, and ringing in the ears. To date, more objective biomarkers of concussion remain elusive (Kim, Tsao, & Stanfill, 2018).

Although there are studies that measure coaches', athletic trainers', and athletes' knowledge of concussion symptoms (Kaut, DePompei, Kerr, & Congeni, 2003; Naftel, Yust, Nichols, King, & Davis, 2014; Torres et al., 2013; White et al., 2014), some studies show that despite an adequate knowledge base, concussion symptoms are still minimized or unreported (Anderson, Gittelman, Mann, Cyriac, & Pomerantz, 2016; Kurowski, Pomerantz, Schaiper, Ho, & Gittelman, 2015). If the athlete continues to play while injured, this may place the athlete at risk for further injury or possible long-term sequelae. At the very least, a failure to be immediately removed from athletic activity when concussed predicts a prolonged recovery trajectory (Asken et al., 2016). Underreporting behaviors have been shown to be especially common among high school (McDonald, Burghart, & Nazir, 2016; Register-Mihalik, Guskiewicz, et al., 2013) and collegiate athletes (Meier et al., 2015). Although education about concussions, coaches' attitudes, and social norms have been shown to be associated with concussion-reporting behaviors in secondary school athletes, these factors are tempered by the availability of medical professionals and a fear of not letting people down (Kay, Welch, & Valovich McLeod, 2015). Other factors may also be found to play a role for both high school and collegiate athletes, given the recent explosion in concussion literature on such topics.

The purpose of this systematic review was to describe barriers and facilitators for concussion reporting among high school and college athletes. The goal of this work was to enhance our knowledge of these factors in order to design more effective interventions that will then increase reporting behavior for these athletes.

METHODS

A systematic review was completed using PubMed, SCOPUS, CINAHL Complete, and Cochrane Library to better identify barriers and facilitators to reporting of concussions by high school and collegiate student athletes. Search terms included "concussion" OR "mild traumatic brain injury" AND "athlete." These were combined with the terms "self-report," OR "reporting," OR "reporting behavior." Other terms were used early on in the development of this systematic review, including "brain injury," "traumatic brain injury," and "*report*" (allowing for wildcards on either end that would include unreported/unreporting/nonreported/nonreporting), but these were not found to be precise enough for our research question and returned many results on more severe forms of traumatic brain injury. Results were limited to those published in English and to studies using human subjects. Original research articles were deemed eligible if they contained either qualitative or quantitative data on facilitators and barriers of high school and collegiate athletes self-reporting concussion symptoms to athletic staff (defined for our purposes as any adult acting in an official capacity on behalf of the athletic team). Specific reasons must have been stated in the article for either reporting or not reporting these symptoms, although no particular symptom or category of symptom (i.e., physical, cognitive, or emotional) of concussion weighed more heavily than any other. Rather, the focus for our review was on an athlete having any possible symptom of concussion and then reporting or not reporting that information to athletic staff. Furthermore, an intention or attitude related to reporting was not sufficient; only the actual act of reporting was considered sufficient for inclusion in this review as this is what will decrease playing while injured and will enable the athlete to get proper medical attention. The search was deemed complete on October 10, 2018. After duplicates were removed, the reference lists of articles included in this review were searched for other relevant articles, and more recent studies were identified through a reverse-citation search on Google Scholar.

RESULTS

The aforementioned search parameters resulted in 878 articles from which 24 met criteria to be included in this review. During the screening phase, the majority of articles (827) were eliminated for the following reasons (most to least common): did not measure reasons for reporting or not reporting to athletic staff; population was not high school or collegiate athletes; article was a review article; article discussed only the likelihood of experiencing a particular symptom; study was not performed in human subjects; and publication was in a language other than English. For a PRISMA-style diagram of the included articles and a brief description of those that were screened but removed during the eligibility phase, see Figure 1 (Liberati et al., 2009).

Figure 1. PRISMA diagram of included and excluded studies (

The authors critically read each article and summarized reasons for reporting or not reporting concussive symptoms to athletic staff. For each reason, the authors categorized this into a barrier or a facilitator of concussion-reporting behavior. The summary of these reasons is included in Table 1 and further described later.

TABLE 1 Facilitators and Barriers to Reporting of Sports-Related Concussion Among High School and Collegiate Athletes

Facilitators

Demographic characteristics may contribute to concussion-reporting behaviors. Female sex was the most common facilitator for reporting symptoms of concussion to athletic staff (Cusimano et al., 2017; Kurowski, Pomerantz, Schaiper, & Gittelman, 2014; Miyashita, Diakogeorgiou, & VanderVegt, 2016; Wallace, Covassin, & Beidler, 2017), whereas younger age (Baugh, Kroshus, Daneshvar, & Stern, 2014; Davies & Bird, 2015; Kurowski et al., 2014) and participation in soccer (Kurowski et al., 2014) were other facilitators for reporting behavior. Increased knowledge of potential long-term effects of untreated concussion was cited in three studies (Chrisman, Quitiquit, & Rivara, 2013; Kurowski et al., 2014; Lininger, Wayment, Huffman, Craig, & Irving, 2017). Two studies discussed that having a medical professional present at the time of the injury may increase reporting behavior (Delaney, Lamfookon, Bloom, Al-Kashmiri, & Correa, 2015; Register-Mihalik, Linnan, et al., 2013).

Barriers

The most common barrier to reporting of concussion symptoms by student athletes was a fear of losing current or future playing time. This was cited in the majority (16/24) of included studies (Chinn & Porter, 2016; Chrisman et al., 2013; Davies & Bird, 2015; Delaney et al., 2015; Donnell, Hoffman, Sarmiento, & Hays, 2018; Kerr, Register-Mihalik, Kroshus, Baugh, & Marshall, 2016; Kroshus, Baugh, Daneshvar, & Viswanath, 2014; LaRoche, Nelson, Connelly, Walter, & McCrea, 2016; Llewellyn, Burdette, Joyner, & Buckley, 2014; McCrea, Hammeke, Olsen, Leo, & Guskiewicz, 2004; McDonald et al., 2016; Miyashita et al., 2016; Register-Mihalik, Guskiewicz, et al., 2013; Wallace, Covassin, & Beidler, 2017; Wallace, Covassin, Nogle, Gould, & Kovan, 2017a,2017b). Other common barriers were that the student athletes did not feel that their injury was serious (n = 15 studies; Chinn & Porter, 2016; Cusimano et al., 2017; Davies & Bird, 2015; Delaney et al., 2015; Donnell et al., 2018; Kerr et al., 2016; LaRoche et al., 2016; Llewellyn et al., 2014; McCrea et al., 2004; McDonald et al., 2016; Miyashita et al., 2016; Register-Mihalik, Guskiewicz, et al., 2013; Wallace, Covassin, & Beidler, 2017; Wallace, Covassin, Nogle, et al., 2017a,2017b), they did not want to let their team down (n = 14 studies; Anderson et al., 2016; Chrisman et al., 2013; Davies & Bird, 2015; Delaney et al., 2015; Donnell et al., 2018; Kerr et al., 2016; Kroshus et al., 2014; Lininger et al., 2017; Llewellyn et al., 2014; McCrea et al., 2004; Register-Mihalik, Guskiewicz, et al., 2013; Wallace, Covassin, & Beidler, 2017; Wallace, Covassin, Nogle, et al., 2017a,2017b), or they were not sure that the injury was a concussion (n = 13 studies; Chinn & Porter, 2016; Chrisman et al., 2013; Cusimano et al., 2017; Davies & Bird, 2015; Kerr et al., 2016; Lininger et al., 2017; Llewellyn et al., 2014; McCrea et al., 2004; McDonald et al., 2016; Register-Mihalik, Guskiewicz, et al., 2013; Wallace, Covassin, & Beidler, 2017; Wallace, Covassin, Nogle, et al., 2017a,2017b). Some form of external pressure to not report was mentioned in many studies (Chinn & Porter, 2016; Chrisman et al., 2013; Cusimano et al., 2017; Delaney et al., 2015; Donnell et al., 2018; Kroshus et al., 2014; Kroshus, Kubzansky, Goldman, & Austin, 2015; Lininger et al., 2017; Register-Mihalik, Guskiewicz, et al., 2013). This pressure were attributed to teammates, coaches, fans, or parents (Chinn & Porter, 2016; Chrisman et al., 2013; Cusimano et al., 2017; Delaney et al., 2015; Donnell et al., 2018; Kroshus et al., 2014; Kroshus et al., 2015; Lininger et al., 2017; Register-Mihalik, Guskiewicz, et al., 2013). Other studies reported that student athletes stated that they did not want to be seen as "weak" or that they felt that it was embarrassing to report a concussive injury (n = 7 studies; Chrisman et al., 2013; Cusimano et al., 2017; Donnell et al., 2018; Kroshus et al., 2014; Wallace, Covassin, & Beidler, 2017; Wallace, Covassin, Nogle, et al., 2017a,2017b). Some (n = 6) studies reported that the coaches' attitudes (whether the coach became angry or upset or was disappointed in the student) influenced reporting behavior (Baugh et al., 2014; Chinn & Porter, 2016; Chrisman et al., 2013; Miyashita et al., 2016; Register-Mihalik, Guskiewicz, et al., 2013; Wallace, Covassin, Nogle, et al., 2017a). Some student athletes did not report because they were concerned that they would jeopardize their future athletic career by reporting or they felt that they might risk an athletic scholarship if they were to report (n = 6 studies; Chinn & Porter, 2016; Delaney et al., 2015; Donnell et al., 2018; Wallace, Covassin, & Beidler, 2017; Wallace, Covassin, Nogle, et al., 2017a,2017b). Finally, other less common reasons related to the timing of the concussion (n = 4 studies; Delaney et al., 2015; Wallace, Covassin, & Beidler, 2017; Wallace, Covassin, Nogle, et al., 2017a,2017b) were mentioned, including concerns for upsetting the family of the student athlete (n = 4 studies; Delaney et al., 2015; Wallace, Covassin, & Beidler, 2017; Wallace, Covassin, Nogle, et al., 2017a,2017b), not wanting to go to the doctor (n = 3 studies; Wallace, Covassin, & Beidler, 2017; Wallace, Covassin, Nogle, et al., 2017a,2017b), a lack of health insurance (n = 3 studies; Wallace, Covassin, & Beidler, 2017; Wallace, Covassin, Nogle, et al., 2017a,2017b), strong identity as "an athlete" (n = 3 studies; Chrisman et al., 2013; Kroshus et al., 2015; Lininger et al., 2017), sports-specific cultural issues (n = 3 studies; Cusimano et al., 2017; Delaney et al., 2015; Lininger et al., 2017), and concerns for how reporting might affect the athlete's standing within the team (n = 3 studies; Delaney et al., 2015; Donnell et al., 2018; Kroshus et al., 2014). A general culture of underreporting behavior was mentioned in two studies (Kroshus et al., 2015; Register-Mihalik, Linnan, et al., 2013), and the latter mentioned that a perception of control over reporting behavior could be influential (Register-Mihalik, Linnan, et al., 2013). Single studies also mentioned that a lower GPA was associated with underreporting (LaRoche et al., 2016), along with other reasons such as a fear of isolation from teammates (Delaney et al., 2015), a misconception that it is not risky to play when injured (Delaney et al., 2015), a concern that he or she cannot return to play when ready (Kroshus et al., 2014), and the ability to sandbag diagnostic testing (Lininger et al., 2017).

DISCUSSION

Our systematic review found that major facilitators in reporting of sports-related concussions are female sex and younger age. The major barriers are a fear of losing current or future playing time, a misconception that concussive injury is not serious, a fear of letting the team down, and a lack of knowledge of concussive injury signs and symptoms. All of these would be amenable to educational intervention, as has been suggested or incorporated into interventions by different groups (Carroll-Alfano, 2017; Daugherty et al., 2019; Greenwald, Chu, Beckwith, & Crisco, 2012).

Yet, underreporting of concussion symptoms remains a serious problem for high school and collegiate athletes. This problem has been addressed through legislation to increase education and to earmark funds for prevention and treatment programs (National Conference of State Legislatures, 2018). Although the specifics vary by state, all 50 states have some requirements in place. More specifically, these programs aim to protect young athletes from further injury and/or returning to play too early, with many states requiring concussion training for coaches (see http://www.ncls.org/research/health/traumatic-brain-injuries-among-youth-athlete for further information; National Conference of State Legislatures, 2015). Although these efforts have led to improved general knowledge of concussion symptoms, many concussions are still going unreported despite an adequate knowledge base (Kurowski et al., 2014, 2015). Many of the mandated educational efforts have focused more on recognizing the symptoms of concussion and have not specifically emphasized the risk of continued play while concussed. It is reasonable to think that an increased knowledge of the risks of not reporting a concussion would have the potential to foster safe behaviors, although Anderson et al. (2016) and Chinn and Porter (2016) have shown that despite having knowledge of both concussion symptoms and risks of playing while concussed, underreporting remains an issue. Despite this, future educational and intervention efforts should focus on the dual prongs of concussion symptom recognition and the dangers of playing while concussed.

Adding to this underreporting problem, educational efforts to increase reporting behavior suffer from disparities by age, parental income, sex, and geographical area (Donnell et al., 2018). We have shown here that a younger age and female sex are facilitators to better reporting behavior. Thus, disparities in these characteristics are concerning. One study even demonstrated that girls are more likely than boys to alter their reporting behavior after educational interventions (Miyashita et al., 2016). Ideally, future student athletes should be indoctrinated into safe concussion-reporting behaviors prior to their involvement in sports at the more advanced level as seen in high school and college (Daugherty et al., 2019). Educational efforts must occur then in primary schools, with age-appropriate information being given at each level. As the athlete develops, additional detail and reasoning can be given such that information is tailored as the child advances in cognitive capability and in educational status. But in any circumstance, all efforts should be made to reduce concussion education disparities to eliminate some of these effects and to specifically target those who are more likely to exhibit behavioral change in response to education (i.e., younger and female athletes).

But researchers and health care providers must intervene in other areas outside of player education. Educational efforts need to also focus on coaches, as we found here that pressure from coaches and the attitudes of coaches were possible barriers to reporting behavior. It is imperative that coaches understand the importance of being approachable by their athletes to better evaluate their possible symptoms of concussion. Coaches who present a supportive attitude will likely have safer reporting behaviors practiced within their teams. Likewise, effective education for parents, teammates, and fans is likely to promote more supportive practices. Future interventions should include relationship-building activities to promote trusting relationships among athletes, teammates, and coaches in order to increase reporting behavior. Parents of student athletes would benefit from focused and interactive education with coaches in order to increase communication and trust. Fans would also benefit from further education on the serious nature of playing while concussed so that they will not inadvertently create further pressure on an athlete to continue play.

Ongoing availability of on-site athletic trainers present during all practices and games may also be important to increasing reporting behaviors (Delaney et al., 2015; Register-Mihalik, Linnan, et al., 2013). An injured student athlete may take comfort in being evaluated by a dispassionate professional who is uninvolved in the outcome of the game (vs. being evaluated by a coach who is motivated to win). An unaffiliated health care professional may be one of the best options to alleviate any ongoing player concerns about the partiality of assessment. The student athlete knows that the evaluation is unbiased, and return-to-play decisions become clearly secondary to medical need. It is imperative that health care professionals and athletic trainers should be easily accessible and trusted by the student athletes in any concussion interventions (Table 2).

TABLE 2 Specific Suggestions for Future Concussion-Reporting Interventions

Any future interventions will also utilize all of the following strategies, which can be categorized into either primary or secondary prevention (Pless & Hagel, 2005). A primary prevention strategy is one whereby injury is prevented and includes items such as the implementation of more effective safety equipment, hit counts or head impact monitoring (though the precise "danger" threshold may as of yet be up for debate), and coaching or playing strategies that decrease the potential for injury (Greenwald et al., 2012). Sports that are most likely to have head impact could even undergo a modification of the rules in order to minimize injury (e.g., flag football instead of tackle football).

However, it is unrealistic to think that all sports-related concussions are preventable. Secondary prevention strategies can then help prevent future injury after a concussive injury has already occurred. These include educational efforts to increase knowledge of concussion signs/symptoms and the risks of playing while concussed, the development of strict guidelines for removal from play (along with consequences for athletic departments if they are not followed), the engagement of sideline concussion-specific medical personnel, and threshold-based head impact monitoring, in which any head impact that registers at a potentially concussive threshold triggers automatic removal from play (Greenwald et al., 2012).

Limitations

Given the relatively small number of studies meeting inclusion criteria for this review, a formal analysis of study quality or bias could not be completed. However, several concerns were identified. Many of the included studies had relatively small sample sizes, which may introduce bias. Chrisman et al. (2013), Cusimano et al. (2017), Lininger et al. (2017), and McDonald et al. (2016) all had sample sizes of less than 100. It is not clear whether this may have biased some of our results.

Our review included articles with both fixed response and open-ended questions (Table 1). These methods of questioning could elicit very different responses and also introduce bias if only fixed responses are used. Furthermore, data collection instruments were not available for many of the included studies, and so it was not clear whether all studies evaluated each of the possible barriers and each of the possible facilitators to concussion-reporting behavior. Future researchers should include all data collection instruments in publications such that this information could be easily evaluated.

Another limitation lies in the nature of the specific barriers and facilitators that were reported. Each barrier and facilitator is reported in the language that was used by the original authors, and so it is possible that the opposite characteristic could potentially also be associated with reporting behavior. For instance, female sex was found to be a facilitator of reporting behavior in four studies. But we cannot fully conclude from this information that male sex would be a barrier for reporting behavior.

CONCLUSIONS

Despite these limitations, we found that female sex and younger age are facilitators for concussion reporting, while a fear of losing current or future playing time, a misconception that concussive injury is not serious, a fear of letting the team down, and a lack of knowledge of concussive injury signs and symptoms are barriers to reporting of concussion symptoms. Educational efforts should focus on these factors and should be inclusive of players, teammates, coaches, and fans. Early intervention and education will be key to increasing reporting behavior among high school and collegiate student athletes.

KEY POINTS

* Female sex and younger age were found to be major facilitators of concussion-reporting behavior.

* Barriers were a fear of losing playing time and of letting one's team down.

* A lack of knowledge of concussion symptoms and severity also was a barrier.

* Future interventions should address these issues and emphasize the long-term risks of playing while concussed.

Acknowledgments

This study was funded by the University of Tennessee Health Science Center, College of Nursing Dean's Research fellowship award (PI: Stanfill). The authors thank Mr. Curtis Roby for his editorial assistance with the manuscript and Ms. Ryan Blue for her beginning work in the development of the theme of the manuscript.

REFERENCES