Athlete concussion under-reporting and pressure from stakeholders

By: Christine Baugh

As concussions are increasingly seen as a public health problem, under-reporting and under-diagnosis of concussion is recognized as one barrier to improving the safety of sports participation. A number of studies have previously characterized the extent of under-reporting of concussions among athletes, particularly at the collegiate level. Furthermore, existing research has examined the applicability of theories of behavior change to concussion reporting and created relevant frameworks for examination. Although a growing body of evidence suggests that reporting (or not reporting) a concussion is a decision actively made by the athlete weighing relevant factors, the extent to which interpersonal, intrapersonal, environmental, or policy factors influence athletes’ decisions about whether or not to report a concussion is not fully understood.

A recent study, on which I am a co-author, titled “Concussion under-reporting and pressure from coaches, teammates, fans, and parents,” published in Social Science and Medicine aimed to understand one possible contributory factor to athlete under-report of concussion: pressure on athletes from relevant stakeholders. (Abstract available here.) The survey-based study queried a sample of 328 athletes from 19 contact or collision sports teams (notably excluding football and hockey teams) at 4 colleges in the northeast region of the United States. Among other things, the study asked athletes whether they experienced pressure to return to play after a head impact, specifically asking about pressure from coaches, teammates, parents, and fans.

Approximately one-quarter of athletes agreed that they had experienced pressure to return to play from at least one source. There was no significant difference in pressure reported by male and female athletes. Using statistical techniques, the authors determined that the best way to model the pressure experienced by athletes was to categorize a low pressure group that experienced minimal pressure from all sources, a team pressure group that experienced moderate or high pressure from coach and teammates and low pressure from other sources, and high pressure group that experienced moderate or high pressure from all sources. It is interesting, though perhaps unsurprising, to note that the high pressure group included more “first team” or “starter” athletes than the other two groups, indicating that these athletes may experience more pressure than their teammates to continue to play through concussion. Using this preferred three-group model, the authors found that individuals in the high pressure group had significantly lower intention to report their concussion symptoms than either of the other two groups. In previous work, intention to report concussion has been established as a significant predictor of concussion reporting behavior. In line with previous estimates, around half of the athletes in the study indicated that they had continued to play while experiencing a concussion.

This study adds to our current understanding of the interpersonal factors that may influence athletes’ decisions whether or not to report concussion. Timely reporting, diagnosis, and treatment is imperative as continued play through an unrecognized or unreported concussion can have serious neurological consequences. The authors wrote, “These findings underscore the importance of designing interventions that address the system in which athletes make decisions about concussion reporting, including athletes’ parents, rather than focusing solely on modifying the individual’s reporting cognitions.” Continued research on factors influencing athletes decision-making processes is needed in order to more fully understand the concussion reporting phenomenon.

[This post reflects my own views only.  It does not necessarily represent the views of the Petrie-Flom Center or the Football Players Health Study at Harvard University.]


At the end of her fellowship year, Christine Baugh was a PhD student in Health Policy at Harvard University. She received her BA in History and Science from Harvard College in 2010 and her MPH from Boston University School of Public Health in 2012, concentrating in Health Law, Bioethics, and Human Rights. At the time, Christine's primary research area was brain trauma sustained through sport, and she has written about the epidemiology, risk factors, policy approaches and implications, as well as the possible long-term effects of repeated brain injury. Broadly, Christine’s research interests involve the interaction between evolving science, policy, and society. While a student fellow at the Petrie Flom Center, Christine explored conflicts of interest in the collegiate sports medicine setting in a manuscript titled "Trust, Conflicts of Interest, and Concussion Reporting in College Football Players."

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