Provision of Concussion Information From Coaches and the Presence of Athletic Trainers: Findings From the 2021 YouthStyles Survey

Self-report data were analyzed from the youth wave (YouthStyles) of Porter Novelli’s 2021 ConsumerStyles survey.¹²  In June 2021, youth ages 12 to 17 years residing with parents who were members of the Ipsos’ KnowledgePanel and completed the 2021 SummerStyles survey were invited to answer the annual YouthStyles web-based survey. Ipsos’ KnowledgePanel adult SummerStyles members are randomly recruited using probability-based sampling and include respondents regardless of whether they have landline phones or internet access. Adult SummerStyles panel members participated in a corresponding survey immediately before their child’s YouthStyles participation and provided electronic consent for the youth to participate. A total of 833 adolescents (out of 1751 sampled parents) qualified, resulting in a completion rate of 47.6%. Adults who completed the survey received 10 000 cash-equivalent reward points (worth approximately $10), and youth received an additional 5000 points (worth approximately $5). Data were weighted to be nationally representative based on sex, age, race or ethnicity, education, household income and size, US census region, metropolitan status, and parental status of children ages 12 to 17 years. No personally identifying information was included in the data file provided to the Centers for Disease Control and Prevention (CDC).^* Access to SummerStyles data was granted through a data use agreement with Porter Novelli Public Services.

As part of a separate project examining the effect of question wording on mTBI reporting, respondents were randomly assigned to receive 1 of the following 2 questions to assess self-reported lifetime history of a brain injury (full survey is provided in the Appendix):

1. In your lifetime, do you believe that you have ever had a concussion?

2. In your lifetime, do you believe that you have ever had a mild traumatic brain injury?

Although a higher proportion of respondents reported having sustained a concussion (11.3%) than an mTBI (5.5%) during their lifetime, no differences were seen in the outcome of interest (ie, concussion safety). Therefore, responses to these 2 questions were combined to create a dichotomous “yes, concussion or mTBI” or “no, no concussion or mTBI” variable. Henceforth, all self-reported brain injuries will be referred to jointly as mTBIs. Four respondents were dropped from the analysis due to their failure to complete the mTBI questions, for a total analytic sample of 829 youth.

All respondents, regardless of their mTBI experience, were asked a series of questions regarding their past 12 months of sports participation. Questions included whether their coaches provided them with concussion safety information, how concerned they believed their coaches were about concussion safety, and the frequency of an AT presence at practices or games (see the Appendix for the full survey). We analyzed all data using SAS (version 9.4; SAS Institute Inc) and SPSS (version 29.0; IBM Corp). Frequency distributions were calculated for each question. We conducted χ² tests to determine if providing safety information differed by the presence of ATs. The complex survey design was considered in the analysis.¹² 

The demographic composition of the respondents is shown in Table 1. One in 12 (8.3%) respondents reported sustaining an mTBI in their lifetime (Table 2). Approximately 19.1% of respondents participated in only a school-based sport in the past 12 months, 13.2% participated in only a nonschool-based sports league, and 6.9% participated in both. Youth who played sports had a higher prevalence of lifetime mTBI (12.9%) than those who did not play any sports (5.0%; P = .0044; results not shown). More than 9 in 10 youth (91.5%) who reported participating in sports in the past 12 months played a contact or limited-contact sport, and about 21.2% played a noncontact sport (the categories were not mutually exclusive).

About 47.0% of youth who played sports indicated that their coaches talked to them about concussion, 32.0% indicated that their coaches gave them a printed handout about concussion, and 22.9% indicated that their coaches sent them an email or had them watch a video about concussion in the last 12 months. Overall, 57.5% of youth who played sports reported that their coaches provided any sort of concussion education or information to them in the past 12 months; this percentage was higher among youth who played only school sports (65.0%) than youth who played only nonschool sports (39.1%; data not shown). Two-thirds of respondents (66.0%) agreed or strongly agreed that their coaches were concerned about concussion safety. About half noted that they always or sometimes had ATs at practices (54.7%) or games (54.5%) in the past 12 months; overall, 63.4% of youth athletes always or sometimes had ATs at practices or games in the last 12 months. Always or sometimes having access to ATs was more common among youth who played only school sports than those who played only nonschool sports (71.6% and 49.3%, respectively; data not shown).

Always or sometimes having an AT at practices or games was associated with a greater proportion of coaches providing concussion education to their athletes (Table 3). Among those who always or sometimes had ATs at their practices or games, 63.3% reported that a coach talked to them about concussion compared with 23.9% of those who rarely or never had ATs at practices or games (P < .0001). Similarly, among those who always or sometimes had ATs at practices or games, 41.6% were given a handout about concussions from coaches, in contrast to the 20.4% given a handout who rarely or never had ATs at practices or games (P = .0014). Also, among the youth who always or sometimes had ATs at practices or games, 33.5% received an email or watched a video from their coaches about concussion safety, compared with 8.8% of those who rarely or never had ATs at practices or games (P < .0001). Overall, among those youth who always or sometimes had ATs at practices or games, 76.2% received some type of coach education on concussion in the past 12 months compared with 31.9% of those who rarely or never had ATs at practices or games (P < .0001).

This study demonstrated that mTBI is common among youth, as 8.5% of adolescents reported a lifetime mTBI. Additionally, those who had played sports in the past year had a higher prevalence of lifetime mTBI than those who had not. Concerns about repeat concussions or mTBIs, as well as the possible long-term effects of concussions and mTBIs on young athletes, have led to several efforts to address concussion prevention and response among youth. Unfortunately, in 1 investigation,¹³  more than 50% of high school athletes did not report their concussions, which compromises the ability of coaches, health care professionals, and others to protect them from the potentially harmful consequences of concussions and mTBIs. Common reasons for not reporting concussions or mTBIs include inadequate understanding of the seriousness of the injury, not wanting to be removed from play, and not wanting to let teammates down.¹³ 

Researchers¹⁴  have suggested that coach communication with athletes about concussion increases the likelihood of symptom reporting by helping to set safety-promoting norms regarding reporting and being removed from play when injured. Supporting this effort includes building awareness of concussion among coaches and providing education. High school coaches are required to receive educational materials or training about concussion in nearly all states.¹⁵  Still, despite these widespread efforts, 2 in 5 youth athletes in this study indicated that they did not receive any concussion information from their coaches in the past 12 months. Coaches may not communicate with athletes about concussion due to a lack of objective criteria for diagnosis and recovery of concussion, pressure to win, and the belief that they should defer to the medical staff because it is not their role.¹⁶  Conversely, other efforts to improve coach-athlete communication about concussion include focusing educational materials on improving coaches’ attitudes and beliefs about concussion¹⁷  and educational interventions addressing the importance of encouraging coach concussion communication.¹⁸ 

Coaches value communication with medical staff about athlete health and often describe a positive relationship.¹⁶  We found that always or sometimes having access to an AT at practices or games was positively associated with the provision of education to athletes by coaches. Although this result is encouraging and despite the well-documented benefits to athlete safety, expanding access to ATs is an ongoing challenge. Data collected as part of the Athletic Training Locations and Services Project demonstrated that access to AT services varied widely by state; only 1% of secondary schools in Alaska had full-time AT services versus 80% of secondary schools in New Jersey.¹⁹  We determined that as many as a third of athletes rarely or never had any AT access at practices or games, which closely matches national estimates.¹⁹  Additionally, AT access was more common among youth who played only school sports than those who played only nonschool sports. Earlier authors¹¹  noted that access to ATs increased concussion identification among athletes. This information is vital, as ATs play a key role in concussion prevention efforts in primary prevention (preventing concussions), secondary prevention (identifying and diagnosing concussions), and tertiary prevention (managing athletes with concussions). Furthermore, ATs help ensure that athletes do not return to play prematurely, thereby decreasing the potential long-term effects of concussion and the risk of sustaining a repeat concussion. High schools with greater AT access had better engagement with coaches and parents, which increased the likelihood that management recommendations (eg, limiting early return to sport and monitoring school performance and physical exercise) were being followed.²⁰  As the AT’s role in concussion safety involves working with various stakeholders (eg, coaches, parents, school professionals, and athletes themselves), the CDC, in partnership with the National Athletic Trainers’ Association, created an online training course for ATs that includes best practices for implementing concussion safety and response plans, as well as how to bring stakeholders together to promote a culture of concussion safety.²¹ 

Our study was subject to at least 2 limitations. First, the data only allowed for reporting associations, not causality. It is possible that the types of environments that have a greater AT presence are the same environments that have a more robust safety culture overall and thus are more likely to require that coaches provide concussion information to athletes. Second, data in the survey were based on self-reports and are therefore subject to recall bias. However, the data do provide preliminary findings that can be used to inform larger, more robust studies.

Several efforts to promote concussion safety among coaches have been implemented over the last decade. Still, 2 in 5 youth athletes in this study indicated that they did not receive any concussion information from their coaches in the past 12 months. Increasing access to ATs and adapting current concussion training and educational materials for coaches to increase their focus on the importance of coach-athlete communication may be beneficial.

(Note: Questions 1a and 1b were randomized so that half of respondents were shown each version.)

In your lifetime, do you believe that you have ever had a concussion?

Select one.

In your lifetime, do you believe that you have ever had a mild traumatic brain injury?

Select one.

Do you currently or did you participate in an individual or team sport during the last 12 months?

Select all that apply.

Which sport(s) did you participate in?

Select all.

Did your coach(es) talk to you about concussion within the last 12 months?

Select one.

Did your coach(es) give you a printed handout or make you read about concussion within the last 12 months?

Select one.

Did your coach(es) send you an email or have you watch a video about concussion within the last 12 months?

Select one.

My coach(es) is/are concerned about concussion safety.

Select one.

How often did you have an athletic trainer at practices in the last 12 months?

Select one.

How often did you have an athletic trainer at games in the last 12 months?

Select one.

When is a good age for kids to start playing tackle football?

Select one.

Do you think it is safe for kids to play tackle football?

Select one.