The development, implementation, and evaluation of a theory-based concussion education programme for secondary school Gaelic Athletic Association (GAA) athletes
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Sport-related concussion (SRC) is a public health concern (Thurman, Branche, & Sniezek, 1998), especially among children and adolescent athletes, as their brains are still developing (Field, Collins, Lovell & Marron, 2003; Halstead & Walter, 2010; Toledo et al., 2012). Each year, it is estimated that between 1.1 to 1.9 million sport- and recreational-related concussions are sustained by US children ≤18 years old (Bryan, Rowhani-Rahbar, Comstock, & Rivara, 2016). Empirical evidence suggests that athletes who fail to report symptoms of a possible concussion and continue to play while experiencing symptoms are at increased risk of further injury and potential catastrophic brain injury (Bramley, Patrick, Lehman, & Silvis, 2011; McCrory et al., 2017), including second impact syndrome (Cantu, 1998; McCrory & Berkovic, 1998). Yet, many concussions go unreported and therefore undiagnosed (Chrismnan, Quitiquit, & Rivara, 2013; LaRoche, Nelson, Connelly, Walter, & McCrea, 2016; Llewellyn, Burdette, Joyne, & Buckley, 2014; McCrea, Hammeke, Olsen, Leo, & Guskiewicz, 2004; Meehan, Mannix, O’Brien, & Collins, 2013; Register-Mihalik et al., 2013a). One way to approach the underreporting of SRC and to limit the potential negative consequences of this injury is through concussion education and awareness programmes (Tator, 2012). Such programmes are increasingly being mandated for athletes across athletic populations and competition levels (Kroshus, Baugh, Daneshvar, & Viswanath, 2014a; Tomei, Doe, Prestigiacomo, & Gandhi, 2012). However, the immediate- and short-term impact of current concussion education programmes is not clear. To answer this critical gap in the literature, this study set out to systematically develop, implement, and evaluate a theory-driven concussion education and awareness programme for secondary school-aged Gaelic Athletic Association (GAA) athletes, an under-studied population of athletes. In order to do this, this study used a multi-method approach. The first phase of this study assessed the concussion-related training and education needs of GAA coaches in Ireland, as well as the preferred method of concussion education delivery. Using a self-report questionnaire data was collected electronically from a convenience sample of 108 GAA coaches. Data were captured on coaches’ (i) informational needs and desires, (ii) preferred methods of delivery, and (iii) concussion practices and procedures. Coaches indicated that they were most interested in receiving information about the (i) signs and symptoms of concussion, (ii) assessment of concussion, and (iii) return-to-sport guidelines. Over two-thirds of participants indicated that in-person training would be the most effective mode of delivery of concussion education for this population of coaches. Additional results demonstrated that an overwhelming majority of coaches (90%) do not talk to their athletes about concussion and the importance of disclosing symptoms to a supervising adult, prior to the start of the athletic season. Coaches who reported being formally educated about concussion were more likely to indicate that they talk to their teams about concussion and concussion safety. Baseline data was then collected from athletes (Phase II), in order to assess their concussion-related knowledge, attitudes, intentions, and reporting behaviours; and to explore whether gender differences are evident. A total of 435 secondary school-aged GAA athletes (52.2% female; mean age, 14.55 ± 1.67 years) completed the survey. Approximately 60% of the participants stated that they have played in practice or during a game (this season) with concussion symptoms. Participants demonstrated an incomplete understanding of concussion including the signs and symptoms, mechanism, and potential health consequences of this injury. Findings also revealed that some athletes have unfavourable attitudes towards concussion and concussion safety. Compared with their female counterparts, males expressed more negative outcomes of concussion reporting and lower concussion reporting intention. The third phase of this study evaluated the immediate and short-term effectiveness of the concussion education programme. To evaluate this programme, the study employed a non-randomised control group pretest-posttest design, with the intervention group receiving the full concussion education programme, and the control group receiving no form of concussion education. Assessments were carried out before (T1), immediately after the delivery of the intervention (T2), and at three-months post-implementation (T3). The control group did not complete the assessment at T2 (immediately after the delivery of the intervention). The process of implementation was also examined at T2 using a structured questionnaire. A total of seven teams from five schools (n = 428) were assigned to either the intervention (n = 229) or control group (n = 199). 212 participants (59 intervention group; 153 control group) completed assessments at all timepoints. It is clear from the evaluation that this programme resulted in a number of significant positive effects, immediately following programme implementation and at three-months follow-up. Specifically, the programme had a significant positive effect on athletes’ knowledge, perceived behavioural control (PBC), and reporting intention. These results were maintained at three-month follow-up, with the exception of PBC. The programme did not have a significant impact on athletes’ attitudes towards concussion reporting and subjective reporting norms. Nonetheless, the programme was well received by participants. The fourth and final phase of this study used a longitudinal study design to assess athletes’ PBC, attitudes towards the perceived consequences of reporting, subjective reporting norms, reporting intentions, and in-season reporting behaviours. Data were collected from 153 secondary school-aged athletes ages 12 to 18 during the 2016-2017 academic year (102 females; 51 males). Consistent with the TPB, results revealed that PBC and reporting intentions contributed to the prediction of disclosure behaviours. Reporting intentions, in turn, were strongly influenced by PBC, attitudes, and subjective norms. Unlike previous reports (Kroshus et al., 2014a; Kroshus, Baugh, Daneshvar, Nowinski, & Cantu, 2015a; Register-Mihalik et al., 2013b), I found PBC to be the strongest predictor of concussion reporting intentions and in-season reporting behaviours among this population of adolescent athletes. As this is the first study, to systematically design, implement and evaluate the effectiveness of a theory-driven concussion education programme, this study is well positioned to make a novel contribution to the literature. These findings revealed that many athletes’ lack knowledge about concussion, which may lead to delayed recognition/reporting of concussion and to delayed care seeking behaviours, thereby prolonging symptoms and recovery (Asken et al., 2016; Asken, Bauer, & Guskiewicz, 2018; Elbin et al., 2016; Thomas et al., 2018). Results also revealed that many athletes have unfavourable attitudes towards concussion and concussion safety; thus, highlighting the need for additional actions to change athletes’ perceptions of concussion and the culture of concussion reporting among youth GAA athletes. Furthermore, these findings suggest a need for a multifaceted approach to concussion education and prevention, tailored to the needs and learning preferences of the target population. Health promotion communication campaigns, coupled with concussion education and awareness programmes, could be utilised to further highlight the importance of timely concussion management, and to create a culture in which the reporting of concussion is considered normative. At a national level, these results could be used to inform the development of concussion legislation and policy to promote the protection of young athletes involved in sport. At a broader level, the use of the Intervention Mapping (IM) process to systematically design and evaluate the programme will advance the field’s understanding of theory-driven and educational interventions.