Copyright by Carisa Maria Raucci 2015

by Carisa Maria Raucci 2015

THE DISSERTATION COMMITTEE FOR CARISA MARIA RAUCCI CERTIFIES THAT THIS IS THE APPROVED VERSION OF THE FOLLOWING DISSERTATION:

The Effects of Knowledge, Attitudes, Self-Efficacy, and Treatment

Practices on Concussion Management in the High School Setting

Committee:

Mary A. Steinhardt, Supervisor

Jessica Duncan Cance, Co-Supervisor

John B. Bartholomew

Fred L. Peterson

Edmund T. Emmer

The Effects of Knowledge, Attitudes, Self-Efficacy, and Treatment

Practices on Concussion Management in the High School Setting

CARISA MARIA RAUCCI, B.S., M.S.ED.

DISSERTATION Presented to the Faculty of the Graduate School of The University of Texas at Austin

in Partial Fulfillment of the Requirements for the Degree of

DOCTOR OF PHILOSOPHY

THE UNIVERSITY OF TEXAS AT AUSTIN MAY 2015

Acknowledgements

I would like to thank all of those that have been instrumental in supporting me through the doctoral process, because without you, this would still be a thought in the back of my mind. First, I would like to thank my advisor and co-chair of my dissertation committee, Dr. Mary Steinhardt. Your dedication to me and the athletic department have been unyielding. Thank you to the co-chair of my dissertation committee, Dr. Jessica

Cance, for showing me the ropes and giving me the confidence I needed to succeed. Thank you to Dr. Fred Peterson for taking a chance on me and giving me the opportunity to be a part of the Kinesiology and Health Education department. Without you, I would not be here. Thank you to Dr. John Bartholomew for showing me there are no limits when it comes to bridging athletics and academics. Thank you to Dr. Ed Emmer for showing me how exciting and beneficial qualitative analyses can be. Thank you to Tina Bonci for all of your words of wisdom. I wish you were here to see the final product.

I also want to acknowledge my boss, Allen Hardin, for giving me the opportunity to pursue my educational and professional careers at the same time. You have given me the ability to attain a lifetime of learning by allowing me to partake in both. You have always managed to inspire me, and I hope to be as great of a leader as you one day. Additional thanks to Brian Farr for giving me the opportunity to improve my teaching skills in the best undergraduate athletic training program in the country. Thank you to my family, friends, and coworkers for all of your love and support throughout the last several years. I would like to give special thanks to my parents for always providing an ear to listen and a shoulder to cry on. Your confidence in me from as far back as I can remember has been inspirational. I cannot wait to start the next chapter of life with all of you.

iv The Effects of Knowledge, Attitudes, Self-Efficacy, and Treatment

Practices on Concussion Management in the High School Setting

Carisa Maria Raucci, PhD The University of Texas at Austin, 2015

Supervisor: Mary A. Steinhardt

Co-Supervisor: Jessica Duncan Cance

The purpose of this dissertation was to examine athletic trainers’ (ATs’) and emergency room physicians’ (MDs’) perceptions of concussion management in the high school athlete. The first study looked at the implementation process of a new state concussion law as perceived by a group of high school ATs. Semistructured interviews were given to n = 14 ATs and reported on four topics that should be considered when implementing a school concussion protocol: (a) a school-level concussion policy’s implementation is dependent on salient facilitators; (b) a school-level concussion policy’s implementation is dependent on having fewer barriers than facilitators; (c) a state- mandated school concussion law requires support from within the school and community; and (d) a school-level concussion policy’s implementation is dependent on the positive impact of the Concussion Oversight Team. In the second study, a cross-sectional self- report survey examined knowledge, attitudes, and self-efficacy as they relate to n = 534

ATs’ and n = 29 MDs’ endorsement of concussion treatment practices. Of the literature’s most recommended treatment practices, only 16.4 percent of ATs and 19.2 percent of

MDs were using all eight practices. Using hierarchical linear regression, race was

v significantly positively related to treatment practices (β = .12, p < .05) in which white licensed health care providers (LHCPs) endorsed more practices than non-white LHCPs.

Self-efficacy was significantly positively associated with treatment practices (β = .70, p <

.05), and the final R2 = .12 percent. Further, job title moderated this positive relationship

(p < .05), such that, as concussion management self-efficacy scores increased, LHCPs’ endorsement of treatment practices also increased. Self-efficacy was more influential for

MDs (t(400) = 4.69, p < 0.001) than ATs (t(400) = 2.52, p < 0.05). Additionally, ATs had significantly higher knowledge, attitude, and self-efficacy scores than MDs.

Together, results of these studies highlight practical implications for provider education in concussion management. Results extend the literature by providing ATs’ and emergency room MDs’ baseline levels of knowledge, attitudes, and self-efficacy toward concussion management treatment practices, as well as examining the implementation of a concussion law in the state of Texas as perceived by high school ATs.

vi TABLE OF CONTENTS

List of Tables ...... xi

List of Figures ...... xii

Chapter One: General Introduction ...... 1

Theoretical Framework ...... 4

Purpose ...... 6

Research Questions ...... 7

Definition of Terms ...... 7

Delimitations ...... 9

Chapter Two: Review of Relevant Literature ...... 11

Introduction ...... 11

State Legislation...... 12

School Health Policy Implementation ...... 12

Magnification in the Media ...... 14

Return-to-Play Legal Responsibilities ...... 15

Incidence Rates ...... 16

Pathophysiology ...... 18

Adolescent Development ...... 19

Signs and Symptoms ...... 20

Multidimensional Treatment Approach ...... 21

Evaluative Guidelines ...... 22

Long-term Health Consequences ...... 23

Post-concussive syndrome ...... 24

Second impact syndrome ...... 24

vii Chronic traumatic encephalopathy ...... 25

Concussion Knowledge, Attitudes, and Self-Efficacy ...... 26

General public ...... 26

Athletic trainers ...... 28

Physicians ...... 29

Behavioral Constructs for Licensed Health Care Professionals ...... 31

Health Belief Model ...... 31

Chapter Three: Study I—Examination of the Implementation of House Bill 2038 on Concussion Management in the High School Setting ...... 35

Abstract ...... 35

Introduction ...... 36

Methods ...... 38

Participants ...... 38

Data Collection ...... 39

Ethical Considerations ...... 40

Data Analysis ...... 41

Results ...... 43

Topic 1: Policy Facilitators ...... 44

Topic 2: Policy Barriers ...... 49

Topic 3: HB 2038 Support ...... 58

Topic 4: Impact of the Concussion Oversight Team ...... 61

Discussion ...... 64

Chapter Four: Study II—Examination of the Knowledge, Attitudes, Self-Efficacy, and Treatment Practices of Athletic Trainers and Physicians Regarding Concussions in High School Athletes ...... 71

Abstract ...... 71

viii Introduction ...... 72

Health Belief Model ...... 74

Research Questions ...... 76

Methods ...... 77

Participants and procedures ...... 77

Measures ...... 78

Demographics ...... 79

Knowledge of concussion management...... 79

Attitudes regarding concussion management ...... 80

Concussion management self-efficacy ...... 80

Concussion treatment practices...... 80

Statistical Analysis ...... 82

Results ...... 83

Descriptive Statistics ...... 83

Most Recommended Treatment Practice Utilization ...... 86

Differences Between Athletic Trainers and Emergency Room Physicians ..89

Hierarchical Multiple Regression ...... 89

Discussion ...... 92

Chapter Five: Conclusion ...... 101

Introduction ...... 101

Summary of Key Research Findings ...... 102

Limitations ...... 104

Future Research...... 106

Health Behavior Implications ...... 107

Summary ...... 107

ix Appendix A.1: School District Participation Checklist ...... 109

Appendix B.1: Qualitative Interview Questions ...... 110

Appendix C.1: Recruitment Letter ...... 112

Appendix D.1: Consent for Participation in Research ...... 114

Appendix E.1: Approval from School District ...... 117

Appendix F.1: Approval from the Institutional Review Board ...... 118

Appendix A.2: Permission Letter for Directory Use from TSATA...... 122

Appendix B.2: Permission Letter for Email Use from CEA ...... 124

Appendix C.2: Approval from the Institutional Review Board ...... 126

Appendix D.2: Recruitment Letter ...... 130

Appendix E.2: Consent to Participate in Internet Research ...... 132

Appendix F.2: Internet Survey Instrument for Athletic Trainers ...... 134

Appendix G.2: Internet Survey Instrument for Physicians ...... 156

Appendix H.2: Final Follow-up Email ...... 180

Appendix I.2: Permission Letter for RoCKAS Survey Use ...... 182

References ...... 183

x LIST OF TABLES

Table 2.1. Legal Cases Involving an Athlete and Return-To-Play Status ...... 16

Table 3.1. Demographic Composite of Students in the District ...... 38

Table 3.2. Summary of Topic 1 Themes...... 44

Table 3.3. Summary of Topic 2 Themes...... 49

Table 3.4. Summary of Topic 3 Themes...... 58

Table 3.5. Summary of Topic 4 Themes...... 62

Table 4.1. Sample Characteristics ...... 85

Table 4.2. Recommended Concussion Treatment Practices ...... 87

Table 4.3. Endorsement of Concussion Treatment Practices Between Athletic Trainers and Physicians...... 88

Table 4.4. Hierarchical Regression Analysis for Variables Predicting Number of Concussion Treatment Practices Endorsed ...... 91

xi LIST OF FIGURES

Figure 2.1. .... Number of head injuries in football articles published by year in The New York Times ...... 15

Figure 4.1. The moderating effect of health care profession on the relationship between self-efficacy and number of concussion treatment practices endorsed ...... 92

xii

CHAPTER ONE: GENERAL INTRODUCTION

A concussion is defined as a "complex pathophysiological process affecting the brain induced by traumatic biomechanical forces" resulting from a blow to the head, neck or torso (McCrory et al., 2009, p. 435). A concussion may present with a plethora of symptoms or very few symptoms at all. The average concussion takes five to 10 days to recover and adolescents are at an increased risk of Second Impact Syndrome (SIS). SIS is a rare but catastrophic condition that occurs when a second concussion is sustained prior to complete physiological recovery of the initial head injury. In addition to an increase in the number of reported concussions, the increased coverage of concussions in the media has caused public concern for adolescent safety. The state of Texas passed

House Bill (HB) 2038 (Texas State Athletic Trainers’ Association, 2015) into law in May of 2011 proving how salient this concern has become. The HB states that public schools must follow a safety protocol for all student-athletes (SAs) with a suspected head injury.

Any SA with a suspected head injury must be removed from participation and examined and cleared by a physician prior to return-to-play (RTP). This law was designed to help protect the SAs by placing RTP decisions solely in the hands of the supervising athletic trainers (ATs) and physicians (MDs). HB 2038 was implemented with the understanding that balancing the engrained culture of wanting to RTP as quickly as possible, while ensuring the safety of the student-athletes, results in better concussion management.

There is a growing concern for athlete safety throughout organized athletic programs due to a near doubling of reported concussions in the last decade (Daneshvar,

Nowinski, McKee, & Cantu, 2011). The Centers for Disease Control and Prevention

(CDC) estimate approximately 1.7 million sports-related traumatic brain injuries occur

annually (Faure, 2010), but with changing diagnostic guidelines and a lack of injury surveillance in younger populations, estimates may be closer to 3.8 million (Halstead &

Walter, 2010). In high school settings, concussions represent approximately 8.9 percent of all injuries and about 51 percent of these occur in football. The next closest sport is girls’ soccer representing from 8.2-12.9 percent of all reported concussions (Gessel,

Fields, Collins, Dick, & Comstock, 2007; Marar, McIlvain, Fields & Comstock, 2012).

Research has shown that a concussed brain requires a sufficient amount of healing time in order to decrease the risk of sustaining a secondary concussion and long-term brain damage due to repetitive brain trauma (Guskiewicz et al., 2003; Zemper, 1994).

The high prevalence of concussions in conjunction with the high variability of diagnostic guidelines creates a wide range of outcome potential for diagnosis and treatment of such injuries. Although evidence exists for the efficacy of concussion management protocols, there are recognized gaps in the areas of implementation and policy development (Kelly

& Rosenberg, 1998). This trend highlights the importance of examining large-scale policy adoption for the purpose of limiting such diagnostic variability.

Concussions may present with a multitude and variety of symptoms, which makes consistent treatment protocols necessary. Currently, an inconsistency in concussion management and RTP decisions exists. For example, updated guidelines employ a more conservative approach to brain imaging, only ordering imaging tests for those head injuries presenting with specific hemorrhage and/or skull fracture symptoms (Broglio et al., 2014; Herring, Cantu, Guskiewicz, Putukian, & Kibler, 2011; Meehan, d’Hemecourt,

Collins, & Comstock, 2011). Even with these newer guidelines, one in five imaging tests are performed on unwarranted head injuries (Meehan et al., 2011). Taking such

unnecessary steps may result in an overuse of resources such as insurance claims and hospital beds and longer waits for imaging. Numerous grading scales and guidelines are used to treat concussions, and recent studies suggest a multidimensional treatment approach for concussion management (Alla, Sullivan, Hale, & McCrory, 2009; Covassin,

Elbin III, & Stiller-Ostrowski, 2009). Within these treatment approaches, licensed health care professionals (LHCPs) such as athletic trainers and physicians are most often directly responsible for decisions regarding athlete-readiness to RTP and take a more conservative approach than the general public such as coaches, parents, and student- athletes (Mackenzie & McMillan, 2005). ATs assess more than 94 percent of high school concussions and determine RTP decisions in 46.2 percent of all cases (Kissick &

Johnston, 2005), while physicians account for 50.1 percent of RTP decisions (Meehan et al., 2011).

Due to the considerable variability in symptomology, concussion management knowledge, attitudes, and self-efficacy could help explain LHCPs’ treatment approaches.

Given the tremendous pressure for a quick RTP, the variability of symptoms and treatments, and the new effort of House Bill 2038 to improve the standard of care for concussions in the state of Texas, it is essential to understand LHCP’s knowledge of, attitudes toward, and self-efficacy of concussion management. As researchers, physicians, athletic trainers, lawyers, and the general public continue to address the best ways to manage concussed athletes, public schools are becoming an integral component in combating the epidemic (Nationwide Children’s, 2013). New state laws are enforcing the strict adherence of safe concussion management practices to protect adolescent athletes from long-term brain damage and other negatively related health outcomes. The

choice to use safe treatment practices can be influenced by practitioner knowledge and attitudes.

Theoretical Framework

The health belief model (HBM) was developed by social psychologists

Hochbaum, Rosenstock, and Kegels who worked for the United States Public Health

Service in the 1950s (Hochbaum, 1958). The model is used to understand and predict the likelihood that an individual will engage in health-related behaviors by focusing on individual attitudes. Student-athletes need protection against concussions by implementing routine ways to prevent and detect head injuries. LHCPs treating this type of injury have the choice to use, or not use, specific concussion management protocols.

The HBM can be applied to these providers’ health-related actions (i.e., concussion treatment practices) in order to better understand the most commonly used practices as well as determinants of these practices.

The HBM posits that an individual’s health behavior is influenced by his or her personal beliefs or perceptions and strategies available to enhance a healthy lifestyle

(Hochbaum, 1958). More recent versions of the model have been updated to acknowledge the important role that knowledge and perceptions play in personal responsibility (Balbach, Smith, & Malone, 2006; Conner & Norman, 1996). This personal responsibility can also be applied to LHCPs that are accountable for the health and safety of patients.

Using the HBM as a guide, an LHCP must perceive a threat to be severe enough that it ignites a certain health-related behavior. In this case, the threat of a misdiagnosed or improperly treated concussion must be perceived as salient enough that the provider

chooses to correctly utilize the safest and most up-to-date treatment practices. If the threat of the potential negative health outcome is not great enough to change the behavior of the LHCP, then the provider may choose not to adapt to the most current evidence- based treatment practices. This lack of adaptation allows for the practice of unsafe or obsolete medicine. In addition, the LHCPs must have enough self-efficacy (i.e., the confidence in one’s ability to take action) (Bandura, 1977) and cues to action (i.e., knowledge resources to activate readiness to manage concussions) (Cao, Chen, & Wang,

2014) to appropriately perform the best evidence-based concussion treatment guidelines.

If the provider believes the perceived barriers (i.e., potential negative aspects of managing a concussion) outweigh the perceived benefits of appropriate concussion management (i.e., various management options for reducing the concussion threat), then the provider is less likely to change his or her behavior and follow appropriate protocol

(Cao, Chen, & Wang, 2014). Finally, if the provider has low perceived severity (i.e, belief about seriousness of the condition and/or leaving it untreated), the provider will also be less likely to change his or her behavior (viz., endorsement of an evidence-based concussion treatment approach).

Past research has applied the HBM to a broad range of health behaviors and populations such as but not limited to: preventive health behaviors; sick role behaviors; and clinic use including physician visit behaviors (Cao, Chen, & Wang, 2014; Conner &

Norman, 1996; Donadiki et al., 2014; King, Vidourek, English, & Merianos, 2014). In this dissertation, the HBM constructs mentioned above will be applied to the behavior of

LHCPs (viz., concussion treatment practices) as a function of their knowledge, attitudes, and self-efficacy regarding concussion management. This falls under the category of

preventive health behaviors as ATs and MDs must use evidence-based practices to prevent further concussion-related injury.

Purpose

The purpose of this dissertation is three-fold: (a) to examine ATs’ perceptions of the implementation of House Bill (HB) 2038 in order to determine facilitators and barriers for current and future concussion policy propagation; (b) to determine what systems and guidelines LHCPs are using to improve concussion management; and (c) to determine areas in need of concussion education by examining LHCPs’ knowledge, attitudes, self-efficacy, and behaviors (viz., treatment practices) regarding concussions.

Results of this study will enhance the education of LHCPs with theory to practice interventions.

The proposed dissertation is comprised of two studies that together attempt to examine concussion management guidelines and practices used by LHCPs. Theoretical support based on components of the health belief model will guide this dissertation.

Study I examined ATs’ perceptions of HB 2038, specifically examining the facilitators and barriers of implementation of a new state law mandating schools manage concussions with specific guidelines in place. Study II examined LHCPs’ most endorsed concussion treatment practices and their knowledge, attitudes, and self-efficacy, of said treatment practices as a means of identifying relationships among the four in an effort to improve concussion management.

Research Questions

Study I.

What areas of HB 2038 are essential for implementing a school concussion management policy?

Study II.

In order to examine the relationships among knowledge, attitudes, self-efficacy, and concussion treatment practices of athletic trainers and physicians, the following will be tested:

Research Question 1: Do athletic trainers utilize more of the top recommended concussion treatment practices than emergency room physicians?

Research Question 2: What is the relationship of knowledge, attitudes, and concussion management self-efficacy to utilization of the top recommended treatment practices?

Research Question 3: Does the relationship between knowledge, attitudes, concussion management self-efficacy, and treatment practices vary by health care profession?

Definition of Terms

Athletic Trainer. “Certified health care professionals who collaborate with physicians to optimize activity and participation of patients and clients” (National

Athletic Trainers’ Association, 2015).

Attitude. One’s favorableness, opinions, or feelings regarding the safety of concussion management and RTP decision making. This is part of the summative

Concussion Attitude Index (CAI) score in which a higher score reflects safer attitudes toward the management of concussions.

Concussion. "Complex pathophysiological process affecting the brain induced by traumatic biomechanical forces" resulting from a blow to the head, neck, or torso

(McCrory et al., 2009, p. 435).

Concussion management. A medical practice by a licensed health care professional that includes both an initial assessment and treatment plan (including a return-to-play protocol) for a concussed patient. More than 25 different systems and guidelines have been published, many of which determine severity based on loss of consciousness, confusion, and amnesia (Doolan, Maerlender, Gorforth, & Gunnar, 2012).

Group membership. A licensed health care professional certified to be an athletic trainer or physician.

Knowledge. Information and skills acquired through experience or education; the theoretical or practical understanding of concussion causes and sequelae. This is part of the summative Concussion Knowledge Index (CKI) score in which a higher score reflects greater correct understanding.

Number of years of training. The number of years the licensed health care professional has been practicing.

Physician. A licensed health care professional who practices medicine and is licensed by the Texas Medical Board; who is concerned with promoting, maintaining, or restoring health.

Return-to-play. The decision-making process of returning a student-athlete to practice or competition after sustaining a concussion.

School district size. The school or district in which the licensed health care professional is affiliated; in Texas, schools are classified as 1A, 2A, 3A, 4A, or 5A with

1A being the smallest enrollment schools and 5A being the largest enrollment schools.

Self-efficacy. One’s confidence in self to perform a specific task or behavior. An individual must feel competent to overcome perceived barriers in order to take action

(Bandura, 1977).

Treatment practices. The guidelines and/or grading scales used to diagnose and care for concussed patients. The scope of grading scales and guideline systems used to manage concussions.

Delimitations

The first study has several delimitations. Participation in this study is delimited to licensed athletic trainers currently working for one of the high schools in the school district selected. Both the head and the assistant ATs from each school were sampled.

Participants had to complete an open-ended semistructured interview. ATs’ knowledge and opinions about House Bill 2038 will be generalizable to other districts and states as they begin to implement the new law or a similar law, respectively. This study was supported by the health belief model’s constructs of benefits and barriers in order to examine the implementation process of a new health-related law in the school setting.

The second study will be guided by the theoretical framework of the health belief model examining the constructs of knowledge, attitudes, self-efficacy, and behavior (viz., treatment practices). Currently employed Texas high school ATs and practicing emergency room MDs with the ability to treat concussed athletes will be included in the study’s sample. The participants will be recruited from member directories and do not

necessarily generalize to all LHCPs. The survey will utilize a self-report and cross- sectional format.

CHAPTER TWO: REVIEW OF RELEVANT LITERATURE

Introduction

The 3rd International Conference on Concussion in Sport defined a concussion

“as a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces” (McCrory et al., 2009, p. 435). Licensed health care professionals

(LHCPs) are often the first responder when an athlete sustains a concussion. These professionals, generally athletic trainers (ATs) and physicians (MDs), have a responsibility to treat such injuries like any other injury despite their level of concussion knowledge. There are medical as well as legal ramifications for returning an athlete to sports participation (Weistart & Lowell, 1979). With the potential for a patient to present with a multitude of signs and symptoms, as well as a plethora of available diagnostic tools, it is increasingly difficult for LHCPs to manage this injury effectively and consistently. In addition, new treatment guidelines and concussion knowledge are emerging on a regular basis (Broglio et al., 2014; Giza et al., 2012; Harmon et al., 2013;

Herring, Cantu, Guskiewicz, Putukian, & Kibler, 2011). This compounds the challenge for LHCPs to keep up with changing guidelines. Regardless, with the number of diagnosed concussions and cases of long-term concussion-related negative health outcomes, it is imperative to patient safety that LHCPs be educated on, and choose to adopt, updated concussion management information in a timely manner. In order to speed up the adoption and implementation process, legislations have chosen to create state-mandated school concussion laws. In the state of Texas, House Bill 2038, also known as Natasha’s Law, was signed into law in May 2011 in order to protect student- athletes from sport-related concussions.

State Legislation

Currently, all states have a sport-related concussion law in place. According to

Wickner (2013), 20 states have passed these laws since 2011. Some recurrent themes found in the laws include: concussion management training for coaches and athletic trainers with annual review and periodic recertification, educational training for student- athletes (SAs) and parents with signed informed consent paperwork, no same day return- to-play (RTP) for SAs who sustain a concussion, and written clearance from an LHCP before RTP (Fjordbak, 2011). The most commonly omitted component is a requirement for baseline screening in student-athletes. This would help with return-to-play decisions, but cost has been a concern in trying to have such requirements passed. The wording of the laws can vary from state to state. For example, some laws oversee all youth sports, while some are limited to public high school sports. In regards to RTP, some laws require a physician written release (Texas), while others more broadly identify a licensed health care professional (Oregon), and still others say an LHCP specifically trained in concussion evaluation and management (Washington) (Doolan et al., 2012). Every state law is different and therefore concussion management as defined by each state should be taught to LHCPs regardless of where his or her medical training was completed.

School Health Policy Implementation

The recent push by state legislation to implement a concussion safety protocol with HB 2038, advocates for the successful and long-term commitment by schools to implement a new type of health policy in the school setting. Rogers (2003) found that most interventions are not sustainable long-term, regardless of their early implementation success. This is important for program developers to understand before implementing a

school health policy. Because House Bill 2038 went into law as recent as 2011, no research has been done to examine ATs’ perceptions of law implementation. However, implementation measurements have been studied in other health-related school policy interventions and should be used as models (Deschesnes, Martin, & Hill, 2003; Evenson et al., 2009; McGraw et al., 2000; Perez-Rodrigo et al., 2001). Measurement of program implementation and policy adoption is used to identify elements that may need to be modified or eliminated completely. These program evaluations often look at facilitators and barriers related to implementation. Milio (1988) found policy adoption was facilitated when program planners agreed with policy planners on the nature of the problem, the importance of the problem, possible solutions to the problem, and ultimately who is responsible for decision making. One study examining the implementation of nutritional guidelines found theory driven strategies, adequate time and intensity for the intervention, family involvement, including a self-evaluation tool for students, and inclusion of the community outside of the school to all be facilitators for successful educational nutrition programs (Lytle & Achterberg, 1995). Evenson et al. (2009) looked at implementation barriers for a state policy requiring 30 minutes of daily exercise.

Challenges for implementation included: time, teacher attitude or a lack of participation, academic concerns, faculty/staff constraints, resources, training concerns, student attitude/lack of student participation, consistency of daily activities with these changing based on school schedules, the size of the school, and disruptions in the classroom.

Although these factors may not apply in every situation, they are a good indicator of reasons why school health policy implementation and sustainability can be difficult.

Magnification in the Media

With an exponential increase in concussion knowledge being uncovered by researchers over the past decade, there has been a consequent increase in media coverage

(Grilli, Ramsay, & Minozzi, 2004; “Head injuries in football”, 2014; Slobounov et al.,

2013). Wide-spread media coverage in addition to coverage of some high profile concussed athletes, has led to an increase in concussion awareness (Slobounov et al.,

2013). The media has been shown to influence the behavior of LHCPs as well as the general public (Grilli, Ramsay, & Minozzi, 2004; Irwin, 2001). For example, a poll taken by The New York Times found 57 percent of parents surveyed would not let their children play football based on the media coverage of sports-related concussions (Lavigne, 2012).

Another study looked at concussion-related articles in four large newspapers in the

United States of America and Canada from 1985-2011. Cusimano et al. (2013) found major recurring themes to include aggression, perceptions of brain injuries, attitude toward rules, regulations, and equipment to be main themes. The authors made note of safer attitudes and more positive perceptions of sport-related concussions over the span of the study as well. In addition to the newspaper, social media such as Twitter has also gained steam with concussion awareness. Sullivan et al. (2012) observed Twitter over a

7-day period and found 3,484 tweets related to concussions. This demonstrates how social media such as Twitter can be a far-reaching tool for concussion education and management. Finally, The New York Times has been a hub for information in the media about concussions (Head injuries in football, 2014). Since the first head injury in sport article was published in 1894, there have been 430 articles published to date (see Figure

2.1).

100

Number of Articles of Number 30

1997 1894 1910 1928 1933 1938 1948 1984 1987 1992 1995 1999 2002 2005 2007 2009 2011 2013 Year of Publication

Figure 2.1. Number of head injuries in football articles published by year in The New York Times. Note: Adapted from http://topics.nytimes.com/top/reference/timestopics/subjects/f/football/head_injuries/inde x.html.

Return-to-Play Legal Responsibilities

There is an ingrained culture for athletes to play through pain and want to RTP as quickly as possible, but it is the legal responsibility of the LHCP to protect the athlete’s health and safety. LHCPs may feel pressure to hastily return an athlete to play from coaches, parents, SAs, administrators, teammates, or other factors such as social, economic, political, or legal concerns (McFarland, 2004). The practitioner must rely on the best objective data possible in the RTP decision making process. This also entails a complex structure of weighing the potential risks and benefits. A rational decision- making model was introduced by Creighton et al. in 2010. This model comprises a health status evaluation, a full assessment of injury risk and weighing all advantages and disadvantages of alternative therapies. Medical clearance for sports participation

involves medical and legal constraints. Lawsuits have taken place in cases where athletes were cleared prematurely as well as when athletes have not been cleared to RTP

(Osbourne, 2001; see Table 2.1). It is important to note that competitive athletes will often want to play regardless of the inherent health consequences, and in those situations, the SA does not assume the LHCP’s negligence in a court of law. The importance of adopting and updating concussion guidelines is addressed:

Adherence to outdated sports medicine guidelines should not be a recognized defense. Standards should be updated and modified periodically as the practice of sports medicine evolves to promote the health and safety of athletes. Giving legal effect only to guidelines consistent with the medical state of the art provides an incentive to medical organizations to revise the guidelines to stay current with advances in sports medicine research. (Osbourne, 2001, p. 321)

Table 2.1. Legal Cases Involving an Athlete and Return-To-Play Status 1. Kampmeier v Nyquist. 553 F.2d 296 (2d Circ. 1977) 2. Grube v Bethlehem Area School District. 550 F. Supp. 418 (E.D. Pa. 1982) 3. Wright v Columbia University. 520 F. Supp. 789 (E.D. Pa. 1981) 4. Poole v South Plainfield Board of Education. 490 F. supp. 948 (D.N.J. 1980) Note. From "Principles of liability for athletic trainers: Managing sport-related concussion" by B. Osbourne, 2001, Journal of Athletic Training, 36(3), p. 316.

Until a standard of care has been determined, it is crucial for the AT and MD to work together and use the most objective data available under established current guidelines as to protect themselves in a court of law.

Incidence Rates

The word concussion has become infamous in the high school setting and often synonymous with contact sports. With approximately 8.9 percent of all sport-related injuries coming from concussions, it has been deemed a major medical concern by

LHCPs as well as the general public (Gessel et al., 2007). It is believed that

approximately 1.6-3.8 million sport-related concussions occur annually in the United

States of America (Maroon & Bost, 2011). The US Government Accountability Office stated in front of the House Committee on Education and Labor, the overall estimated incidence rate of concussions is not available (Jinguji, Krabak, & Satchell, 2011). This ambiguous number may be in part due to constant modifications of diagnostic guidelines causing definitional changes, a lack of injury surveillance in adolescent populations

(Halstead & Walter, 2010), an inability to effectively recognize a concussion due to a lack of knowledge, and underreporting of head injuries by student-athletes (Jinguji,

Krabak, & Satchell, 2011) due to social norms (Echlin, Grady, & Timmons, 2012). From

2001-2005 there were over 151,000 concussions seen in 14-19 year olds in the emergency department (Bakhos, 2010). Yard and Comstock (2009) estimate over

395,000 concussions occur each year in nine high school sports: boys’ football, soccer, basketball, wrestling, and baseball, and girls’ soccer, basketball, volleyball, and softball.

Football experiences the most concussions with roughly 51 percent of all reported cases

(Gessel et al., 2007), but this number can be misleading. If the total number of athlete exposures and injuries is taken into account, football concussions make up 10 percent of the total number of football injuries, whereas girls basketball concussions account for

11.7 percent (Junguji, Krabak, & Satchell, 2011) and girls soccer concussions account for

8.2-12.9 percent of injuries (Gessel et al., 2007; Marar et al., 2012). When comparing sports in which both boys and girls participate, females have double the risk of sustaining a concussion (Lincoln et al., 2011). Therefore, all contact sports regardless of gender are at risk for sustaining head trauma.

Lincoln et al. (2011) have found a 16.5 percent increase in the number of reported concussions over the last decade. This may be due in part to the employment of more athletic trainers, who are able to better recognize, head injuries and an increase in knowledge and safer attitudes toward the reporting of concussions by athletes. It is also important to note that concussions are severely underreported, with less than 50 percent being reported by high school athletes (McCrea, Hammeke, Olsen, Leo & Guskiewicz,

2004). This alludes to the fact that there may be many more concussions than what is reported, suggesting an even higher overall incidence rate. This underreporting trend has also been seen in the military (Maroon & Bost 2011), demonstrating adults with fully developed brains are sometimes not able, or choose not, to voluntarily report head trauma.

Pathophysiology

A concussion occurs when the brain is violently forced against the skull in which the cerebrospinal fluid cannot absorb the impact and brain cells are destroyed or left vulnerable to future trauma. There may be breaking of blood vessels, and/or nerve damage; all of which may lead to a neurometabolic cascade response (Signoretti,

Lazzarino, Tavazzi, & Vagnozzi, 2011). According to animal models, the brain triggers a flux of neurotransmitters and ions due to a neuronal membrane disruption (Halstead &

Walter, 2010). These models showed an acute efflux of potassium to the extracellular space which causes a depolarization and inhibition of neuronal activity. In order to help restore membrane potential, adenosine triphosphate and glucose are used in excess by the sodium-potassium pumps (Almasi & Wilson, 2012). A subsequent accumulation in lactate decreases cerebral blood flow causing a hypermetabolic state. Over time calcium

accumulates in the cells and may impair oxidation causing cell death (Giza & Hovda,

2001). As the glucose metabolism increases, a hypometabolic state may persist for up to four weeks post-injury (Yoshino, Hovda, Kawamata, Kawamata, & Becker, 1991;

Sunami et al., 1989). Any increase in intracranial pressure causes more problems and has the potential to increase symptoms.

Adolescent Development

The psychosocial development of the adolescent brain has implications for the effective management of concussive injuries. Patel, Shivdasani, and Baker (2005) have divided the period of adolescent brain development into three categories: early (12-14 years old), middle (15-16 years old) and late adolescence (17-19 years old). During all three phases, the adolescent brain is going through rapid and substantial cognitive growth. The neurons are constantly re-networking making them more sensitive to stress and trauma. This fragility requires a longer time to heal than the adult brain which is why college and professional athletes generally have a shorter return-to-play time than high school athletes (Baillargeon, Lassonde, Leclerc, & Ellemberg, 2012). This should be taken into consideration when treating this population and making RTP decisions.

According to Patel et al. (2005), during the early phase, the adolescent brain is characterized by concrete thinking in which the individual is less likely to understand long-term consequences. This is important when teaching an SA of this age the importance of reporting head injuries immediately as to avoid long-term damage to the brain. At this stage of development it may be more influential to tell a SA they will miss school or playing time if they were to sustain a secondary hit without reporting the first.

The middle adolescence period is characterized by an independence from parents and a

greater influence by peers and the media. This group is more likely to take risks; making it essential to educate the SAs on the importance of not playing with a head injury. The negative stories in the media regarding concussion and long-term consequences may impact an adolescent of this age when it comes to reporting head injuries. A late adolescent brain is characterized by abstract thinking and maturation. This developmental period involves abstract thinking and maturation allowing for a real appreciation of the significance of sustaining a concussion both in the short and long- term (Patel et al., 2005). These student-athletes should be role models for the younger athletes in regards to reporting head injuries. Although collegiate athletes incur more concussions than those in high school (Almasi & Wilson, 2012), the high school athlete is three times more likely to sustain a catastrophic head injury (Boden, Tacchetti, Cantu,

Knowles, & Mueller, 2007).

Signs and Symptoms

Concussions have a high rate of morbidity with many potential signs and symptoms. According to the Centers for Disease Control and Prevention (CDC), signs and symptoms include but may not be limited to: difficulty thinking clearly; feeling slowed down; difficulty concentrating; difficulty remembering new information; headache; fuzzy or blurry vision; nausea or vomiting; dizziness; sensitivity to noise or light; balance problems; feeling tired or having no energy; irritability; sadness; more emotional; nervousness or anxiety; sleeping more than usual; sleeping less than usual; and trouble falling asleep (Centers for Disease Control and Prevention “Injury Prevention

& Control”, 2015). Concussion symptoms may present similar to those with depression, anxiety, or attention-deficit disorders. Those with learning disabilities or other cognitive

impairments may present with similar symptoms, thus making it more difficult to manage

(Halstead & Walter, 2010). An individual may not know whether he or she has concussive symptoms often making it difficult to report and recognize. The time course for symptom recovery in cognitive function is generally five to 10 days (Guskiewicz et al., 2003). Meehan et al. (2011) found 23.5 percent of concussed high school SAs were symptom free within 24 hours and 77.9 percent within 7 days. This study also found 19.2 percent of concussed SAs had symptoms lasting up to one month, and 2.8 percent had symptoms lingering for greater than one month. It is important to note here that symptom resolution may be transient, in that acute resolution may show symptom return within the first 36 hours, supporting the need for removal from competition for the first 24 hours regardless of immediate symptom resolution following a head trauma. There are inconsistencies in the research however, as many studies do not determine a preconcussive baseline to compare to postconcussive performance (Makdissi et al.,

2010).

Multidimensional Treatment Approach

Due to a wide array of variables influencing concussions, there are a number of facets of treatment that must be utilized to understand the management breadth of a concussion’s severity and susceptibility. Concussion management, for both physicians and athletic trainers alike, has changed significantly in the past decade. The Second

International Conference on Concussion in Sport in 2004 was one of the first to introduce the concept of cognitive rest when dealing with concussions (Arbogast et al., 2013).

Now, with panels of experts all over the globe recommending concussion management protocols, the number of tests involved in properly diagnosing and evaluating

concussions from baseline to RTP has drastically grown. There are no evidence-based guidelines available for the treatment of concussed athletes with a slow recovery

(Schneider et al., 2013). The cornerstone of concussion management revolves around rest both cognitively and physically. According to the Concussion Statement on

Concussion in Sport from 2012, however, there are several areas of treatment that should also be included: objective balance testing, neuropsychological baseline and post-injury testing, obtaining a functional MRI, pharmacological therapy and psychological management (McCrory et al., 2013). With so many areas of testing required post-injury, a multidisciplinary team of LHCPs is often warranted for those with a slow recovery, at an increased risk of re-injury, professional athletes, and anyone with the financial means to do so (Boriboon, 2013). As new guidelines continue to be implemented (Echemendia,

Putukian, Mackin, Julian, & Shoss, 2001; McCrory et al., 2013; Harmon et al., 2013), there is a need for further research to examine if LHCPs are utilizing these newer guidelines.

Evaluative Guidelines

There have been over 25 researched concussion evaluation guidelines discussed in the literature since 2001 (Doolan et al., 2012). These protocols may be used interchangeably for physicians and athletic trainers. At the time of this dissertation, the most recent, cited, and well-known organizational guidelines and protocols written were the American Academy of Neurology (Giza et al., 2013); the American College of Sports

Medicine Team Physician Consensus Statement (Herring, Cantu, Guskiewicz, Putukian,

& Kibler, 2011); the American Medical Society for Sports Medicine (Harmon et al.,

2013); the Centers for Disease Control and Prevention Heads Up Concussion program

(Centers for Disease Control and Prevention “Facts for Physicians”, 2013); the National

Athletic Trainers’ Association (Guskiewicz et al., 2004); and the Zurich Guidelines

(McCrory et al., 2013). More objective tests are constantly being developed and used.

For the purposes of this dissertation, both physician and athletic trainer’s organizational guidelines were used as to not show bias toward either profession.

There is no gold standard for evaluating a concussion, which increases the complexity of concussion management. Changes in concussion diagnosis guidelines continue to occur, making it difficult for lay people to actively assist with the diagnosis and recovery process. No longer can concussions be broken down into simple (i.e., symptoms lasting less than 10 days) or complex (i.e., symptoms lasting longer than 10 days) based on whether an individual experienced a loss of consciousness (LOC)

(Makdissi, 2009). The most recent International Conference on Concussion in Sport in

Zurich in 2012 suggested LHCPs categorize concussions by symptom severity instead of an arbitrary score which used to be a grade of I, II, or III (McCrory et al., 2013). Both the Zurich consensus and the CDC believe a coach should not be allowed to evaluate a student-athlete and should remove the athlete and refer to an LHCP (McCrory et al.,

2013). Although there are many guidelines used in the literature, the scope of this paper is to delineate concussion management roles and responsibilities of LHCPs at the high school level and determine which treatment practices are the most commonly utilized.

Long-term Health Consequences

With a growing number of long-term concussion related health consequences, it is important for LHCPs to understand and implement evidence-based treatment practices in order to decrease the likelihood of the following negative health outcomes.

Post-concussive syndrome

Symptoms that do not resolve in the first week are generally considered postconcussive syndrome (PCS). Although no standard diagnostic guidelines exist, usually three or more symptoms persist including but not limited to: headache, dizziness, fatigue, and personality changes (Maroon & Bost, 2011). It can impact concentration, memory and abstract thinking, making it difficult to perform well in school. Spinos et al.

(2010) found the rate of PCS in patients with mild traumatic brain injury (viz., a concussion) at 1, 3 and 6 months post-injury was 10.3 percent, 6 percent, and 0.9 percent, respectively. The study also showed the syndrome was more frequent among women (17 percent) versus men (6 percent). It is known that long-term symptoms can be debilitating to a young person whose brain is still developing, is adjusting to social and societal pressures, and is attending school full-time. The literature on treatment of PCS is also very limited and controversial (Dean, O’Neill, & Sterr, 2012; Maroon & Bost, 2011).

Some trials with glutamate receptor antagonists, calcium channel blockers, and hyperbaric oxygen therapy have been tried, but the nonpharmaceutical treatments are gaining headway such as dietary supplements, vitamins, and minerals as a safe alternative

(Maroon & Bost, 2011). The main treatment focus is ameliorating symptoms.

Second impact syndrome

Another major concern when managing an athlete with a concussion is second impact syndrome (SIS). An athlete is at an increased risk of sustaining this injury if he or she sustains a second head trauma while still symptomatic from the initial head trauma.

SIS is characterized by cerebral vascular congestion (Cantu & Voy, 1995) which can progress to diffuse cerebral swelling of the brain (Yard & Comstock, 2009) caused by a

rapid loss of cerebral auto-regulation (Doolan et al., 2012) that may result in death. This injury has a 50 percent mortality rate and a 100 percent morbidity rate and has not been documented in individuals over 20 years old except in the sport of boxing where chronic blows to the head take place (Doolan et al., 2012). There has been some debate as to the number of traumas to the brain required to develop SIS, but the consensus seems to be there must be an initial concussive incident in which the brain does not fully heal prior to a second concussive blow to the head (Doolan et al., 2012; McCrory, 2001). Although prevalence data are not available, any injury with such a high chance of mortality and guaranteed morbidity should be managed with the utmost care.

Chronic traumatic encephalopathy

The third major health concern related to concussions is known as chronic traumatic encephalopathy, or more commonly, CTE. Known to be correlated with multiple concussions and deficits during neuropsychological testing, it generally occurs during the fourth and fifth decades of life, many years after receiving concussive traumas

(Doolan et al., 2012). CTE was originally introduced in 1928 and termed “dementia pugilistica”. It is a chronic neurodegeneration causing cognitive, neuropsychiatric, and physical symptoms (Omalu, Bailes, Hammers, & Fitzsimmons, 2010) and is characterized by deteriorations in memory, concentration, and attention similar to

Alzheimer’s (McKee et al., 2009). Other symptoms may occur over time such as problems with insight, judgment, dizziness, headaches, confusion, and disorientation.

Currently, no biomarkers exist for diagnosing CTE, but new research has shown a larger prevalence than originally expected. McKee et al. (2009) reviewed known case studies on CTE and out of 51 confirmed cases, 90 percent were former athletes. In addition, in

cases of repetitive mild traumatic brain injury, at least 17 percent develop CTE. No well- designed prospective studies have yet to look at the incidence rate of this injury, but it is expected to be even higher. These high prevalence rates support the notion for an evidence-based treatment approach to concussion management.

Concussion Knowledge, Attitudes, and Self-Efficacy

Little research has been done to examine LHCPs general knowledge, attitudes, and self-efficacy toward concussion management. The general public has demonstrated a lack of knowledge demonstrating the importance of LHCPs’ possessing a solid knowledge base for the safety of the general public.

General public

The general public, while increasing their awareness in recent years, has a limited understanding about concussions. Few studies have looked at the layperson’s general knowledge and attitudes toward concussions. Recently, Weber and Edwards (2012) surveyed 227 members of the general public in the United Kingdom. They were asked to identify the seriousness of injury indicators and statements. The authors found participants to have some misperceptions regarding concussion knowledge, and more importantly, when given a choice between a definite and non-definite response, the respondents commonly chose an inaccurate definite response. In addition, the seriousness of sports concussions were underestimated, suggesting a lack of knowledge.

Weber and Edwards (2012) also found personal experience with a head injury may yield a false sense of security.

A study done by McKinlay, Bishop, and McLellan (2011) illuminates further support for a lack of concussion knowledge in the general population of New Zealand.

The authors randomly polled 103 members of the community regarding their experience with head and brain injuries and their general knowledge about concussions.

Approximately 20 percent of the knowledge statements were incorrectly identified and another 20 percent of the responses were uncertain. The authors found this representation of the general public’s knowledge to be substantially inaccurate, even with 41 percent of the respondents having personal experience with a brain/head injury. Although more studies were performed in years past, the amount of research, media, and interventions done with the general public since the research was conducted has greatly increased; therefore, these studies are now obsolete and will not be analyzed here (Guilmette &

Paglia, 2004; Hux, Schram, & Goeken, 2006; Willer, Johnson, Rempel, & Linn, 1993).

The general public also consists of parents and coaches, despite their experience with sports, as the majority of these two groups do not have professional training on effectively managing concussions. Guilmette, Malia, and McQuiggan (2007) surveyed high school football coaches, without ATs accessible at practice, as to their understanding and assessment of concussed SAs. On average, the coaches knew more than a previously sampled general public group, but still had some misconceptions. Most participants were conservative in how they would manage a concussion, and when prompted with a scenario of concussive symptoms, 70-95 percent would refer the athlete to an LHCP

(Guilmette, Malia, & McQuiggan, 2007). In addition, a study done by Newton et al.

(2014) found coaches of the Australian football and rugby leagues had less self-efficacy to treat concussed athletes than their sports trainers. Because the most up-to-date RTP protocols also recommend referral to an LHCP, coaches will not be analyzed in this study.

The assessment of concussion knowledge in parents has been limited. A study done by Sullivan et al. (2009) surveyed 200 parents of male rugby players at high school games. Although 83 percent of the parents were able to recognize a concussion and 96 percent knew the inherent risks of playing with a concussion, only about half (51 percent) were aware of the existing RTP criteria. This study was limited because it does not represent all of the parents that were not present at the games. These figures may be an overestimate, because the parents attending the games may be more actively involved and therefore better informed than those parents not in attendance. More research needs to be done comparing concussion knowledge of athletes’ parents and the general public.

Athletic trainers

Athletic trainers play an integral part of injury management among high school athletes; so much so that AT jobs are expected to grow 30 percent from 2010-2020

(United States Department of Labor, 2012). This rate is compared to the expected national job average growth of 14 percent (United States Department of Labor, 2012).

ATs work under the direct supervision of an MD and are responsible for sport-related concussions at his or her affiliated school. They are generally the first point of contact for a concussed athlete and act as a liaison for the providing physician. ATs have the most concussion training and background of all high school setting personnel (viz., administration, nurses, teachers, coaches, student-athletes, and parents). According to

Kissick and Johnston (2005) early recognition is the first and most important step in effectively managing concussions. According to Rosenbaum’s unpublished dissertation, he found ATs to be the athlete’s primary source of concussion knowledge, and ATs had more knowledge than coaches, SAs and non-athletes (Rosenbaum, 2007). Naftel et al.

(2014) found ATs were better at identifying concussion symptoms than coaches and SAs and needed improvement in recognizing subtle concussion symptoms such as difficulty sleeping. The assumption that all ATs have a working knowledge of the most up-to-date concussion practices is concerning, as concussion research was extremely limited less than one decade ago. As mentioned earlier, Australian rugby and football sports trainers had more concussion treatment self-efficacy than their respective coaches (Naftel et al.,

2014). As ATs’ RTP decision-making ability goes hand-in-hand with the treating physician, it is essential that both types of providers possess a high level of knowledge, safe attitudes, and a positive self-efficacy toward concussion management.

Physicians

Medical doctors are usually the first point of medical care for a concussed athlete following release from the emergency room (Mackenzie & McMillan, 2005). There has been limited research effectively examining physician knowledge, attitudes, and self- efficacy of concussion management in the athletic population. With 70-95 percent of coaches saying they would consult an LHCP for advice on RTP of an athlete, it is imperative that physicians understand that concussions are a multifaceted problem

(Guilmotte et al., 2007). Mackenzie and McMillan (2005) found general practitioners estimated the duration of symptoms to be longer than the general public or individuals with a mild traumatic brain injury. This could be in part due to a high level of knowledge and safe attitudes toward concussion management that leads to a more conservative approach. The researchers also found physicians did not necessarily associate postconcussive symptoms with a concussion unless prompted. This may limit the number of

PCS patients that seek help if they do not recognize their symptoms as part of their

previously sustained head trauma and the physician does not educate them about it. In addition, when including bogus symptom response options on the survey, physicians demonstrated a high level of knowledge by differentiating applicable symptoms and those that were not. The current study will follow suit and include bogus symptom response options.

Although most of the physician-based research supported a significant concussion knowledge base, one study done by Boggild and Tator (2012) found a significant amount of medical students and residents lacking knowledge about concussion management.

Almost half of the respondents did not recognize CTE or SIS as potential long-term risks of a concussion. In addition, 24 percent of the medical students did not believe a physician was warranted for every concussion case as part of the management protocol

(Boggild & Tator, 2012). Alarmingly, Zonfrillo et al. (2012) found that pediatricians and emergency room doctors do not have enough training to properly treat concussed patients despite the regular need for concussion management. Although no specific research has been done, interviews of prominent physicians have shown the relentless pursuit of physician knowledge and improvements in evidence-based practices and how primitive concussion knowledge and treatment is to date (Pennington, 2013). Specific additional education may be needed to enhance LHCP’s concussion background in order to ensure patient quality of care. Meehan et al. (2011) suggested physicians have more education including updated guidelines in their journals and at their annual continuing education conferences. These findings warrant further examination of physicians’ understanding of concussions.

Behavioral Constructs for Licensed Health Care Professionals

There is an inherent challenge in trying to motivate LHCPs to change their treatment practices. This adoption of new habits, like any other health behavior, requires a permanent behavioral change. Often, established guidelines can influence an LHCP’s behavior, but compliance to these guidelines is not guaranteed (Lin et al., 2000; Yates,

1999). Compliance with medical practice guidelines is often low due to implementation and adherence barriers including a lack of awareness, familiarity, self-efficacy, outcome expectancy, agreement, and external barriers such as organizational and environmental

(Cabana et al., 1999; Cabana et al., 2000). Physicians appreciate educational tools that assist them as opposed to those that restrict them. When surveyed, physicians prefer cues to actions such as journal articles, grand rounds, regional meetings (Brown et al., 2001), experts in the field, and colleagues (Brinsley et al., 2005). The HBM can be used as a framework to better understand which knowledge, attitudes, and self-efficacy predictors influence practitioner behavior to adopt evidence-based guidelines.

Health Belief Model

The HBM is the most commonly used psychological theory in health-related behavior research (Lai, Hamid, & Cheng, 1999). The primary focus of this model is to improve public health by examining failure to adopt preventive health measures. This value-expectancy model posits that individual behavior is directly driven by perceived benefits and barriers; perceived threat; self-efficacy; cues to action; and indirectly driven by modifying variables such as knowledge and age (Kim, Ahn, & No, 2012). For the purposes of this paper, attitudes toward perceived benefits, barriers, and threat will be used synonymously with individuals’ attitudes toward the behavior. In this dissertation,

the LHCP’s attitude is based on the overall favorableness, or emotional response, toward concussion safety. Studies examining LHCP’s behaviors have begun surfacing throughout the literature (Betz et al., 2013; Eriksen, Melberg, & Bringedal, 2013;

Ibrahim, Chew, Zaw, & Bever, 2014; Karbach et al., 2011; Potosky et al., 2011; Reiner,

Sonicki & Tedeschi-Reiner, 2010).

Many studies have used this theory’s framework to predict patient behaviors

(Carpenter, 2010; Cronin, 1986; Lai, Hamid, & Cheng, 1999) and LHCPs’ behaviors

(Brinsley et al., 2005; Hyman, Baker, Ephraim, Moadel, & Philip, 1994; Nujum et al.,

2012). A meta-analysis done by Carpenter (2010) looking at the effectiveness of the

HBM’s perceived severity, susceptibility, benefits, and barriers in predicting behavior found benefits and barriers to be the strongest predictors of health behavior. Further, studies have found the patient-practitioner relationship to influence patient behavior using the HBM (Becker & Maiman, 1975; Brinsley et al., 2005; Hyman et al., 1994).

Perceived barriers such as a deviation from normal communication patterns have been suggested between the patient and provider such as when the physician is too formal; rejecting; controlling; in complete disagreement; or lengthy interviewing without feedback (Davis, 1968). Others have suggested attitudes such as a physician’s lack of personality and brevity of the office visit to influence patient compliance (Coe & Wessen,

1965). With these studies supporting the notion that practitioners play a vital role in patient compliance, the HBM model can also be used to predict physician behaviors.

The HBM has also used knowledge and other modifying variables to predict

LHCPs’ behaviors. Brinsely et al. (2005) found modifying factors such as individual demographics, perceptions, and preferred cues to action were all influential variables for

predicting behavior clinician behavior. Other studies have examined physician attitudes as a cause for mammography screening of patients in which specific modifying factors such as sex, age (Bassett et al., 1986; Wheat, Kunitz, & Fisher, 1990), and specialty (Fox et al., 1988) of physicians were shown to influence patient screening. On a similar note,

Kvamme, Catlin, Banta-Green, Roll, and Rosenblatt (2013) found physician specialty to be associated with prescription writing behaviors. Similarly, Ruiz-Moral, Rodriguez,

Perula de Torres and de la Torre (2006) found that communication behaviors were different among different types of physician providers. Results imply specific training sessions based on physician specialty would produce the greatest effect on provider communication skills. These findings suggest LHCP specialty may influence a provider’s endorsement of best practices.

According to the HBM, the construct of self-efficacy has a direct influence on behavior. Self-efficacy is a measure of belief in one’s own capability to succeed in performing a specific behavior (Bandura, 2006). Self-efficacy can influence how a provider acts toward a treatment practice, and therefore, is associated with an LHCP’s utilization of treatment practices (Anchondo et al., 2012; Burglehaus, Smith, Sheps, &

Green, 1997; Harkins, Lundgren, Spresser, & Hampl, 2012; Makowsky, Guirguis,

Hughes, Sadowski, & Yuksel, 2013; Visser et al., 2008). Norgaard, Ammentorp, Kyvik, and Kofoed (2012) found LHCPs often lack confidence in their ability to communicate with patients, subsequently leading to a lack of care. Further, Marteau and Johnston

(1990) demonstrated low self-efficacy can lead to the absence of treatment practices since a provider needs a positive self-efficacy to perform a related behavior. Finally, McRee,

Gilkey, and Dempsey (2014) found that improving providers’ self-efficacy would be

influential in supporting recommended treatment practices. LHCPs must feel efficacious regarding their ability to successfully endorse concussion management best practices. In other words, LHCPs have the ability to control whether or not they use evidence-based concussion management protocols, and if so, which ones.

CHAPTER THREE: STUDY I—EXAMINATION OF THE IMPLEMENTATION

OF HOUSE BILL 2038 ON CONCUSSION MANAGEMENT IN THE HIGH

SCHOOL SETTING

Abstract

Concussions in the adolescent population are occurring at an alarming rate. The need for state-level policy to manage these injuries is exemplified by the growing number of concussion management bills being passed into law. Texas’s House Bill

2038, also known as Natasha’s Law, targets the public school setting for safely managing concussions; however, the implementation of this bill has yet to be examined.

Semistructured interviews were conducted with 14 athletic trainers to study public high school athletic trainers’ perceptions of implementing the required HB 2038 guidelines.

Athletic trainers reported on four topics that must be taken into consideration when implementing a school concussion protocol: (a) a school-level concussion policy’s implementation is dependent on salient facilitators; (b) a school-level concussion policy’s implementation is dependent on having fewer barriers than facilitators; (c) a state-mandated school concussion law requires support from within the school and community; and (d) a school-level concussion policy’s implementation is dependent on the positive impact of the Concussion Oversight Team. Within each of these topics emerged three to five common themes. From this study, results regarding important aspects of implementing a state-mandated concussion management policy that can help guide other school districts and states with implementation in the future were discovered.

Introduction

Concussions are a growing concern throughout organized athletic programs, with a near doubling of reporting in the last decade. The CDC estimates approximately 1.7 million sports-related traumatic brain injuries occur annually (Faul, Wald, & Coronado,

2010), but with changing diagnostic guidelines and a lack of injury surveillance in younger populations, estimates may be closer to 3.8 million (Halstead & Walter, 2010).

The concussion incidence rate among high school athletes is approximately 0.24 per

1,000 (Lincoln et al., 2011) with concussions representing approximately 8.9 percent of all injuries (Gessel et al., 2007).

In May 2011, the Texas legislature signed House Bill 2038 into effect, requiring all schools to follow a set of concussion management guidelines, including a return-to- play (RTP) protocol and creating and implementing a Concussion Oversight Team

(COT). House Bill 2038 is a health promotion policy, mandated by state law, to protect student-athletes from mismanaged concussion treatment practices. Health policy is the framework through which a healthy school environment is created and implemented to become a part of the school culture (Grebow et al., 2000). Bridging policy and practice is essential in supporting improved educational and health outcomes, because health policy can establish healthy norms, shift toward more healthy behaviors, and provide information in regards to what is important or valued in society.

Little research has been conducted to examine why health policies are or are not implemented in schools (Grebow et al., 2000). This is also the first time a concussion oversight team has been implemented to help coordinate and oversee successful implementation of a concussion management state law. To date, no research has been

done to understand the role of the COT in promoting change efforts. In a similar manner, according to Kann et al. (2007), even though roughly 70 percent of schools nationwide have implemented Coordinated School Health Teams to diffuse new health policies, little has been done to examine the implementation process of such teams.

Public schools that participate in interscholastic athletic activities were given one year to implement HB 2038 in its entirety. Large school districts with the most students, largest budgets, and most administrative support are likely to be early adopters of this law and therefore will be used for the purposes of evaluation in this study. Interviews with

ATs were conducted to understand how this new health-related law was spread and ultimately implemented within the district. As HB 2038 is in its infancy, it is important to discern how this policy information has been channeled down to the school level and how the administration is implementing its components. Unearthing facilitators toward and barriers against policy implementation will assist other schools, districts, and states transitioning to policy adoption.

The aim of the present study was to examine how ATs perceived the implementation process of the new concussion law. In order to achieve this, an exploratory interview study was chosen as the best way to understand these perceptions.

Content analysis was used to develop emerging themes grouped under main overarching topics. Findings from this study may assist policy-makers, school administrators, and health care professionals in better understanding, from the perspective of athletic trainers, the necessities related to implementing a school-level concussion management policy.

Methods

Participants

Research was conducted at one of the largest school districts in the state of Texas, with over 110,000 enrolled students. The district employs 2 ATs at each of the 10 high schools for 20 twenty athletic trainers. Fourteen of these ATs voluntarily e-mailed or faxed their signed consent form for the study. Employment by the district was the only inclusion criteria, and 1 of the 20 athletic trainers had officially resigned prior to the start of the study, leaving a response rate of 14 out of 19 (73.68 percent). Exactly half (n = 7) of the responding participants were female, and 9 of 14 (64.29 percent) were head athletic trainers. This sample represents 9 of the 10 high schools’ head athletic trainers’ perceptions and feedback on the implementation of the house bill. Appendix A.1 has a checklist of the school district’s participation information, such as the dates and duration of each interview for each high school. The student demographic breakdown can be seen in Table 3.1. This district was chosen for this study because of its substantial financial and administrative resources, allowing for early adoption of HB 2038.

Table 3.1 Demographic Composite of Students in the District Ethnicity % of Population African American 16.30 Asian 8.40 Hispanic 43.30 Multiracial 2.20 Native American 0.50 Pacific Islander 0.07 White 29.20

Data Collection

Each participating athletic trainer in the district was interviewed about decision- making, policy adoption, and implementation. Each interview was semistructured with open-ended questions for flexibility (see Appendix B.1). These guiding questions allowed for further exploration of participant responses as needed. Probing questions were used to go beyond any superficial answers and help delve into a more in-depth understanding (Ritchie & Lewis, 2003). Before initiating the interviews, a document analysis and retrieval of archival data was performed to familiarize the researcher with critical school information. This information helped to establish a deeper context for the interviews. Strategies used to analyze the data included transcription, categorization, and contextualization (Corbin & Strauss, 2008). Main questions, along with additional probes, were used to structure the interviews, but the primary investigator was able to lead the interviews based on participants’ responses, as outlined by the procedures of

Bogden and Biklen (1998). Qualitative feedback allowed for collection and assessment of the participants’ observed facilitators and barriers of the policy. The role of resources

(viz., administrative support) and community context (viz., accessibility to health care, social norms, and parental support) was also considered during the interviews to establish a more comprehensive understanding of what areas of the bill are most influential in implementation.

A recruitment letter (see Appendix C.1) was e-mailed to each high school AT after receiving e-mail addresses from the district’s athletics department. Within one week, a general voluntary participation consent form was e-mailed to each AT (see

Appendix D.1). All signed consent forms were collected by the principal investigator

prior to the start of the interviews. A follow-up phone call took place within one week of obtaining each signed consent form to schedule a time for a phone interview. The one- time interview took between 25 and 56 minutes (with an average of 31 minutes and 42 seconds). This interview was digitally recorded and later transcribed for the purposes of qualitative analysis and will be destroyed three years following the end of the data collection. No video recording took place.

Although the district would allow only one interview per participant, two participants voluntarily contacted the primary investigator post-interview to clarify a few earlier comments. This allowed the PI to perform a midpoint interpretation check of the results by summarizing each participant’s responses and asking them to verify the interpretations in order to determine accuracy. The two participants were read a summary of the findings of each of the main topics (including related themes) and asked if they agreed, disagreed, or had anything else to add to each topic summary. There was a consensus found between the participants’ thoughts and the investigator’s interpretations of the main topics and related themes and no new concerns were raised with the data. Obtaining agreement from the respondents demonstrated a limited attempt at credibility of the study’s findings as defined by Harper and Cole (2012). This method was used in an effort to establish trustworthiness of the data by verifying the interpretations were consistent with the perspectives of the participants and not the researcher (Rager, 2005).

Ethical Considerations

Before beginning the study, the school district and The University of Texas

Institutional Review Board gave approval for the research (see Appendix E.1 and F.1,

respectively). Great effort was taken to follow the school district’s procedures regarding contacting athletic trainers for research purposes. The school district was not informed of participant involvement or specific feedback, and it would only have access to the overall results of the study. The de-identification process was done by assigning registration numbers to each participant in order to keep responses confidential. Registration numbers were directly linked to participant names in order to schedule interviews, but were only accessible to the principal investigator on the PI’s password-protected personal computer and were destroyed immediately following the participant’s interview.

Data Analysis

The participants’ responses were read and reread for context by the primary investigator to determine which overarching topics of implementation were to be addressed. Once these four topics were established, the interview data were then analyzed using the Grounded Theory’s constant comparative approach. This approach allowed for the emerging of specific themes, within each topic, related to athletic trainers’ perceptions of concussion management policy implementation and adherence.

Corbin and Strauss (2008) defined Grounded Theory as a systematic way to explain a phenomenon using a theoretical framework by developing categories such as concepts and themes. The data in this study were analyzed using the guidelines of the four steps described by Glaser and Strauss (1967): open coding, axial coding, selective coding, and defining a central category. Content analysis was used to identify key concepts related to the implementation of the new legislation in the district’s athletic departments.

In the first step, open coding was used to examine each line of the transcriptions to define actions and events and help organize the information (Corbin & Strauss, 2008).

This process, known as “memoing,” occurred when important and relevant information such as an event, opinion, or behavior was noted in the margins of the interviews. The primary investigator made a set of broad codes in this first step. The second step, axial coding, allowed for the development of conceptual connections between related subcategories (2008). As each interview was reread, memos were grouped into ideas by recurring similarities and written in the margins. This also allowed for the identification of central phenomena. The third step, selective coding, allowed for relationships among the phenomena to be examined and validated, or further explored (Creswell, 1998). This step produced a more definitive group of concepts among all of the more general phenomena. In the fourth step, all recurring concepts were narrowed down into a topic, in which there were four common topics. Of the 14 participants, everyone referenced each of these topics at some point in the interview. Within each topic, there were specific themes that emerged.

The comparative analytical method was used to ensure all codes and categories were compared and contrasted until all data were accounted for in the core topics. The analysis was further reviewed by assessment of the convergence of the themes with other data sources provided by the school district. Archival data included the district’s concussion policy and online profile entailing demographics, budgeting, and health and wellness programs. These documents were reviewed and compared to the themes that emerged in green ink. The trustworthiness of this study was supported through memos and archival data as a means to compare the participants’ responses for verification purposes.

Another attempt to provide trustworthiness of the interpretations resulted in the presentation of participant responses to a group of three experts in the field. The transcripts were read and analyzed by these professionals, in which the three individuals established which topics needed to be addressed and their subsequently emerging themes.

The group then compared topics and themes, determined whether any topics and/or themes were missing or unwarranted, and ensured all concepts were represented by the four agreed-upon topics. All discrepancies were discussed until a consensus was reached.

The meeting was concluded with the affirmation that no new topics or themes had emerged.

Results

In total, 14 respondents participated in the study and represent 9 of the 10 high schools in one of the nation’s largest school districts. This group comprised a wide range of experience and perceptions regarding concussions and school safety policies. Their feedback demonstrated the complexity of designing, implementing, and maintaining a new school safety policy, as well as the contextual factors involved. The interviews generated rich feedback about the practitioner’s perceptions of concussion policy at the school level. Emerging themes from four overarching topics regarding ATs’ perceptions of the new house bill’s implementation process were the focus of the study. These topics include: (a) a school-level concussion policy’s implementation is dependent on salient facilitators; (b) a school-level concussion policy’s implementation is dependent on having fewer barriers than facilitators; (c) a state-mandated school concussion law requires support from within the school and community; and (d) a school-level concussion policy’s implementation is dependent on the positive impact of the Concussion Oversight

Team. There was a wide-reaching consensus on the importance of each of these, as the house bill’s policy was implemented and diffused into the individual schools, as well as across the district. This study provides a more comprehensive understanding of how the new law has impacted student-athlete safety. The experiences of this group of pioneers can be used as a model for future concussion management policies.

Topic 1: Policy Facilitators

The first topic that materialized from the coding was that a school-level concussion policy’s implementation is dependent on salient facilitators. In order for a bill to be appropriately implemented into a school policy, it must be soundly written for legal and practical purposes, and there must be more facilitators than there are barriers.

For the purposes of this study, facilitators were considered anything the athletic trainers perceived to be helpful with implementing the bill into a school-wide policy that protects the student-athletes. It was evident from the emerging subcategories within the themes that facilitators were perceived as fixes to the inherent issues of past concussion management protocols. According to the participants, spreading bill awareness via word of mouth to the community and district were equally important to policy facilitators as creating a uniform management policy that had state-level support. The five themes that underlay this topic can be seen in Table 3.2.

Table 3.2 Summary of Topic 1 Themes 1) Law was soundly written for legal and practical purposes 2) State concussion law was influential and widespread in the community 3) School community held a consistently communicated common vision 4) Significant in protecting the safety and well-being of the students 5) Concussion policy uniformity for district implementation and compliance

The first emerging theme regarding bill facilitators involved the perception that the bill was soundly written for legal and practical purposes by providing a concrete management protocol using clarity, consistency, and uniformity. In order for a bill to be implemented and subsequently adhered to, it must be written in a way that people can understand. The bill has a clear definition for what constitutes removal from participation, as well as the need for physician intervention, and which individuals by definition need to be on the Concussion Oversight Team. The bill seems to “get the job done,” as one athletic trainer stated. Prior to bill implementation, there was a lack of concussion management consistency throughout the district. Prior to HB 2038, every campus handled concussion management differently, and inconsistency was pervasive.

“The new law gives more documentation and paperwork to use to educate the parents and keep everything in line. That way every situation [is] treated the same; gives a leg to stand on when they say, ‘Hey, um, we’re going to hold your kid out until you see a doctor because it’s the law.’” Before the bill, athletic trainers would base their RTP protocol on things like loss of consciousness, number of previous head injuries, and number of present symptoms. There is now a required five-step RTP protocol that cannot be initiated without physician approval. This law also makes the RTP protocol more concrete because the coaches cannot have any input on the course of treatment or timeline. One AT mentioned, “Coaches don’t have an option of trying to push to get somebody back faster because it’s right there in black and white.” Another AT recalled,

“It used to be when doc said one week, they were back playing in one week no matter what the symptoms were.”

In addition, the bill provides justification and support for how head injuries are managed. Before implementation of the bill, it was harder for the ATs to justify their actions, despite the obvious safety measurement, when managing concussed SAs. The

ATs see this new law as giving them the authority to make decisions without being questioned about their actions. “There was a lot of pressure from head coaches: ‘Oh, they need to get back in. We need to get ‘em back in. He’s all right.’ The coaches all say

‘Well, I had about 18 times [where] my bell was rung.’ [The bill] has given more leeway to say, ‘Hey coach, it’s the law. We have to have them out.’ It’s eased the old coach mentality . . . we’ve really cracked down a lot.” Now that a law has been passed regarding concussions, everyone understands the importance of proper injury management, and there are legal ramifications for not abiding by the law.

Another important theme that emerged purported that the state concussion law was influential and widespread in the community. This helped build support for a new school-level concussion policy. Word of mouth and athletic training organizations helped spread the word in order for schools and districts to begin working on a concussion policy before the mandatory implementation deadline. Organizations like the

Texas State Athletic Trainers’ Association, the Southwest Athletic Trainers’ Association, and the National Athletic Training Association all used social media such as Twitter, list- serves, and their associations’ websites in order to educate the profession on the upcoming bill—some as far as two years in advance. Journals, newsletters, continuing education workshops, and state forums were also mentioned as facilitators that helped to spread the word. Other examples specific to this school district included UIL updates, posting the concussion handbook to the district’s website, local media coverage, and

paperwork sent home to parents as a means of gaining awareness throughout the community and not just among students and staff.

Communication throughout the district required a consistent message as to exactly what the district planned and expected in regards to concussion management. Theme 3 states that the school community held a consistently communicated common vision. All but one respondent felt the need for good communication and felt the district had done a good job. Policy implementation occurs because such a large number of stakeholders

(viz., teachers, athletic trainers, student-athletes, coaches, etc.) received the same message. With so many personnel, students, and community relations, communication among the schools was imperative. One school decided to introduce the new bill in the spring of 2011 at the end-of-year coaches’ meeting, which spurred a district-wide meeting regarding the new bill so that all athletics staff would be aware of and educated about the reasons for the upcoming concussion management changes for the 2011–2012 academic year. This launched a domino effect that led to annual preseason educational meetings with coaches—and another one for parents and student-athletes. One athletic trainer mentioned that this was “a really good coaching in-service where the athletic trainer told everyone and went over the policy and discussed any concerns at the time.”

The language of the new policy was explained and kept simple at the coaches’ meetings, as the middle school coaches would be left on their own to implement policy without a supervisory athletic trainer. Another athletic trainer said, “Our district works together and bounces ideas off each other; asks questions to one another.” This district-wide communication was unequivocally the most efficient way to implement the change

smoothly within each high school. It helped that each school could use each other for advice and feedback as needed.

A fourth theme emerged from the commonality of responses regarding the protection of the student-athletes. Theme 4 states the school’s concussion policy was significant in protecting the safety and well-being of the student-athletes. The purpose of the policy was relevant and salient, which helped facilitate district and community support. One of the original purposes of the bill was to protect the student-athletes from injury or a subsequent increased risk of re-injury. This purpose was used to the bill’s advantage when being passed into law. According to all 14 participants, when the school district and community saw a need for safeguarding their student-athletes, policy implementation became expedited and more broadly supported. In theory, the health and interest of the adolescent should be put ahead of winning, but this is not always the case

(Kerr et al., 2014). This can be difficult if there is a supervisory coach being pressured to win or a lack of funding for employing an athletic trainer at every practice, competition, or school. One went so far as to say, “A drastic change with a policy like this helped open the coaches’ eyes.” The administration realizes the law protects the district’s personnel, and the parents realize, with some education, the law protects their children.

Providing consistency among the athletic trainers in regards to concussion management was another important facilitator for policy implementation. Theme 5 states that the school district’s concussion policy was well-implemented because there was concussion policy uniformity for district implementation and compliance. Prior to HB

2038, each school had its own way of handling concussions. According to all of the participants, there was no standard practice, and every school treated head injuries very

differently. The immediate and continued support of the house bill from the athletic trainers and the administration was evident throughout the interviews. One AT talked about the days before the policy was implemented: “The older policies, we were more coaches’ trainers. I mean, we did what’s best for the athletes, but we also do what’s best for the team, what’s best for the situation.” Another participant said it has helped them

“really crack down” on head injuries. These positive feelings about the new district concussion policy were expressed by all of the participants interviewed. It is important to note that the previously mentioned facilitators were thought to expedite the implementation and acceptance of the new policy within the district.

Topic 2: Policy Barriers

With any new bill signed into law, inherent barriers to implementation will arise.

Topic 2 states that a school-level concussion policy’s implementation is dependent on having fewer barriers than facilitators. It is important that the designers and practitioners recognize these barriers and work to make them manageable and less salient than the relative facilitators. Emerging subcategories within the themes were all demonstrative of concerns with day-to-day bill logistics, such as time requirements, community knowledge, and classroom accommodations. The conceptual themes contained in this policy barrier topic can be seen in Table 3.3.

Table 3.3 Summary of Topic 2 Themes 1) Lack of awareness within the community (including parents, teachers, coaches, local physicians, and English as a Second Language [ESL] parents) 2) Time requirement for paperwork associated with completion, tracking, and reporting 3) Financial barrier requiring all student-athletes with suspected head injuries to see a physician

Theme 1 states that a lack of awareness within the community (including parents, teachers, coaches, local physicians, and English as a Second Language [ESL] parents) was a major barrier for concussion management policy implementation. Although it was noted earlier that this district did a good job of reaching all facets of the community to raise awareness of the new policy, some subgroups still need more educating. As with many school-implemented policies, not everyone is immediately aware of and/or understands the new policy. In regards to the parents, it has been found to be difficult for the ATs to use the new concussion safety policy when the parents are unfamiliar with the state-mandated rules. One AT discussed this lack of awareness by saying, “Many parents are apolitical. They aren’t going to follow what’s going on until it affects them.” When a SA is removed from competition for a suspected head injury and the policy says that student must see a physician, if a parent is not educated on the policy, then it is challenging for this part of the policy to be carried through. When asked about educating the community about this new bill, many responded that the parents do not understand the bill’s requirements, and the learning curve for this new policy will take time.

“Educating the parents more [about the new district concussion policy] is a slow process.” Another AT was unconvinced of the community’s general awareness: “Not enough word spread to parents, need to do a better job moving forward.”

According to the athletic trainers, the teachers also need further education about the new law. Often, teachers resist making accommodations for the concussed SA in the classroom. One AT felt there were “not enough classroom accommodations, kind of a lot of fights from the teachers that won’t do it or [don’t] think it’s a big deal.” Another participant mentioned, “Sometimes [there are] problems with teachers; they can’t see the

injury, so they don’t think it’s real.” Reasons for teacher opposition included disbelief the SA was concussed and questioning whether the concussion actually impacted the student’s ability to perform in the classroom. Others might believe the student-athlete is taking advantage of the injury in order to get out of participating in the classroom and/or other school-related tasks. One example was given in which an SA was symptomatic for over six weeks, at which point the teacher questioned the AT about the likelihood of having symptoms after such a long time. A few of the ATs suggested a solution for increasing teacher support by increasing support of the administration for the policy’s influence in the classroom. One AT said, “[We] need the support from the administration to get the teachers on board.” Another said, “If having a problem with a teacher, I let an assistant principal know, and they take care of it.” On the other hand, three respondents mentioned some success with teacher recognition and acceptance regarding this new policy. “Teachers are good about letting a kid go to the nurse and lie down for 5 or 10 minutes.” Not all of the teachers were found to be inhibitors of the new policy.

According to three ATs, the teachers are more aware than they had been in the past and have been compliant with the new bill.

When a physician’s orders mentioned altering classroom activity following a concussion, there seemed to be quite a bit of discrepancy as to how that should be handled. The word accommodations was interchanged with modifications regarding these types of classroom alterations throughout most of the interviews, although

“modifications” is not correct in this case. In the state of Texas, those students with modifications require special paperwork and individualized educational plans (IEPs); however, a student can have short-term accommodations without involving the special

education program and potential school funding. These accommodations may be developed by the treating physician or the school personnel and may include (a) frequently scheduled cognitive breaks; (b) later start time or a shorter day; (c) decreased workload; (d) limited, modified, or no testing; and (e) increased time allotted for certain assignments (Sady, Vaughan, & Gioia, 2011). All of the respondents agreed that the physician must determine whether an SA should have additional classroom help; however, the appropriate method in determining how this should be implemented was dependent on the physician and the school. “Some [doctors] don’t know the difference between modifications and accommodations” and “some doctors write

[accommodations], and some don’t.” ATs have worked closely with area physicians to make sure the terminology does not target special education funding and paperwork.

Some ATs found it helpful to include the nurses and Director of Instruction (DI; the individual that acts as a liaison between the administration and the teachers) to ensure effective classroom education occurs. It was helpful for the DI to inform the SA’s counselor and individual teachers of classroom accommodations prescribed by a physician. The ATs believe that an increasing number of physicians are prescribing altered classroom instruction as concussion awareness grows; however, the majority of

ATs have yet to see any prescribed accommodations.

Despite the educational trainings and informational staff meetings regarding the new concussion policy stemming from HB 2038, there is a lack of acceptance of the mandated guidelines by the coaches. This group of individuals plays an integral role in the management of concussed student-athletes, especially if the school does not employ an athletic trainer or physician. If the coaches do not understand this type of injury, there

is an increased risk of further or subsequent injury to the adolescent. For the most part, the coaches have been receptive and understanding of the new policy, but there is still pressure and an “old-school” mentality to win. One head athletic trainer said there was

“still some resentment with old-school coaches who tell you 1,000 times they’ve had so many [concussions] and the jersey colors were changing and they were knocked out and dizzy and had a headache all the time. There’s still a little bit of resentment to the coach when . . . you pull out that stud because, you know, they got a concussion.” Another potential reason for coaching resistance has to do with the culture of Texas football. Its traditions are deeply engrained and have a long history. One AT said, “If you’re talking

Texas and football, the coaches are going to be the roadblocks. They say things like ‘I go out and have a six-pack every night, and I have a headache the next morning. That’s a concussion. I kill brain cells.’” A third reason mentioned for coaches’ lack of understanding is the time commitment required for a two-hour UIL required concussion training. If the coaches do not make this training a priority, then they will be unaware of the importance of the new law and its associated rules.

Of all of the community barriers, it appears that the physicians’ lack of awareness regarding the existence and details of the new house bill is the most pressing. The physicians are required by law to evaluate, treat, and clear the SA prior to initiation of the

RTP protocol. If the physician is unaware of or lacks training in the house bill’s requirements, then the concussions will be mismanaged, and the risk of injury will be increased. According to half of the athletic trainers, the physicians have not been adequately educated on the new concussion guidelines. “Doctors often don’t specify whether they have found a concussion or not, or [if] they think it’s [a] concussion or not.

A lot of times, [the student-athletes] come back and say, ‘[The doctors] didn’t say if I had one or not, but they ordered an MRI.’” Another AT said, “A lot of the doctors don’t understand the law; pediatricians and urgent care facilities especially [when they say] they can return to practice and game in three days, or they’ll run a CT and it’s normal, so they’re fully cleared. Wonder if they even know the law exists?” One respondent felt it was the medical association’s fault for not educating the physicians. The ATs

“preemptively handled that by creating a letter for the student-athlete to give to the doctor.” This educational letter sent by the schools with the injured SA to the area doctor is not something the ATs believe other districts are utilizing.

On a similar note, when asked about awareness of the new policy within the ESL parent and student community, there was an overwhelming need for increased education of this population. The majority of respondents felt that short of concussion paperwork and policy information being translated into Spanish, there was no concrete way of educating parents that spoke a language other than English. With such a diverse demographic group such as this school district embodies, it was imperative to the majority (92.9 percent) of interviewees that more work needs to be done in this area (see school demographics in Table 3.1). Some schools have been successful with student-to- parent or parent-to-parent translation during parent meetings, but most of the ESL parents do not attend the parent meetings. Many athletic trainers believe this is because they work more than one job and do not have time to attend. Some athletic trainers went so far as to say that even the translated documents are not helpful because many of the parents “can’t read anyway, so it’s kind of a moot point.” Another AT said, “The [ESL] parents are equally educated as far as not really knowing anything about it.” It was also

noted that no ATs in the district spoke Spanish, so it was difficult to educate these parents. Some ATs felt educating ESL families was an unnecessary concern because their affluent student population did not have ESL families, but when prompted, they had no statistics to support these notions.

Another barrier mentioned by several of the staff was the time it takes to implement and continue to use a new policy such as HB 2038. As with any new school policy, it takes time to make everyone aware of and in compliance with the policy. One

AT noted. “They gave us three months [to implement the new law], so if you weren’t aware [that the law was coming], you were already behind.” Theme 2 states that the most frequently cited barrier for the new concussion policy was the time requirement for paperwork associated with completion, tracking, and reporting. The University

Interscholastic League (UIL) and the school district have forms that must be signed by the SA and a parent in order for the SA to participate in sports, and another form following a sustained head injury for RTP purposes. At the beginning of the season, the parents are asked to attend an educational meeting about the new law, and parents must sign and return paperwork showing they understand the new rules. This must be done prior to any student being allowed to participate in athletics. Next, if a player gets hurt, there is a form that must be signed by the student, parent, physician, and athletic trainer in order for the player to return to competition. The purpose of the paperwork is to inform the parents and SAs about the concussion policy, but it is unclear at this point whether all of the parents are reading the paperwork closely and/or asking questions if anything seems unclear. According to Esbensen et al. (2008), the average rate of returned consent forms by parents in schools is about 78 percent, which means that if the

schools require 100 percent of SAs to return approved forms in order to participate in sports, there is an increased risk of parents not reading the concussion forms thoroughly.

Interviews showed some parents seemed resistant to their children being removed from competition following a suspected head injury, which supports the notion that not all of the parents are attending the educational meetings and/or clearly reading the concussion paperwork.

In addition to all of this paperwork, the athletic trainer is also responsible for tracking the injury date and return to play date and reporting this to the Concussion

Oversight Team; although this is not required by the state, only by this particular school district. In total, there are five forms the athletic trainer must obtain and/or complete once a head injury has occurred. This paperwork commitment makes the policy time- consuming and often inefficient, especially at the middle school level. Many of the high school ATs felt the RTP protocol and paperwork at the middle school level were not being completed up to the district’s standard. One head athletic trainer that was not a member of the COT mentioned, “I don’t think a lot is getting done over there.” Each of the respondents gave a different answer as to who was responsible for the protocol at their feeder middle schools. Responses included head coaches, campus coordinators, campus nurses, and various combinations of all three.

The final potential barrier discussed by the ATs for this type of policy dealt with the financial component. Theme 3 states that there is an associated financial barrier requiring all student-athletes with suspected head injuries to see a physician. Similar financial concerns have been seen recently, with the Affordable Care Act requiring all citizens of the United States to obtain medical insurance regardless of ability to afford

coverage (Morgan et al., 2014; Ngo-Metzger et al., 2012). This financial concern is mainly for those student-athletes without insurance or other financial means to seek out health care, especially for those nonemergency situations. All of the athletic trainers interviewed that have come across this type of problem (57.1 percent of respondents) have been able to work with area doctors, clinics, and/or the team’s physician to have a student-athlete seen either for a reduced rate or pro bono. In addition, the school district has supplementary athletics insurance that is free and required of the school in order to participate in athletics. This has been found helpful, because it acts like primary coverage when the SA does not have insurance. Often, team physicians will see an injured student-athlete with only a supplemental policy. Area pediatric clinics have also recently opened “that [accept] WIC, Medicaid, and anyone without insurance.” Although the ATs have been extremely creative with finding ways to have an injured SA seen by a physician, some ATs believe this takes the choice of health care provider out of the hands of the patient.

The majority of [our] demographic is Hispanic, so they often see Clinica Hispanica and walk-in clinics. May not be the best for student-athletes but at least they are seeing someone. They may say ‘no concussion found’, and it’s like ok, you actually found a concussion before? I don’t know if they completely understand the new law and key to concussions. I think it’s great that they see a physician as far as the legal aspect, it takes me out of the loop, but as far as the best care for the kids, I don’t know if that’s the best choice, but you know, my hands are tied.

The less affluent schools, as perceived by the interviewees, mentioned that the most cause for concern is the financial obligation that goes with the new bill. One AT said the biggest problem with the new bill is the money: “Kids that have a concussion have an automatic trip to the doctor. Concussions turn into a cuss word.” All of the ATs

said they were able to find some source of health care even for those with financial constraints. Creativity and building partnerships was key in many of these cases.

Topic 3: HB 2038 Support

House bill support was unanimously mentioned as a crucial component of successful policy implementation. Topic 3 states that a state-mandated school concussion law requires support from within the school and community-wide. Without sweeping support of a house bill, the policy, no matter how well-written and organized, would not be successful in the eyes of the participants. The most important factor regarding support was the timeliness of the support in different stages of policy adoption, implementation, and evaluation. As subcategories emerged, it was evident that participants felt each source of support, whether it be from the school nurse or the media, would be beneficial in such a way that the bill would be more widely accepted and, consequently, implemented. A summary of themes found within this topic can be seen in Table 3.4.

Table 3.4. Summary of Topic 3 Themes 1) Community-wide support during legislative voting, immediately after it was signed into law, and during the implementation process 2) School administration and parents supported the concussion bill from which the school policy originated 3) The media was not used to its maximum potential for community influence

The emergent Theme 1 states that there was community-wide support during legislative voting, immediately after it was signed into law, and during the implementation process. It was important that HB 2038 gained support before it was officially signed into law in order to gain traction in the committee review and voting process. From there, it was important to have support once the bill was turned into law in order to build support within the district. During the implementation process, it was

found imperative to have all health care providers and district administrators on board.

The next stage of support involved the teachers and community. Once the policy had been implemented, it was helpful for the ATs to feel they had support from everyone that was influential to the SAs, such as parents and teachers. Finally, the evaluative period, which immediately follows the implementation period, must maintain its level of support over a long period in order to be successful.

Every athletic trainer interviewed referenced the overwhelming support of the new bill. In order to have a smooth transition from a lack of a formal policy to a state- mandated law, it is important to gain the support of all integral parts of the school community, including the athletic trainers, administration, teachers, coaches, and parents.

Theme 2 states that the school administration and parents supported the concussion bill from which the school policy originated. The ATs felt this school concussion policy was needed, so their first step was asking the administration for support in moving forward.

“Yes, we’ve all had the backing in the world from up above. The board was [really] happy and encouraged by this. We got a lot of positive feedback when we did it.” All of the ATs felt support from the administration was imperative to completing the design and successful implementation of the new policy. “You must have support from the AD and school board. So if you don’t have support from the very basic level on up, you’re just going to hit a wall.” Without administrative support, there would be assumed problems with teachers and parents. Luck was also mentioned by several of the interviewees.

They felt they were lucky if the coaching staff and administration was supportive of their efforts to enforce the bill, although no one mentioned any specific examples of having a lack of coaches’ support even when this topic was probed further.

The ATs felt it necessary to have the administration support the bill in case there was pushback from the parents. For the most part, parents seemed to be supportive when appropriately educated, but occasionally there was some resistance. “Some [parents] try to finagle around it and get kids back faster, but the principal supports us using our best professional judgment.” This administrative support was found to be a huge part of the policy’s success at the individual school level. The parents seem to be supportive once they know what the new bill entails. “When you sit parents down and discuss with them, they are generally very good.” Once the parents understand that the health and safety of their child is being protected, they are generally very supportive as well.

The media was found to be lacking in support for the new bill. The majority of athletic trainers (64.3 percent) agreed that the media could have done more to build community support. In an effort to gain widespread support of the concussion bill,

Theme 3 states that the media was not used to its maximum potential for community influence. The interviewees felt the publicity was short-lived, negative, or did not exist.

One athletic trainer said, “The media is all the negative stuff, like Junior Seau [killing] himself,” while another AT, when asked about the media, said, “I don’t think it’s done a great job. We still have problems with doctors and hospitals not understanding this.” It was apparent that the ATs felt they were doing great things to protect their student- athletes and that publicizing it more through the media would be a good way to spread the word about the bill and gain community support. Many of the ATs felt the media uses “concussion” as a buzzword and talks about it regularly, but there was not enough discussion about the new bill and how the schools are implementing concussion policies to protect the SAs:

They did at the beginning, but it was very vague. “There’s a new concussion law. Students now have to see the doctor.” I don’t think it was in detail, and after two weeks, the coverage just kind of died down, and nobody really thinks about it anymore because it’s not new. And you know how the news is: if it’s not new, then it’s not news.

The majority of ATs felt the media was an untapped resource for helping to educate the community and gain support of the new bill.

Topic 4: Impact of the Concussion Oversight Team

With this new law came the creation of a Concussion Oversight Team (COT).

The law required every district to have a COT in order to assist with policy implementation and provide specialized health care professionals as a resource when making concussion management decisions. One of the biggest justifications for having a

COT was the requirement for an AT to be staffed on each committee, thus circuitously requiring AT employment in every district. The district chosen for the study had one

COT (as opposed to one for each high school) that consisted of four of the high schools’ head athletic trainers, the administrator for school nurses, a junior high school athletics representative, and a local neurologist. The assistant athletic director for the district told the COT to “run with it” when initially formulating the new district-wide policy.

Emerging subcategories revealed that the day-to-day and initial long-term tasks of the

COT, such as researching, building, and evaluating a concussion management protocol, were all important in the implementation and early sustainability of the district concussion protocol. Relevant tasks emerging within the COT topic led to the themes listed in Table 3.5.

Table 3.5 Summary of Topic 4 Themes 1) Catalyst for creating a concussion management policy by building and gathering data 2) Was a resource for the district to utilize when difficult or new concussion-related scenarios emerged 3) Positive way to evaluate and supervise the execution of the district’s concussion policy over time

The first emerging theme for this topic states that the Concussion Oversight Team was the catalyst for creating a concussion management policy by building and gathering data. According to the COT’s athletic trainers, they were the pioneers for the new policy, as most other districts around the state had no policy in place at the time of this district’s policy creation and implementation. These participants called many other districts statewide to see what others were doing prior to design of their own concussion management policy. The COT members used the NCAA, the National Federation of High schools, colleges, universities, and the Mesquite Independent School District policies as templates for their own policy. Definitions of concussion, RTP protocols, and signs and symptoms of a concussion were all taken from other templates and modified to fit the district’s needs. Their goal as one team member put it was not to “reinvent the wheel.” Initially, during the development phase, the group met for a total of over 100 hours, gathering either weekly or semimonthly. At the time of data collection, the COT was meeting once per month or every other month, with several e-mail and phone exchanges between meetings. During the initial development period, when the team was researching and drafting a policy, the team met more often than post-implementation. According to one member of the COT, the team’s purpose seemed to change over time: “The importance of the COT is to keep [the policy] current, keep it updated, and to disseminate the information.” In order to keep the policy current, the members of the COT must obtain

and analyze concussion data and community feedback on how the policy is working. The majority of participants supported the COT’s catalytic duties.

Theme 2 states that the Concussion Oversight Team was a resource for the district to utilize when difficult or new concussion-related scenarios emerge. The majority of participants (64.3 percent) agreed with this statement. The athletic trainers in the COT felt ATs and administrators employed by the district were (and do) frequently refer to the team regarding concussion management decisions. One AT mentioned, “Yes they’ve researched more than I have; I’m going to be honest about that. More minds

[are] better than one mind. The more people you can get involved, the better.” At the same time, the majority of ATs (57.1 percent) felt they would “use them if needed,” but most of the schools have their own team physicians to help with concussion management.

Now that a concussion policy has been established, there appears to be less of a need for the COT. One assistant athletic trainer said, “I had no idea there was a COT,” and three other athletic trainers seemed impartial to the COT’s use post-implementation. Despite some participants not supporting the usefulness of the COT, it appears that 13 of the participants agreed that it should continue operating post-implementation, and one participant was neutral.

As with any new school health policy, there needs to be someone responsible for the supervision of its implementation and continued evaluation of its competence in protecting the students. Theme 3 states that the Concussion Oversight Team is a positive way to evaluate and supervise the execution of the district’s concussion policy over time.

The schools are required by this particular district to report the number of concussions they receive to the COT on a yearly basis in order to monitor injury surveillance trends.

The COT also helps a district of this size to keep everyone on the same page. “You have a chain of command. The committee determines how you handle a situation.” Another

AT said, “You can’t do it without one. It gives you more credibility when you go tell a coach this is the policy. This is the law.” The COT was compared to a “watchdog” by one AT, who said, “There has to be somebody that coaches have to answer to if the rules are not followed.” Another participant described the COT’s importance because there is a

“need to monitor. Better than a coach overseeing it. They don’t have any expertise. It’s like me trying to make a game plan for the offense.” The COT was perceived by the respondents as a catalyst for policy development and an enforcer of the rules post- implementation.

Discussion

With a sample of 14 athletic trainers in a large Texas school district, this study was designed to examine high school athletic trainers’ perceptions of the implementation of HB 2038. Overall, results indicated that athletic trainers were satisfied with the content of the concussion bill and resultantly implemented a concussion management policy district-wide. Specific findings, such as understanding the importance of the

Concussion Oversight Team, suggest bill content that may be used in future concussion policy planning and that some areas, such as educating the ESL population, need further refinement.

Arguably, the largest catalyst for policy implementation was the Concussion

Oversight Team. These individuals pioneered the early stages of development, gathered administrative support, helped spread the word about the new policy, and acted as a support team for any staff with questions or concerns. According to Chriqui et al. (2013),

five years after a federal mandate for public schools to adopt a wellness program was enacted, only 61 percent had adopted such a policy, and out of those, only 83 percent planned to evaluate it over time. This is indicative of the difficulty in ensuring all schools and districts are adopting such policies and why the COT was instrumental in preventing a potential lag time in policy adoption. This delay would have increased the time needed to put together a policy and gather support, thus leading to a longer period of increased risk to the student-athletes.

The majority of respondents agreed that the COT should be used by other institutions creating concussion management policies in the future, although the team seems to be less important once the policy is in effect. At the time this study began in

October 2011, there were 33 states with youth sports concussion laws. To date, all 50 states and the District of Columbia have enacted such laws (National Conference of State

Legislatures, 2015), and many states are now revising these laws as new concussion management protocols are being researched and developed. For example, Rhode Island enacted an amendment one year after its original bill was passed requiring coaches and other support staff to have an annual concussion education refresher course in addition to the required training (Brain Injury Association of America, 2014). In addition, Oregon has added Jenna’s Law (2014) to the original Max’s Law (2010) to ensure all parents and individuals over the age of 12 sign concussion information sheets in order to participate, and youth sports now fall under the state mandate as well (The Center on Brain Injury

Research and Training, 2015). This amendment came within three years of the original bill, demonstrating the need to continue researching the most appropriate means of managing concussions. This study’s results are crucial to the future of concussion policy

adoption and implementation, as states and institutions are continually finding ways to improve on their concussion management policies.

HB 2038 also guarantees each school district has an athletic trainer on its COT, indirectly suggesting that every district should hire at least one AT. Moreover, according to the Bureau of Labor Statistics, the athletic training profession is expected to grow 19 percent from 2012–2022 (United States Department of Labor, 2014). This job growth may be beneficial for other states amending laws, or for organizations implementing similar policies. According to the participants in this study, having an athletic trainer on the COT to adopt and implement concussion management guidelines is imperative, and prospective groups should keep this in mind during the planning and/or modifying process. Future research should be focused on whether the number of employed ATs in public schools based on this requirement increases.

This study highlighted an important problem facing the English as a Second

Language population. None of the participants were able to suggest a way to educate

ESL parents and student-athletes about the new policy. In addition, most of the ATs felt that just because the policy was in Spanish on the website and the forms were also available in Spanish, all ESL parents were educated. There was no consideration from a single participant for those SAs or their parents, who may not speak or read any language other than English or Spanish. Although prevalence of languages spoken by students and parents is not available, it can be inferred by the school district’s demographics and sheer size that some of the population speaks something other than those two languages. From these interviews, it can be confirmed that the possibility of some, if not many, ESL families are being overlooked in the concussion policy education process. At the time of

this study, no research has been designed to examine this population in regards to concussion management in the secondary school setting, although the topic warrants further examination.

This study suggests clear recommendations for school concussion policies during the implementation phase. Instructions regarding the new concussion law and subsequent school policy should be made accessible to local physicians. A handout with school requirements and information about HB 2038 can be delivered to the physicians when a student-athlete with a potential head injury is seen in the office. In this document, there should also be information on the types of modifications and accommodations the school may offer a concussed student-athlete to assist them with their academic return-to-learn process. In addition, those parents that cannot speak or read in English or Spanish should be educated on the bill in their respective language. Also, the financial concerns for those seeking medical treatment must be addressed by each school. In some instances, the schools carry a supplemental $5.00 sports insurance policy that is required for all student-athletes without their own medical insurance policy. New programs for concussion insurance policies are currently being piloted in Texas. Each of these recommendations should be considered for policy implementation.

The findings support the athletic trainer’s overall positive perception of the new house bill. The respondents demonstrated the importance of establishing a concussion management policy that was made uniform for the district, protected the student-athletes, and provided documentation to protect all parties involved. The importance of having a state law in regards to concussion management was seen in a study done by Williams et al. (2014), in which 40.3 percent of athletic trainers said they sent student-athletes to

physicians based on whether or not there was a state law. The ATs felt confident the new policy was soundly written in such a way that it was important for both the ATs and the administration to support. Defining what constitutes removal from play and the need to see a physician, as well as requiring the RTP protocol, were all mentioned as important factors for sound concussion management. With various sources for concussion guidelines available and significant revisions of practice standards constantly taking place

(Lebrun et al., 2013), it was critical for this newly created policy to be formulated for majority approval.

According to the respondents, the wording and intricacies of the house bill were also important for schools that do not have an athletic trainer on staff. If the policy was too verbose or filled with legal jargon, it would be difficult for schools without health care professionals who are better versed in the medical terminology to discern and implement on their own. The law does not require student concussion education training, nor does it have a specific RTP protocol (just that there is one implemented), but none of the respondents mentioned anything about these two missing variables. The ATs may not think these are necessary components. When asked about this during the midpoint check, the two respondents both thought their district did a good job of educating their student- athletes, and each AT had his or her own approach to RTP.

This research was grounded in a theoretical framework that provided an in-depth analysis of the factors that centered on the development, implementation, and early evaluation of a school concussion management policy based on House Bill 2038. The results of this study can help build a better understanding of both the content and structure of concussion management policy implementation from an athletic trainer’s

perspective, while also looking at the school community. Implementation of the HB

2038 guidelines was influenced by perceptions that the new policy was relatively advantageous compared to status quo, able to provide more influential implementation facilitators than barriers, uniform and consistent for all schools, supported by the school and community throughout all stages of implementation, written for its intended purpose, able to provide support and justification during difficult decision-making and/or legal issues, and supported by the Concussion Oversight Team. The findings of this study contribute to the literature by suggesting areas of concussion policy that are instrumental in implementation at the high school level.

The findings of the present study should be considered in light of several limitations. The results arise from athletic trainers working in one large district in the state of Texas with a substantial amount of resources. For this reason, these results cannot be generalized to other districts or states. Next, each participant was interviewed on only one occasion, so the athletic trainers’ perceptions of the house bill over time were not studied. Further, given that this study was done in the summer, when athletic trainers are the least busy, potential stressors and other contextual variables that occur during the school year may cause a change in perception or support of HB 2038 over time. The final limitation was the lack of having a randomized sample in that this district was one of the most affluent and first to implement a concussion management policy in accordance with HB 2038. The resources available to the interviewed ATs may not be comparable to other schools or districts across the state.

Despite these limitations, the implications of this study are far-reaching. As this study is the first of its kind, no other study has been designed to examine the variables

that influence a school-based concussion management policy. Factors such as the four topics mentioned in this study should be further analyzed in moving forward.

Specifically, schools that do not have easy access to these implementation topics should be examined to identify how influential these topics are with concussion policy implementation. For example, schools that are early or late adopters may be influenced by the discussed topics in this study.

Further research is warranted to identify the most salient variables for designing, implementing and evaluating a concussion management law or policy.

CHAPTER FOUR: STUDY II—EXAMINATION OF THE KNOWLEDGE,

ATTITUDES, SELF-EFFICACY, AND TREATMENT PRACTICES OF

ATHLETIC TRAINERS AND PHYSICIANS REGARDING CONCUSSIONS IN

HIGH SCHOOL ATHLETES

Abstract

Given the extent of concussion guideline and management variability, mixed with the innate pressure for an athlete’s quick return to play, it is important to examine licensed health care professionals’ (LHCPs’) knowledge, attitudes, self-efficacy, and treatment practices for concussion management. The purpose of this research study was to (a) determine what recommended treatment practices LHCPs are using to treat concussed athletes and (b) assess areas in need of concussion education by examining

LHCPs’ knowledge, attitudes, self-efficacy, and treatment practices regarding concussion management. This cross-sectional self-report survey was used to examine 534 licensed athletic trainers (ATs) and 29 physicians (MDs). Of the literature’s most recommended treatment practices, only 16.4 percent of ATs and 19.2 percent of MDs were using all eight of them. In addition, only 43.7 percent of ATs and 22.2 percent of MDs were administering balance testing, and 68.5 percent of ATs and 42.3 percent of MDs were using a graded symptom checklist on concussed patients. Hierarchical linear regression was used to determine that race was significantly positively related to treatment practices

(p < .05) in which white LHCPs, on average, endorsed 0.66 more concussion treatment practices than non-white LHCPs. After controlling for demographic variables, self- efficacy was significantly positively associated with treatment practices (p < .001), and the final R2 = 12 percent. It was also indicated that job title moderated this positive

relationship (p < .05), such that, as concussion management self-efficacy scores increased, ATs’ and MDs’ endorsement of treatment practices also increased. This positive impact of self-efficacy was stronger for physicians (p < 0.001) than athletic trainers (p < 0.05). In addition, athletic trainers had significantly higher knowledge, attitude, and self-efficacy scores than did physicians. Analysis of these findings could highlight practical implications for provider education in concussion management.

Introduction

The Centers for Disease Control and Prevention (CDC) estimates that between 1.6 and 3.8 million sport- and recreation-related concussions are reported annually (Langlois,

Rutland-Brown, & Wald, 2006), with approximately 300,000 of those occurring in high school–aged athletes (Gessel et al., 2007). Gilchrist et al. (2011) found that emergency departments (EDs) treat approximately 173,285 concussions annually for patients between 1 and 19 years old. The number of sports-related concussions seen in EDs in this age group has risen approximately 60 percent in the last decade (2011). These numbers are considered wildly underrepresentative of actual concussion rates due to many individuals not seeking medical attention for this type of injury (Faul, Xu, Wald, &

Coronado, 2010). Studies show that adolescents, whose brains are not fully developed, are at an increased risk of injury and long-term brain damage when compared to adults

(Noble & Hesdorffer, 2013). In addition, the younger an individual is to sustain a concussion, the more likely he or she is to sustain additional concussions and present with longer-lasting symptoms (Eisenberg et al., 2013). For these reasons, concussions in the adolescent population are an important public health concern.

Although there is no known cure or specific way to prevent concussions, the management of concussions to prevent secondary concussions, long-term complications, and/or potential death is critical for this age group. Licensed health care professionals

(LHCPs) are the providers that evaluate, diagnose, and treat head injuries. These three parts of managing a concussion are often referred to as concussion treatment practices.

With the implementation of concussion laws in all 50 states and the District of Columbia,

LHCPs are now required to partake in the health care of a concussion athlete in at least some fashion (National Conference of State Legislatures, 2014). Athletic trainers and physicians most commonly treat concussed athletes in this age range (Meehan, d’Hemecourt, & Comstock, 2010). Concussion training has been continually revised over the years and has only recently been required by LHCPs (Harmon et al., 2013). As with many injuries or illnesses that have seen an increase in incidence and media coverage, not all LHCPs are well-versed or trained in the treatment behavior (Harmon et al., 2013).

In addition to a potential lack of training, those with concussions may present with a multitude and variety of symptoms, making them more difficult to treat

(Daneshvar et al., 2011). Further, a lack of consistency exists for concussion management and return-to-play (RTP) decisions. Since 2001, there have been more than

25 grading scales and guidelines available in the literature for treating and managing concussions (Doolan et al., 2012). Studies point to the need for a multidimensional treatment approach toward concussion management (Aubry et al., 2002; Guskiewicz et al., 2004; McCrory et al., 2013). Due to the considerable variability in concussion symptomology, diagnoses, and treatment, understanding the health care provider’s

knowledge, attitudes, and self-efficacy toward concussions will help determine the utilization of recommended treatment practices.

Health Belief Model

The health belief model (HBM), the most commonly tested psychological theory in health-related behavior research, was introduced to suggest that an individual’s behavior is a function of knowledge that influences beliefs and self-efficacy to determine behavior (Lai, Hamid, & Cheng, 1999; Lo, Chair, & Lee, 2014; Saunders, Dann, Griest,

& Frederick, 2014). The HBM provides a framework to explain why individuals endorse or adapt specific health behaviors (James et al., 2012). Specifically, this model can be used to predict LHCPs’ treatment practices for concussion management using the constructs of knowledge of concussions, attitudes toward concussion safety, and concussion management self-efficacy. Additionally, the HBM can be used to guide educational interventions for the endorsement of LHCPs’ concussion management treatment practices.

According to this model, an LHCP’s concussion knowledge base may influence the way he or she manages a concussed patient. Although knowledge cannot predict treatment practice behaviors alone, there is an influential relationship between the two variables (Karbach et al., 2011). For example, if an LHCP does not have the knowledge to utilize a particular skill set, the behavior will not be performed (Eriksen, Melberg, &

Bringedal, 2013; Mathur et al., 2011). The scientific realm of concussion knowledge has been continually transforming and growing as published evidence increases (Giza et al.,

2013; Guskiewicz et al., 2004; Harmon et al., 2013). It is important to understand health care providers’ knowledge base, and subsequent gaps, as a function of endorsed treatment

practices in order to better design concussion management interventions and improve concussion education in this population.

Attitude is a measure of one’s unobservable response, whether it be positive or negative, about a behavior and the consequences of performing the behavior (Fishbein &

Ajzen, 1975). In the case of concussion treatment practices, LHCPs should have a positive appraisal connected to performing a recommended treatment practice or set of practices, as well as a positive outcome expectation if the behavior is performed. Rigby et al. (2013) found a strong relationship between positive attitude and the use of a multifaceted concussion treatment approach. It is expected that the attitude score will increase (safer score) when more treatment practices are utilized.

Self-efficacy is a measure of belief in one’s own ability to perform a specific behavior. Self-efficacy is important in the health care world because it can influence how an LHCP feels and behaves in regard to a treatment practice. According to Norgaard et al. (2012), LHCPs often lack confidence in their ability to communicate with patients, subsequently leading to a lack of care. This low self-efficacy can lead to the absence of treatment practices, an idea that can be supported by the health belief model (Marteau &

Johnston, 1990). This model is used to show the relationship between knowledge and self-efficacy and how self-efficacy influences behavior (Lo, Chair, & Lee, 2014). It is expected that concussion management self-efficacy scores will increase as the number of recommended treatment practices increases.

The current study is the first to be used to examine the knowledge, attitudes, and self-efficacy of LHCPs as a function of utilizing a multifaceted treatment approach to concussions. Because ATs and MDs are the first line of defense for concussion

management and must collaborate to optimize athlete participation (National Athletic

Trainers’ Association, 2013), the exploration of physicians and athletic trainers is imperative for understanding the knowledge, attitudes, and self-efficacy of the most commonly utilized LHCPs treating concussed adolescent athletes. The purpose of this research study is to (a) determine what treatment practices LHCPs are using to treat concussed athletes and (b) assess areas in need of concussion education by examining knowledge, attitudes, and treatment practices regarding concussions. The results of this study will contribute to a better understanding of knowledge gaps and misconceptions, as well as attitudes leading to behavioral patterns that may facilitate improved education interventions specific to concussion management efforts.

Research Questions

Based on the previously mentioned needs, an analysis of the most commonly used concussion management systems and guidelines LHCPs are using to improve best concussion practices was performed, and the following research questions were examined:

Research Question 1: Do athletic trainers utilize more of the top recommended concussion treatment practices than emergency room physicians?

Research Question 2: What is the relationship of knowledge, attitudes, and concussion management self-efficacy to utilization of the top recommended treatment practices?

Research Question 3: Does the relationship between knowledge, attitudes, concussion management self-efficacy, and treatment practices vary by health care profession?

Methods

Participants and procedures

Participants of this study included two independent groups that met certain inclusion criteria: (a) practicing certified athletic trainers who were members of the Texas

State Athletic Trainers’ Association and (b) practicing emergency room doctors certified by the Texas Medical Board. A group of 1,464 athletic trainers, employed in the state of

Texas, were recruited for the study, with permission from the Texas State Athletic

Trainers’ Association (TSATA) (see Appendix A.2). In addition, a group of 100 practicing emergency room physicians were recruited by the Capital Emergency

Associates (CEA) directory of employees (see Appendix B.2). All athletic trainers with a functioning e-mail address, regardless of work setting and found in the TSATA member directory, were included in this survey.

The exclusion criteria for athletic trainers included employment status of unemployed, retired, or student due to variability in concussion education levels, leaving a response rate of 36.48 percent (n = 534). However, due to partially missing data, 32 athletic trainer surveys were dropped from the analysis, leaving a final response rate for athletic trainers at 34.29 percent (n = 502). There was no exclusion criteria for physicians, leaving a final response rate of 29 percent (n = 29). These response rates were similar to other studies involving ATs ranging from 22.1–41.1 percent (Kahanov,

Loebsack, Masucci, & Roberts, 2010; Mazerolle et al., 2010; Pitney, Mazerolle, &

Pagnotta, 2011; Notebaert & Guskiewicz, 2005; Rigby, Vela, & Housman, 2013). The

Institutional Review Board approved the present study (see Appendix C.2).

This study employed a cross-sectional, self-report research design. A web-based survey was used to maximize the reach of potential participants across the state to minimize cost and provide flexibility and convenience for LHCPs that work nontraditional hours. Participants were e-mailed an initial invitation requesting their participation in the survey in January 2014. This recruitment letter provided a brief description of the study (see Appendix D.2) and details the participant’s rights. A reminder e-mail containing the consent for participation in Internet research and survey access was dispersed one week after the invitation was sent (see Appendix E.2).

The participants were administered the Rosenbaum Concussion Knowledge and

Attitudes Survey (RoCKAS), which was housed on the Survey Monkey server via participants’ e-mail addresses (see Appendix F.2 and G.2). This server is protected from technology intrusion by employing multiple firewalls and is password enabled for protection of data. A final follow-up e-mail was distributed in March of 2014 that looked similar in structure and content to the consent form (see Appendix H.2). The survey was designed so that participation was only allowed by invitation via e-mail for six weeks.

Participation was voluntary, and all participants had the right to withdraw from the study at any time. Respondents were entered into a random drawing where they could win one of 10 gift cards distributed to the ATs and one of 10 gift cards distributed to the MDs (all were $25 Amazon Visa gift cards).

Measures

Modified and implemented for the study was a version of the Rosenbaum

Concussion Knowledge and Attitudes Scale (RoCKAS), developed by Aaron M.

Rosenbaum (Rosenbaum & Arnett, 2010). The author gave permission to the primary

investigator of this study to use his survey with modifications as needed (see Appendix

I.2). All survey items were multiple choice or short answer and specific to the athletic trainer or emergency room physician group, respectively (for a list of questions, see

Appendix F.2 and G.2, respectively).

Demographics

Participants were asked several personal information questions, including zip code, gender, age, race, knowledge of Texas’s concussion law, years of experience, work setting, school district employment, school size classification, and to whom concussed athletes are referred. Additional questions regarding educational materials and concussion grading scales were asked at the end of the survey. These questions were created separately from Rosenbaum’s original survey.

Knowledge of concussion management

The Concussion Knowledge Index (CKI) scale contained 33 total items, and scores ranged from 0–33, with a higher CKI score indicative of a higher level of concussion knowledge. Questions were designed to assess the participants’ knowledge of concussion causes using a true/false format. In addition, there was a symptom checklist that represented the most common symptoms following a concussion. There were also distractor symptoms included in the list to measure response effort. A score of 1 was given for a correct response or identification of a symptom, and no points were given for an incorrect response. Internal reliability for the CKI scale was found to be acceptable in previous research (α = .67; Rosenbaum, 2010).

Attitudes regarding concussion management

The Concussion Attitudes Index (CAI) scale contained 18 total Likert scale items, ranging from “strongly disagree” to “strongly agree.” This scale was used to measure the safeness of attitudes regarding concussions in athletes returning to competition by examining how LHCPs would manage a concussion based on a given scenario. A response in the very unsafe direction scored 1 point (either “strongly disagree” or

“strongly agree,” depending on how the question is coded), a moderately unsafe response scored 2 points (“agree” or “disagree”), a neutral response scored 3 points, moderately safe responses scored 4 points, and very safe responses scored 5 points. The mean of each participant’s Likert scaled score was taken. The greater the mean score was, ranging from 1–5, the safer the participant’s attitudes toward concussions. In previous research, the internal reliability of the CAI scale was acceptable (α = .79; Rosenbaum,

2010).

Concussion management self-efficacy

In this study, self-efficacy was measured by participants’ responses to a single statement: “My confidence level in the knowledge of concussion recognition, evaluation and treatment.” Response options were poor, fair, good, very good, and excellent, leaving a score option of 1–5, with higher scores demonstrating high self-efficacy.

Concussion treatment practices

The treatment practice scale targeted two main questions: (a) “Which of the following tools do you use most in assessing concussions (mark all that apply)?”; and (b)

“Which principal evaluation tools do you use in the return-to-play decisions after concussion (mark all that apply)?”. Responses ranged from concussion practices such as

baseline testing to graded symptom checklist to the recommendation for rest. This section included questions regarding concussion assessment, management, and return-to- play practices. With so many concussion guidelines and protocols available to physicians and athletic trainers, it was important to examine which ones were the most widely recommended and endorsed. In this study, both physician and athletic trainer guidelines and protocols were used as to not show bias to either profession. Prior to 2014, the most recent, cited, and well-known organizational guidelines and protocols written were used for this study. These included the American Academy of Neurology (Giza et al., 2013); the American College of Sports Medicine Team Physician Consensus Statement

(Herring, Cantu, Guskiewicz, Putukian, & Kibler, 2011); the American Medical Society for Sports Medicine (Harmon et al., 2013); the Centers for Disease Control and

Prevention Heads Up Concussion program (Centers for Disease Control and Prevention

“Facts for Physicians”, 2013); the National Athletic Trainers’ Association (Guskiewicz et al., 2004); and the Zurich Guidelines (McCrory et al., 2013). The primary investigator created a list of all recommended concussion management treatment practices for each organization and guideline and tallied the number of times each treatment practice was referenced (as seen in Table 4.2). All treatment practices endorsed by at least four of the organizations or protocols were included in the overall concussion treatment practice variable. This selection procedure was used to identify a set of eight commonly endorsed treatment practices, which were then used as the benchmark for quantifying the depth of participants’ reported tools for concussion assessment. Total scores ranged from 0–8, representing the number of “top eight” practices endorsed by each participant.

Statistical Analysis

All data were analyzed using the Statistical Package for the Social Sciences

(SPSS) Version 19.0 for PC (IBM Corp., 2010). According to the procedures of Pallant

(2010), preliminary examination of the statistical assumptions of normality, linearity, multicollinearity, and homoscedasticity was satisfied. Means, standard deviations, and bivariate relationships were measured using descriptive statistics, Pearson correlations, point-biseral correlations, independent samples t-tests, and chi-square tests. Pearson correlations were used to examine the relationships between concussion treatment practices and concussion knowledge, attitudes toward concussion management safety, self-efficacy of concussion management, age, and years of experience. The relationships among race, sex, school size affiliation, and job title were examined using point-biserial correlations. Due to the high correlation between age and years of experience (r = .93), age was removed from the analyses. Independent samples t-tests were used to compare years of experience, number of concussions treated per year, and scores for knowledge, attitude, self-efficacy, and treatment practices endorsed by job title (viz., athletic trainers and emergency room physicians). The top eight most endorsed treatment practices were further explored by comparing the proportion of ATs and MDs who endorsed all eight. A chi-square test was used to test differences in endorsement between athletic trainers and physicians within each of the top eight treatment practices, individually.

Prior to analysis, some categorical demographic variables were collapsed into binary variables in order to create groups of appropriate relevance: race (0 = non-white,

1 = white), sex (0 = male, 1 = female), and job title (0 = physician, 1 = athletic trainer).

All continuous predictors were mean-centered to limit potential problems with

multicollinearity (Aiken & West, 1991). Using the guidelines of Aiken and West (1991), hierarchical linear regression was performed in three steps in order to examine the direct effects of knowledge, attitudes, and self-efficacy on treatment practices endorsed by

LHCPs. These analyses were also used to examine the moderating effect of job title on knowledge, attitudes, and self-efficacy after controlling for the variance associated with the demographic variables of years of experience, race, and sex.

Step one involved entering the demographic variables into the model, with treatment practice entered as the dependent variable. In the second step, the predictor variables of knowledge, attitudes, and self-efficacy were added. In step three, the three interaction terms for job title with knowledge, attitudes, and self-efficacy were added to the model. A post hoc simple slopes analysis was performed on the significant interaction between job title and self-efficacy in order to establish whether job title had a significant effect on the relationship between self-efficacy and number of treatment practices endorsed.

Results

Descriptive Statistics

Frequencies, percentages, ranges, means, and standard deviations were calculated using descriptive statistics procedures in SPSS. Participants were primarily male (59.0 percent), and the majority (93.6 percent) were aware of the passing of HB 2038 (See

Table 4.1). The most common age range was 30–39, with approximately 33.5 percent of the respondents falling into this age group. In regards to race, 86.5 percent were

Caucasian, 9.1 percent were Hispanic, 2.4 percent were African American, 0.2 percent were American Indian or Alaskan Native, 1.3 percent were Asian, and 0.4 percent

identified as other. Athletic trainers made up the majority of participants (95 percent) compared to MDs. The number of years of experience was similar for both groups of

LHCPs, with ATs employed, on average, for 14.49 years, and MDs employed for approximately 12.88 years. Although no MDs and not all ATs were affiliated with a school, the range of employment affiliations for athletic trainers based on school size reflected state demographics: 2.2 percent were affiliated with 1A schools, 5.1 percent with 2A, 15.6 percent with 3A, 34.4 percent with 4A, and 42.8 percent with 5A

(University Interscholastic League, 2014). The number of concussions treated per year varied greatly and between professions (see Table 4.1).

ATs had greater knowledge, attitudes, and self-efficacy scores than MDs. There was a statistically significant difference in knowledge scores for physicians (M = 28.63,

SD = 1.57) and athletic trainers (M = 29.54, SD = 1.41; t [28.72] = -2.93, p = .007, two- tailed). In regards to attitude, MDs (M = 4.61, SD = .23) scored lower on average than

ATs (M = 4.75, SD = .27; t [31.06] = -2.98, p = .006, two-tailed). Further, there was a statistically significant difference in self-efficacy scores, with MDs (M = 2.48, SD = .98) scoring lower than ATs (M = 3.13, SD = .69; t [27.7] = -3.37, p = .002, two-tailed).

Table 4.1 Sample Characteristics Sample Characteristics (N = 448) N (%) or Mean ± SD Range Gender Male 265 (59.0%) Female 184 (41.0%) Race

Caucasian 391 (85.4%) Hispanic 41 (9%) African American 11 (2.4%) American Indian or Alaskan Native 1 (0.2%) Asian 6 (1.3%) Other 2 (0.4%) Age 21–29 123 (27.3%) 30–39 151 (33.5%) 40–49 96 (21.3%) 50–59 59 (13.1%) 60–69 20 (4.4%) 70 or older 2 (0.4%) School district size affiliation 1A 6 (2.2%) 2A 14 (5.1%) 3A 43 (15.6%) 4A 95 (34.4%) 5A 118 (42.8%) Years of experience 14.40 ± 10.63 1–53 Athletic trainer 14.49 ± 10.63 1–53 Physician 12.88 ± 10.59 1–40 Concussions treated per year 24.96 ± 50.36 0–450 Athletic trainer 19.65 ± 36.68 0–450 Physician 78.25 ± 117.25 0–400 Total knowledge score 29.48 ± 1.44** 24–32 Athletic trainer 29.54 ± 1.41 24–32 Physician 28.63 ± 1.57 25–31 Total attitude score 4.74 ± 0.27* 3.73–5 Athletic trainer 4.75 ± 0.27 3.73–5 Physician 4.61 ± 0.22 4.07–5

Table 4.1 (continued) Total self-efficacy score 3.09 ± 0.73*** 1–4 Athletic trainer 3.12 ± 0.69 1–4 Physician 2.48 ± 0.98 1–4 * p < .05 ** p < .01 *** p < .001

Most Recommended Treatment Practice Utilization

The most frequently recommended concussion management treatment practices can be seen in Table 4.2. Those recommended by the majority of protocols (≥ 4 organizations or guidelines) included (a) baseline exam, (b) balance testing, (c) gradual or stepwise RTP, (d) neurologic exam, (e) neuropsychological testing, (f) recommendation for physical and/or cognitive rest, (g) obtaining the past medical history, and (h) symptom checklist. These recommendations made up the top eight treatment practice variable that is referred to throughout this study. The frequency of each of these treatment practices utilized for concussion assessment and return-to-play management by

LHCPs was tallied for both ATs and MDs (see Table 4.3).

Table 4.2

Recommended Concussion Treatment Practices

(2004)

013)

)

2012

American Academyof Neurology (2 American College of Medicine Sports Team Physician Consensus Statement(2011) American Medical Society Sports Medicinefor (2012) Centers for Disease Controland Prevention Heads Up Concussion program(2004) National Athletic Trainers' Association Zurich guidelines( Total Academic accommodations X X 2 Baseline exam X X X X X 5 BESS or other balance testing† X X X X X 5 Concussion management team X 1 Cranial testing X 1 Determine disposition X X X 3 Evaluation by physician X X X 3 Gradual/stepwise RTP X X X X X 5 Maddocks questions X X 2 Neurocognitive testing X X X 3 Neurocognitive testing for RTP X X 2 Neurologic exam X X X X 4 Neuropsychological testing X X X X X 5 Past medical history X X X X X X 6 Preseason planning X X X 3 Refer to Neuropsychologist X X X 3 Rest (physical and/or cognitive) X X X X X 5 SAC X X X 3 SCAT* X X X 3 Sensory Organization Test X 1 Symptom checklist X X X X X X 6 Take-home instructions X X X 3 †Balance Error Scoring System (BESS or other objective balance testing tool) *Sport Concussion Assessment Tool (versions: SCAT, SCAT2, SCAT3 or NFLSCAT)

The most common treatment practice ATs used for concussion management was the gradual RTP protocol (93.9 percent, n = 355), and MDs reported a tie between neurological testing and obtaining a past medical history (88.5 percent, n = 23). The proportion of individuals from each profession endorsing all eight recommended treatment practices can also be seen in Table 4.3, with 16.4 percent of ATs (n = 62) and

19.2 percent of MDs (n = 5). An independent samples t-test was used to compare the mean number of top eight treatment practices endorsed by ATs and MDs. There was no significant difference in scores for physicians (M = 5.04, SD = 2.22) and athletic trainers

(M = 5.66, SD = 1.82; t [402] = -1.67, p = .096, two-tailed). The magnitude of the differences in the means (mean difference = -.63, 95 percent CI: -1.36 to .11) was small

(Cohen’s d = -.34; Cohen, 1992).

Table 4.3 Endorsement of Concussion Treatment Practices Between Athletic Trainers and Physicians Athletic trainer Physician Significance

Treatment practice n = 378 n = 26 χ2 (df = 1) Baseline testing 281 (74.3%) 14 (53.8%) 5.19* BESS or other balance testing 165 (43.7%) 6 (22.2%) 4.22* Gradual/stepwise RTP 355 (93.9%) 21 (80.8%) 6.52* Neurological testing 302 (79.9%) 23 (88.5%) 1.14 Neuropsychological testing 234 (61.9%) 11 (42.3%) 3.91* Past medical history 309 (81.7%) 23 (88.5%) 0.75 Recommendation for rest (physical and/or 236 (62.4%) 22 (84.6%) 5.19* cognitive) Graded symptom checklist 259 (68.5%) 11 (42.3%) 7.54** Number of individuals using all 8 treatment 62 (16.4%) 5 (19.2%) – practices Average number of treatment practices 5.66 ± 1.82 5.04 ± 2.22 – utilized * p < .05 ** p < .01 *** p < .001

Differences Between Athletic Trainers and Emergency Room Physicians

The proportion of individuals recommending treatment practices was significantly different between job titles for all treatment practices except neurological testing and past medical history. Of all treatment practices except for the recommendation to rest, ATs were more likely to endorse each treatment practice than ER physicians. A higher proportion of ATs used baseline testing (χ2 [df = 1] = 5.19, p = .02), balance testing

(χ2 [df=1] = 4.22, p = .04), a gradual RTP protocol (χ2 [df = 1] = 6.52, p = .01), neuropsychological testing (χ2 [df = 1] = 3.91, p = .048), and a graded symptom checklist

(χ2 [df = 1] = 7.54, p = .01). Job title was significantly associated with the recommendation for rest (χ2 [df = 1] = 5.19, p = .02) in which a higher proportion of

MDs endorsed it compared to ATs.

Hierarchical Multiple Regression

Hierarchical multiple regression was used to assess the ability of concussion knowledge, attitudes toward concussion safety, and concussion management self-efficacy to predict LHCP endorsement of the top eight recommended treatment practices, after controlling for demographic variables. As described earlier and displayed in Table 4.4, the demographic control variables (viz., sex, race, years of experience, and job title) were entered into Model 1, explaining a total variance of 3.0 percent of LHCPs’ concussion treatment practices (F4, 396 = 3.34, p < .05). Following the addition of knowledge, attitudes, and self-efficacy into the second model, the total variance explained was approximately 8.0 percent, which reflected a significant increase in R2 from the previous model (F change3, 393 = 7.05, p < .001). In Model 2, significant main effects were found for both race (β = .12, p < .05) and self-efficacy (β = .19, p < .001). White LHCPs, on

average, endorse 0.66 more concussion treatment practices than non-white LHCPs when controlling for years of experience, sex, and job title. Also, holding all other variables constant, as an LHCP’s concussion management self-efficacy increases by one point, the number of individual treatment practice endorsements by LHCPs was estimated to increase by 1.89.

In the third model, the inclusion of the three interaction terms for job title with knowledge, attitudes, and self-efficacy accounted for an additional 4 percent of the total variance explained (F change3, 390 = 5.10, p < 01). Thus, the final model explained 12 percent of the total variance in treatment practices. In addition, the main effects of race

(β = .12, p < .05) and self-efficacy (β = .70, p < .001) were still significantly associated with the number of endorsed concussion treatment practices.

The coefficient for the interaction between job title and self-efficacy was significant (β = -.53, p < .05), indicating that job title had a moderating effect on the relationship between self-efficacy and the number of treatment practices endorsed, such that the positive effect of self-efficacy was stronger for ER physicians than athletic trainers. This interaction is graphically represented by the two slopes in Figure 4.1, with the physician slope being steeper than the athletic trainer slope. Post hoc simple slopes analyses indicated the positive impact of self-efficacy on the number of treatment practices endorsed was significant for both physicians (B = 1.89, t(400) = 4.69, p < 0.001) and athletic trainers (B = 0.35, t[400] = 2.52, p < 0.05).

Table 4.4 Hierarchical Regression Analysis for Variables Predicting Number of Concussion Treatment Practices Endorsed Model 1 Model 2 Model 3

Variable B SE β B SE β B SE β B B B Years of experience .00 .01 .02 .00 .01 .02 .00 .01 .02 Race† .83 .29 .15** .66 .29 .12* .66 .28 .12* Sex† .28 .22 .07 .33 .21 .08 .28 .21 .07 Job title† .60 .41 .07 .17 .41 .02 -.51 .54 -.06

Concussion knowledge 13 .07 .10 -.27 .25 -.20 Concussion attitude -.11 .36 -.02 1.53 1.73 .21 Concussion self-efficacy .52 .14 .19*** 1.89 .40 .70*** Job title X knowledge .44 .26 .31 Job title X attitude -1.67 1.77 -.23 Job title X self-efficacy -1.54 .43 -.53* Model R2 .03 .08 .12 F for Change in R2 3.34* 7.05*** 5.1*** Note. * p < .05 ** p < .01 *** p < .001 †Race (0 = non-white, 1 = white), Sex (0 = male, 1 = female), Job Title (0 = physician, 1 = athletic trainer) B = unstandardized coefficient; β = standardized coefficient

5 ER Physicians

4 Athletic Trainers 3

2 Endorsed Treatment Practices Treatment Endorsed 1 Low Self-Efficacy High Self-Efficacy

Figure 4.1. The moderating effect of health care profession on the relationship between self-efficacy and number of concussion treatment practices endorsed.

Discussion

Using a sample of n = 502 licensed health care professionals, this research study was designed to examine what guidelines were being used to improve best concussion practices. The most commonly endorsed treatment practices in the literature included baseline exam, balance testing, gradual or stepwise RTP, neurologic exam, neuropsychological testing, recommendation for physical and/or cognitive rest, obtaining the past medical history, and symptom checklist. The average number of treatment practices utilized was similar between ATs and MDs, and balance testing and administering a graded symptom checklist are important treatment practices that were being underutilized by LCHPs. In addition, this study was used to assess areas in need of concussion education by examining concussion management knowledge, attitudes, self- efficacy, and treatment practices after controlling for a number of demographic variables.

Suggested in the study’s findings is a positive association between race and treatment

practices, and self-efficacy and treatment practices. Additional findings showed job title had a moderating effect on the relationship between self-efficacy and number of treatment practices endorsed. This significant relationship was stronger for MDs than it was for ATs. It was also indicated in the results that ATs, on average, scored higher than

MDs on knowledge, attitudes, and self-efficacy scales.

Overall, the majority of treatment practices endorsed significantly differed by job title. Only neurologic exam and obtaining the past medical history were not statistically different between the two professions. As was discussed in a 2012 study, an increase in awareness, educational training, and/or distribution of updated treatment practice recommendations may be the cause of these two practices being well-endorsed by different types of LHCPs (Harkins, Lundgren, Spresser, & Hampl, 2012). Surprisingly, the proportion of individuals endorsing baseline testing based on job title was not only significant, but also extremely low. With only about half of all MDs and less than three- fourths of ATs endorsing baseline testing, it is very difficult to evaluate neurological deficits if no baseline scores are available. These low endorsement rates may be partly due to contract athletic trainer coverage and ER physicians that do not have access to baseline measurements. Regardless, providers should be endorsing these treatment practices according to the most recommended guidelines (Giza et al., 2013; Guskiewicz et al., 2004).

Other surprising underutilizations of treatment practices were uncovered. Five of the six organizations and protocols recommended some form of balance testing, and yet only 43 percent of ATs and 22 percent of MDs endorsed this practice. This could be due in part to the amount of time it takes to perform the test, and further examination of this

noncompliance is warranted. Another surprising difference occurred with the graded symptom checklist. The difficulty with treating concussions is that treatment is based almost entirely on symptom presentation. If an athlete sustains a head injury and has no symptoms following a given period of time, it is unlikely that he or she will be further evaluated. With less than three-fourths of ATs and less than half of MDs endorsing a symptom checklist, there is need for concern and a subsequent opportunity for behavioral change in this area. All six major protocols endorsed this treatment practice due to its necessity in managing concussions (National Collegiate Athletic Association, 2014), exposing a critical area of educational intervention for both professions. Interestingly, the recommendation for rest was the only significantly different practice between professions that had a higher proportion of MDs endorsing than ATs. From an environmental perspective, this may be due to pressures being placed on ATs to return student-athletes back to competition as fast as possible. Future research should be designed to look at this treatment practice from a contextual standpoint, as this was not addressed in the reviewed literature.

Far less than the majority of LHCPs are endorsing all eight of the top recommended treatment practices. With less than 20 percent of each group endorsing all eight practices, it would seem most practical to begin targeting educational interventions around individual treatment practices, specifically those with the lowest rates of endorsement, as opposed to targeting adherence to all eight at once. Also, considering the average number of endorsed treatment practices for both groups is greater than five, it seems more practical to expend resources on targeting specific treatment practice awareness and utilization within each group of LHCPs.

One notable finding was the statistically significant difference in knowledge, attitudes, and self-efficacy scores between athletic trainers and ER physicians. Results in the current study demonstrated that ATs had higher scores in all three areas, but these differences may not be clinically significant. These differences may be due in part to more enhanced and state-mandated concussion training for the AT profession. These observations are consistent with results of other LHCP studies (Ibrahim et al., 2014).

Reiner, Sonicki, and Tedeschi-Reiner (2010) found personal experiences had a greater influence on recommended guideline usage with primary care physicians than with internists and cardiologists. Another study done by Potosky et al. (2011) found differences in knowledge, attitudes, and treatment practices between primary care physicians and oncologists with respect to cancer patient care. Also, Betz et al. (2013), after controlling for other variables, found nurses reported more patient screening for suicidal ideation than did physicians. Higher scores for ATs may be associated with new state regulations, increased length of return-to-play protocols, and a heightened awareness for potential short- and long-term injury.

The current study yielded a significant demographic finding between race and number of treatment practices utilized. This may be in part due to the grouping of all non- white participants into one group, but it may also be due to other contextual factors such as socio-economic status or educational level. Race may be a proxy for another factor or factors that may be influencing the number of treatment practices endorsed. Although no studies have been used to examine treatment practices as a dependent of race, there is research that supports differences in patient-care beliefs based on race. A study done by

Sabin et al. in 2009 found all physicians, except African American physicians,

demonstrated an implicit preference for Caucasian patients. African American doctors did not show a preference for Caucasian or African American patients. Another study done by The Kaiser Family Foundation (2002) showed non-white physicians were more likely to be treated unfairly based on race. This potential for racial beliefs to influence treatment practices may have implications for how educational programs are designed, and for whom they are implemented. Educational interventions may need to be designed to target minority LHCPs.

According to the updated health belief model, knowledge, attitudes, and self- efficacy have been shown to be mutually dependent, as well as influential toward behavior (Rosenstock, Strecher, & Becker, 1988). Oyeyemi, Oyeyemi, and Bello (2007) found that treatment practice knowledge was associated with a positive attitude toward that treatment among physicians. Those with higher knowledge scores also engaged in more of the recommended treatment practices (Oyeyemi, Oyeyemi, & Bello 2007).

These observations are consistent with a similar association between health care providers’ knowledge and practices in other studies (Eriksen, Melberg, & Bringedal,

2013; Mathur et al., 2011). A study done by Karbach et al. (2011) found that knowledge of health care practices is not the only variable that influences treatment practice implementation, indicating that provider attitude may play a role in which treatment practices are used. This study found no significant relationships between knowledge, attitudes, and treatment practices, which may be in part due to the salience of concussions in the public eye. As with other prevalent health care topics such as AIDS, mental health illnesses, tobacco use, and obesity, an increased knowledge by providers may not be the only variable influencing effective treatment practices (Betz et al., 2013; Gonzalez at al.,

2011; Ibrahim et al., 2014; Karbach et al., 2011; Oyeyemi, Oyeyemi, & Bello, 2007;

Reiner, Sonicki, & Tedeschi-Reiner, 2010; Shirreffs et al., 2012).

A significant finding in the present study was that LHCPs who reported greater self-efficacy in concussion management were more likely to endorse the recommended treatment practices. This supports previous findings that an increase in LHCPs’ self- efficacy is associated with an increase in utilization of treatment practices (Anchondo et al., 2012; Burglehaus, Smith, Sheps, & Green, 1997; Harkins, Lundgren, Spresser, &

Hampl, 2012; Makowsky et al., 2013; Visser et al., 2008). With knowledge and attitude variables being controlled, self-efficacy seems to be a driving force in treatment practice endorsement above and beyond these two predicted variables. McRee, Gilkey, and

Dempsey (2014) found that improving providers’ self-efficacy would be influential in supporting recommended treatment practices.

It was also found in the present study that job title had a moderating effect on the relationship between self-efficacy and endorsing treatment practices, such that the relationship was stronger for ER physicians than for athletic trainers. This was supported by Canbulat and Uzun’s 2008 study, where physicians’ use of treatment practices was found to be more influenced by self-efficacy than other health care provider specialties

(viz., nurses and midwives). Although no study has been designed to examine concussion management self-efficacy scores between these two professions, these results may be in part due to the level of autonomy MDs have over ATs. Since ATs must work under the guise of a physician, ATs may feel more efficacious than physicians, as seen by the self-efficacy scores in this study, but they may be limited by the scope of their practice. According to Maylone et al. (2011), autonomy in the work setting is largely

dependent on organizational constraints, public perceptions, and relationships with other health care providers. In some instances, ATs may not be able to perform concussion management best practices in roles independent from supervising physicians, and ATs and MDs should work together to continue building relationships between the two professions. Future research should be designed to look at the potential role of autonomy in regards to utilization of concussion treatment practices. In addition, future studies should be designed to look at potential moderators that predict ATs’ treatment practice endorsement outside of the individual, such as environmental constraints (viz., pressure from coaching staff to win, lack of time, and pressure from parents).

When interpreting these findings, the following limitations should be taken into account. First, the present study was cross-sectional in nature, so the directionality and causality of the relationships among the variables cannot be determined. Analysis of this study is limited to an understanding of the variables in the moment the survey was taken, and changes in knowledge, attitudes, self-efficacy, and treatment practices have not been examined. For example, attitudes may be situational and vary based on a specific game, athlete, or injury. It is possible that the results and implications of the present study may not be generalizable to other LHCPs. It should also be noted here that emergency room physicians see a much broader range of patients than athletic trainers. A concussed patient in the ER may be older with additional systemic problems or may stem from a motor vehicle accident that also sustained musculoskeletal injuries. This context of assessment due to differential diagnosing may play a role in physician responses and should be kept in consideration. Second, both samples were convenience samples, such that the athletic trainers were taken from those enrolled as members of the Texas State

Athletic Trainers’ Association (TSATA), and physicians were from a sample of emergency rooms in Austin, Texas. It is possible that those ATs that voluntarily enrolled in their state association and paid a membership fee were more likely to be involved and progressive in their profession, and therefore to have increased concussion knowledge, attitudes, self-efficacy, and treatment practice scores. This may be similar for physicians that took the time to participate in the survey due to an increased interest or strong opinion in the subject matter. Due to the localized sampling, the findings may not be applicable to other athletic trainers and physicians. Third, there are inherent response bias limitations associated with self-reporting. This may be due to a lack of self- awareness, an exaggerated response viewed as desirable, or an underreported response to minimize a problem (Mantano & Phillips, 1995).

In addition, two treatment practices recommended by the majority of organizations and protocols, serial concussion evaluations and a physical exam, were excluded from the survey due to their innate ambiguity. Although they are both important and highly recommended (Guskiewicz et al., 2004; McCrory et al., 2013), they would be difficult to portray in survey form and had potential for variation in participant response due to perception of the wording. For this reason, they were not included in the top treatment practice recommendations. Finally, attitude was measured in such a way that presented limited variability. Instead of summing the attitude scores, as was done for the treatment practices variable, a mean score was calculated in order to prevent bias due to missingness. This lack of variability may be limiting the effects of the attitude measure found on treatment practices.

Notwithstanding these limitations, this study contributes to the literature in several areas. Suggested in the interpretation of these results is the idea that having the knowledge and attitudes to safely manage concussions is an important fundamental skill, but that other factors such as self-efficacy are more influential on treatment practice endorsement. Although it was surprising to see how few providers are endorsing all eight of the recommended treatment practices, it was more surprising to see significant differences in knowledge, attitudes, and self-efficacy scores between ATs and MDs.

Future research should be designed to look at interventions targeted at increasing the awareness, importance, and ease of use of recommended treatment practices; increasing self-efficacy and its relationship with autonomy; and determining how other environmental factors play a role in concussion treatment practice endorsement.

100

CHAPTER FIVE: CONCLUSION

Introduction

A concussed student-athlete may only return to play when the treating licensed health care professional (LHCP) has deemed it appropriate (Texas State Athletic

Trainers’ Association, 2014). Those LHCPs that follow the recommended concussion guidelines, or in this case best treatment practices, will not allow the injured student- athlete to return to play prematurely; therefore, protecting the student-athlete from further injury or subsequent re-injury. Early diagnosis and allowing for a complete recovery are essential in preventing long-term and cumulative brain injury. Further, in order to protect adolescents from sports-related concussions, evidence-based practice concussion management laws and policies must be implemented in such a way that implementation is guaranteed.

The purpose of this dissertation was to examine licensed health care professionals’ (LHCPs’) perceptions of concussion management in the high school athlete. This purpose was threefold: (a) to examine ATs’ perceptions of the implementation of House Bill (HB) 2038 in order to determine facilitators and barriers for current and future concussion policy propagation; (b) to determine what systems and guidelines LHCPs are using to improve concussion management; and (c) to determine areas in need of concussion education by examining LHCPs’ knowledge, attitudes, self- efficacy and behaviors (i.e., treatment practices) regarding concussions. In order to examine the aims of this dissertation, two studies were performed: a qualitative study that looked at the implementation process of a new state concussion law as perceived by a group of high school athletic trainers; and a cross-sectional study that examined variables

101

related to LHCPs’ treatment practice usage such as knowledge, attitudes, and self- efficacy. Below is a summary of the key research findings, limitations, and suggested directions for future research.

Summary of Key Research Findings

Results of Study I offer new information about the importance of considering specific areas when implementing a school concussion management policy. This was the first study of its kind to examine variables that influence concussion policy implementation at a school-level, specifically from an athletic trainer’s (AT’s) perspective. Implementation was influenced by facilitators such as school-wide communication; public support and consistency with adherence to the policy; the wording and function of the law; the bill’s justification for existence; and the creation and use of the Concussion Oversight Team (COT). In the eyes of the ATs, the COT was the most important catalyst for policy implementation and offers increased job growth for ATs by requiring an AT to be on every school district’s COT. Barriers found to inhibit implementation of a school-level concussion policy were educating specific subgroups such as physicians, teachers, and English as a Second Language (ESL) community members; the time requirement for documentation; and the policy’s innate financial strain on student-athletes and/or their families.

Key findings revealed local physicians and the ESL community to be lacking proper concussion education. The majority of ATs experienced a lack of communication and/or proper training with these groups which was associated with a negative impact on the implementation of House Bill (HB) 2038. In addition, it was imperative for HB 2038 to have support not only from the school district, but from the community as well.

102

Overall community support for the concussion protocol helped aid the implementation of the bill at the school-level. These results suggest specific areas in which policy development and implementation should be focused. Future research should explore ways to further develop the COT or use it in other concussion management programs, as well as examine the knowledge, attitudes, and self-efficacy of physicians and the knowledge and attitudes of ESL student-athletes and parents.

Guided by the health belief model, Study II examined LHCPs’ concussion knowledge, attitudes, self-efficacy, and endorsement of the most recommended concussion treatment practices. The findings in this study were guided by a theoretical framework, in which the relationship between self-efficacy and concussion treatment practice as it relates to job title was shown. Findings support the implementation of state- mandated concussion management protocols in schools as they clearly demonstrate areas of concussion management in which LHCPs can continue to improve. For example, both

ATs and emergency room (ER) physicians (MDs) are currently underutilizing the most recommended concussion treatment practices in the literature and by top organizations.

The recommendation for rest was the only treatment practice that ER MDs endorsed more often than ATs. In addition, white LHCPs endorsed a significantly greater number of treatment practices than other races. It was surprising to find that ATs had greater knowledge, safer attitudes, and higher self-efficacy for concussion management than ER

MDs, despite evaluating far fewer concussed patients per year. ER MDs treated almost four times as many patients as did ATs. One possible explanation is the implementation of HB 2038 increasing the awareness, knowledge, and importance of concussion

103

management best practices. Future studies should look at physician groups that do not treat as many concussions as the present group of emergency department doctors.

The findings of this study are consistent with previous research demonstrating the importance of self-efficacy as a predictor of LHCPs’ treatment practice behaviors

(Harkins, Lundgren, Spresser & Hampl, 2012; Presseau et al., 2014). Another key finding showed as self-efficacy increased, the number of endorsed treatment practices increased for both professions. Although ATs had higher self-efficacy scores, self- efficacy had a greater influence on the number of treatment practices ER physicians utilized. With MDs more likely to possess greater autonomy than ATs, future studies should address self-efficacy in these professions as it relates to autonomy. Study II’s findings support the need for continued concussion management best practices interventions for LHCPs. Intervention research is needed to hasten the adoption of recommended concussion management guidelines among LHCPs. Efforts to increase

LHCPs’ adherence to treatment practice recommendations should be directed at improving awareness of and training in the use of the top recommended treatment practices. Outcomes of these interventions will be the focus of future studies while examining improved training in the development of self-efficacy as it relates to endorsing treatment practices.

Limitations

Results from the present studies should be considered in light of several limitations. While the greatest strength of this research is uncovering concussion areas in need of increased education and training, some of the findings are not generalizable to broader populations. For example, HB 2038 and related concussion protocols are

104

applicable to the state of Texas, and findings may not be representative of ATs’ perceptions of such policies in other areas of the country. Similarly, predictors related to treatment practice endorsement may not be generalizable to physicians outside of emergency room physicians. Physician behavior may be influenced by job title as seen in previous work (Fox et al., 1988; Kvamme et al., 2013; Ruiz-Moral et al., 2006). In addition, while there was some diversity in the sample populations, the majority of participants were white. This limited the statistical analysis because the relationship of race with other constructs was limited to a white versus non-white group comparison.

Future research should incorporate a greater variety of racial groups.

The second study involved some statistical analysis decisions that should be disclosed. Given the limited availability of knowledge, attitudes, and self-efficacy concussion research in LHCPs, the present study’s constructs were measured using the

RoCKAS survey (Rosenbaum & Arnett, 2010). Some anecdotal participant feedback suggested some of the knowledge questions were too easy, and there was little variability in respondent answers. Surprisingly, these results were different from results of other current work that found a correlation between knowledge and provider treatment practices (Kissick and Johnston, 2005; Naftel et al., 2014; Zonfrillo et al., 2012). As concussion awareness and knowledge in the public improve, it may be necessary to increase the difficulty of these questions in future studies. In addition, the results may have differed if the concussion attitude index had been calculated as a continuous sum score (instead of a mean score on the Likert scale). This was done in order to prevent bias due to missingness since a sum score answering four questions would produce a very different score if answering 15 questions. Another possibility is that level of treatment

105

practice endorsement, as operationalized, was not the only way to measure LHCPs’ treatment practices behavior. Although the most recommended guidelines and systems were chosen for this study, it was possible that more or less than the top 8 treatment practices could have been selected to measure this variable. Several studies have examined specific treatment practices utilized by providers, but none to date have examined a set of the most commonly used practices as one total variable (Choe & Giza,

2015; Haran et al., in press; Wells, Goodkin, & Griesbach, 2015). It may be helpful to partake in qualitative interviews with LHCPs examining the most important and useful treatment practices. Creating alternative ways to define treatment practice as a behavior may result in different relationships among knowledge, attitude, and self-efficacy as they relate to this particular behavior. Although common-method variance does exist in this dissertation, it is likely that this limitation is present in all studies to some extent and should be noted when considering the current findings (Spector, 2006).

Future Research

Findings support that as a state-mandated school concussion law is implemented, surrounding community members, specifically physicians and athletic trainers, must be trained regarding any and all new requirements. As Study I found MDs and ESL parents and student-athletes are not being sufficiently educated in terms of HB 2038, Study II was designed to examine ER MDs’ level of knowledge, attitude, and self-efficacy toward concussion treatment best practices. Moving forward, future work will look at these variables in a larger population of physicians, including but not limited to the specialties of family practice, sports medicine, orthopedics, and neurology, as these physicians are likely to evaluate concussed patients in this age group. In addition, examination of these

106

variables will take place in other athletic trainers across the United States, intentionally looking at cultures outside of Texas sports that may or may not include contextual influencers such as pressure to win and increased resources for sport in secondary schools. Further, designing, implementing, and evaluating interventions targeting the

ESL community to increase awareness and knowledge of concussions in sport and increasing LHCPs’ concussion management self-efficacy are necessary. Findings from the present study found individual factors to represent a small percentage of the variance explained in treatment practice endorsement; therefore, future research should examine contextual predictors of concussion treatment best practices such as autonomy, pressure to win from coaches and parents, and types of concussion education trainings.

Health Behavior Implications

Results from this dissertation assisted in (a) establishing a baseline of knowledge, attitudes, and self-efficacy regarding concussion management for LHCPs immediately following the implementation of a new state law; (b) examining what perceptions and factors are most influential in implementing a state-mandated concussion law; and (c) providing input when designing interventions to increase HB 2038 awareness and implementation. Research should examine high school concussion records around the state to determine HB 2038’s effectiveness.

Summary

This dissertation extends the literature by providing a baseline level of ATs’ and emergency room MDs’ knowledge, attitudes, and self-efficacy toward concussion management treatment practices, as well as provides an initial examination of the implementation of a concussion law in the state of Texas as perceived by high school

107

ATs. New concussion safety laws have taken effect in all fifty states, and more and more organizations are publishing their own individual best practices concussion guidelines

(National Collegiate Athletic Association, 2014). Athletic trainers perceived the implementation of HB 2038 as favorable and important for future organizational and state-level policies. HB 2038 provides LHCPs with the support they need to provide a standard level of care to concussed student-athletes; however, the LHCPs’ potential to provide best practices in concussion management and patient education may be increased by ATs’ training in autonomy and MDs’ training in concussion management self- efficacy. Results of the current study have important implications for future concussion management policies and educational interventions targeting specific areas to increase and improve concussion education and consistency among LHCPs.

108

APPENDIX A.1: SCHOOL DISTRICT PARTICIPATION CHECKLIST

Athletic Consent Duration of High Online Trainer’s Position Form Interview Interview School Survey ID Returned (in minutes) A 111 Head

222 Asst B 200 Head X X X 49:23 300 Asst

C 100 Head X X 37:41 999 Asst X X X 51:48 D 800 Head X X X 24:25 900 Asst X X X 13:41 E 333 Head X X X 37:01 444 Asst X X F 555 Head X X X 30:23 666 G 777 Head X X X 55:47 888 Asst X X X 25:22 H 600 Head X X X 22:57 700 Asst X X X 26:57 I 101 Head X X X 20:33 202 Asst X X X 15:51 J 400 Head X X X 32:03 500 Asst

109

APPENDIX B.1: QUALITATIVE INTERVIEW QUESTIONS

Policy Background 1) What is your school’s (or district’s) current policy regarding concussions? 2) How was that policy formulated (or what is the history of policy on concussions at your school/district)? PROBES: a) What was the policy before HB 2038? b) What were the issues that earlier policies addressed and why? c) What people were involved in the policy’s creation and implementation? d) What was the process for formulating policy or for changing it?

House Bill (HB) 2038 also known as Natasha’s Law 3) When/how did you first hear about this law? PROBE: a) Were policy requirements clearly communicated by the district? i) Why would you say that? 4) Would you say that this law’s requirements were effectively spread to schools in your district? PROBES: a) Why or why not? b) What helped to spread the word? c) What got in the way of spreading the law to the schools? 5) Were you able to see how the bill was implemented in other schools? PROBES: a) Why or why not? b) Would/did seeing this implementation in other schools help?

Implementation of this Law 6) Would you say the HB (and resulting concussion management policy) was effectively implemented at schools across the district? PROBES: a) Why or why not? b) What helped to implement the new policy within schools? c) What got in the way of implementing the new policy? 7) Did the district share a vision about the importance of concussion safety? PROBE: a) How did this impact the implementation of the new policy in schools? 8) Was there administrative support (principals and athletic directors) for implementing the new policy? PROBE: a) How did this impact policy implementation? 9) As of yet, has this new policy had any impact on the classroom?

110

10) What problems do you foresee with the new law? 11) Who is responsible at each school (including middle schools) for implementing and sustaining the new policy?

School community 12) In general, within your school district, how engaged are parents? 13) To what extent do the parents and students support this new law? 14) Are there concerns from anyone regarding an increase in the number of student athletes being unnecessarily “held out” from competition because of the new bill? 15) Are there some parents raising concern regarding the cost of seeing a physician once the student athlete is concussed?

Role of the Concussion Oversight Teams (COT) 16) Can you tell me about your COT? ADDITIONAL PROBES: a) What role did the COT play in spreading the new policy throughout the school district? b) What role did the COT play in helping school Principals and other staff implement the new policy at the school level? c) How often do COTs meet? i) Should they meet more often?

Logistics of the Law 17) Are you familiar with the language of the law? PROBE: a) If so, how difficult or straightforward is it to understand? 18) Has the media helped to spread the word about this new law? PROBE: a) Please explain 19) Is the timing of the law good? (i.e. – May 17th implementation right as employees are leaving for the summer) PROBE: a) Would there be a better time to implement this type of policy (i.e. – spring or fall)? 20) Have the majority of athletic trainers shown dissent or agreement regarding the new law? 21) Are the ESL parents and students being equally educated on the new law? 22) Has it been difficult to get concussed student athletes to see a doctor on his/her own for evaluation and/or clearance? 23) Are there any other logistical problems you see now or in the future with this new policy?

111

APPENDIX C.1: RECRUITMENT LETTER

Dear Athletic Trainer,

You are invited to participate in a research study, entitled “Examination of the Implementation of House Bill 2038 on Concussion Management in the High School Setting.” This study is being conducted by Carisa Raucci from the Department of Kinesiology and Health Education and her faculty advisors, Dr. John Bartholomew, Dr. Fred Peterson, and Dr. Mary Steinhardt (see contact information below).

Purpose of Study The purposes of this study are 1) to evaluate the diffusion and implementation of House Bill (HB) 2038 in order to determine facilitators and barriers for current and future concussion policy propagation; 2) to examine the effects of HB 2038 on the rates of diagnosed primary and secondary concussions; and 3) to examine the effects of HB 2038 on the average length of time for return-to-play in diagnosed concussions. You are welcome to contact the investigators to discuss the study.

You will be asked to:  Participate in a phone or face-to-face interview that will take approximately 30 minutes regarding House Bill 2038 and the implementation of the concussion policy in your school district.  Participate in one optional online survey that will take approximately 15 minutes regarding your personal demographics and your beliefs about the new law.  Either type a response or select from multiple-choice options. The survey items will solicit your training and management of concussions.  There is no compensation for completing this survey.

Risks, Benefits, and Confidentiality of Data We do not anticipate any risk or discomfort as you complete the survey. Participation involves no costs; however, your feedback will benefit future athletes involved in sports- related head injuries as a result of catalyzing the diffusion and implementation process of a state law on concussion management in the school setting. The benefits may also help in the identification and subsequent implementation of concussion management policies for current and future athletic trainers that help reduce the long-term prevalence of concussion diagnoses. Your name and contact information will be kept strictly confidential and used only for initial interview scheduling. Only the investigators will have access to the data, and all identifying information will be removed from the final dataset.

Participation or Withdrawal Your participation in this study is voluntary. You may decline to answer any question and you have the right to withdraw from participation at any time. Withdrawal will not affect your relationship with The University of Texas in any way. If you do not want to participate, either simply stop participating or close the browser window. If you do not

112

want to receive any more reminders or to opt out of future emails, notify the investigator at [email protected].

Contacts If you have any questions about this study or need to update your email address, contact the investigators listed below. This study has been approved by The University of Texas at Austin Institutional Review Board; the study number is 2012-01-0062. If you have questions about your rights as a research participant or are dissatisfied at any time with any part of this study, you may contact (anonymously if you wish) the Institutional Review Board by phone at (512) 471-8871 or email at [email protected]. You will receive a follow-up participant consent form in your mailbox in the next 7 days. Thank you for your time and contribution toward this important study.

Sincerely,

Carisa Raucci, MSEd, ATC, LAT, CSCS PhD Candidate in Health Education The University of Texas at Austin, College of Education Department of Kinesiology and Health Education 1 University Station D3700, Austin, TX 78712 Phone: (210) 867-0279; Fax: (512) 232-5054 E-mail: [email protected]

John Bartholomew, PhD Professor and Associate Chair in Exercise and Sport Psychology The University of Texas at Austin Department of Kinesiology and Health Education 1 University Station, D3700, Austin, TX 78712 Phone: (512) 232-6021; Fax (512) 471-0946 Email: [email protected]

Fred Peterson, PhD, CHES, FASHA Professor in Health Education The University of Texas at Austin, College of Education Department of Kinesiology and Health Education 1 University Station D3700, Austin, TX 78712 Phone: (512) 232-5877; Fax: (512) 471-8914 Email: [email protected]

Mary Steinhardt, EdD, LPC, CHES Professor in Health Education, Faculty Ombudsperson The University of Texas at Austin, College of Education Department of Kinesiology and Health Education 1 University Station D3700, Austin, TX 78712 Phone: (512) 232-3535; Fax: (512) 471-8914 E-mail: [email protected]

113

APPENDIX D.1: CONSENT FOR PARTICIPATION IN RESEARCH

Title: Examination of the Implementation of House Bill 2038 on Concussion Management in the High School Setting

Introduction The purpose of this form is to provide you information that may affect your decision as to whether or not to participate in this research study. The person performing the research will answer any of your questions. Read the information below and ask any questions you might have before deciding whether or not to take part. If you decide to be involved in this study, this form will be used to record your consent.

Purpose of the Study You have been asked to participate in a research study about the new House Bill 2038 also known as Natasha’s Law regarding concussion management in sport. This study will serve to guide current and future concussion policy propagation and reveal potential areas for intervention designed to educate student-athletes and the school community on the importance of properly managing head injuries. The purpose of this study is 1) to evaluate the diffusion and implementation of House Bill (HB) 2038 in order to determine facilitators and barriers for current and future concussion policy propagation; 2) to examine the effects of HB 2038 on the rates of diagnosed primary and secondary concussions; and 3) to examine the effects of HB 2038 on the average length of time for return-to-play in diagnosed concussions.

What will you to be asked to do? You will be asked to:  Participate in a phone or face-to-face interview regarding the implementation of the concussion policy in your school district.  Participate in an optional online survey regarding your personal demographics, concussion rates at your school, and your beliefs about the new law.

This study will take approximately 30 minutes for a one-time interview and approximately 15 minutes for an optional online survey. This will include approximately 20 study participants.

This is a research study and, therefore, not intended to provide a medical or therapeutic diagnosis or treatment. The intervention provided in the course of this study is not necessarily equivalent to the standard method of prevention, diagnosis, or treatment of a health condition.

Your participation in the interview portion will be audio recorded.

What are the risks involved in this study? There are no foreseeable risks to participating in this study.

114

What are the possible benefits of this study? You will receive no direct benefit from participating in this study; however, your participation in this study will benefit future athletes involved in sports-related head injuries as a result of catalyzing the diffusion and implementation process of a state law on concussion management in the school setting. The benefits may also help in the identification and subsequent implementation of concussion management policies for current and future athletic trainers that help reduce the prevalence of concussion diagnoses.

Do you have to participate? No, your participation is voluntary. You may decide not to participate at all or, if you start the study, you may withdraw at any time. Withdrawal or refusing to participate will not affect your relationship with The University of Texas at Austin (University) in anyway.

If you would like to participate you may return this form signed to the primary investigator prior to the start of the interview. You will receive a copy of this form.

Will there be any compensation? You will not receive any type of payment participating in this study.

What are my confidentiality or privacy protections when participating in this research study? This study is confidential and your name, telephone number, and email address will be kept during the data collection phase for tracking purposes only. A limited number of research team members will have access to the data during data collection. Identifying information will be stripped from the final dataset and no school or district affiliation will be known to anyone outside of the research team.

If you choose to participate in this study, you will be audio recorded. Any audio recordings will be stored securely and only the research team will have access to the recordings. Recordings will be kept for 1 year and then erased. The data resulting from your participation may be used for future research or be made available to other researchers for research purposes not detailed within this consent form.

Whom to contact with questions about the study? Prior, during or after your participation you can contact the researcher Carisa Raucci at 210-867-0279 or send an email to [email protected]. This study has been reviewed and approved by The University Institutional Review Board and the study number is 2012-01-0062.

Whom to contact with questions concerning your rights as a research participant? For questions about your rights or any dissatisfaction with any part of this study, you can contact, anonymously if you wish, the Institutional Review Board by phone at (512) 471-8871 or email at [email protected].

115

Participation If you agree to participate the signed forms will be collected by the primary investigator prior to the start of the interview.

Signature You have been informed about this study’s purpose, procedures, possible benefits and risks, and you have received a copy of this form. You have been given the opportunity to ask questions before you sign, and you have been told that you can ask other questions at any time. You voluntarily agree to participate in this study. By signing this form, you are not waiving any of your legal rights.

Printed Name

______Signature Date

______Phone number(s) to best reach you

Email address

As a representative of this study, I have explained the purpose, procedures, benefits, and the risks involved in this research study.

______Print Name of Person obtaining consent

______Signature of Person obtaining consent Date

116

APPENDIX E.1: APPROVAL FROM SCHOOL DISTRICT

117

APPENDIX F.1: APPROVAL FROM THE INSTITUTIONAL REVIEW BOARD

OFFICE OF RESEARCH SUPPORT

THE UNIVERSITY OF TEXAS AT AUSTIN

P.O. Box 7426, Austin, Texas 78713 · Mail Code A3200 (512) 471-8871 · FAX (512) 471-8873

FWA # 00002030

Date: 05/04/12 PI: Carisa M Raucci Dept: Kinesiology and Health Education Title: Evaluation of the Diffusion and Implementation of House Bill 2038 on

Concussion Management in the High School Setting

Re: IRB Expedited Approval for Protocol Number 2012-01-0062

Dear Carisa M Raucci

In accordance with the Federal Regulations the Institutional Review Board (IRB) reviewed the above referenced research study and found it met the requirements for approval under the Expedited category noted below for the following period of time: 05/04/2012 to 05/04/2013. Expires 12 a.m. [midnight] of this date. If the research will be conducted at more than one site, you may initiate research at any site from which you have a letter granting you permission to conduct the research. You should retain a copy of the letter in your files.

Expedited category of approval:

1) Clinical studies of drugs and medical devices only when condition (a) or (b) is met. (a) Research on drugs for which an investigational new drug application (21 CFR Part 312) is not required. (Note: Research on marketed drugs that significantly increases the risks or decreases the acceptability of the risks associated with the use of the product is not eligible for expedited review). (b) Research on medical devices for which (i) an investigational device exemption application (21 CFR Part 812) is not required; or (ii) the medical device is cleared/approved for marketing and the medical device is being used in accordance with its cleared/approved labeling.

118

2) Collection of blood samples by finger stick, heel stick, ear stick, or venipuncture as follows: (a) from healthy, non-pregnant adults who weigh at least 110 pounds. For these subjects, the amounts drawn may not exceed 550 ml in an 8 week period and collection may not occur more frequently than 2 times per week; or (b) from other adults and children2, considering the age, weight, and health of the subjects, the collection procedure, the amount of blood to be collected, and the frequency with which it will be collected. For these subjects, the amount drawn may not exceed the lesser of 50 ml or 3 ml per kg in an 8 week period and collection may not occur more frequently than 2 times per week.

3) Prospective collection of biological specimens for research purposes by non-invasive means. Examples:

(b) Deciduous teeth at time of exfoliation or if routine patient care indicates a need for extraction; (c) Permanent teeth if routine patient care indicates a need for extraction. (d) Excreta and external secretions (including sweat). (e) Uncannulated saliva collected either in an un-stimulated fashion or stimulated by chewing gumbase or wax or by applying a dilute citric solution to the tongue. (f) Placenta removed at delivery. (g) Amniotic fluid obtained at the time of rupture of the membrane prior to or during labor. (h) Supra- and subgingival dental plaque and calculus, provided the collection procedure is not more invasive than routine prophylactic scaling of the teeth and the process is accomplished in accordance with accepted prophylactic techniques. (i) Mucosal and skin cells collected by buccal scraping or swab, skin swab, or mouth washings. (j) Sputum collected after saline mist nebulization.

4) Collection of data through non-invasive procedures (not involving general anesthesia or sedation) routinely employed in clinical practice, excluding procedures involving x- rays or microwaves. Where medical devices are employed, they must be cleared/approved for marketing. (Studies intended to evaluate the safety and effectiveness of the medical device are not generally eligible for expedited review, including studies of cleared medical devices for new indications). Examples: (a) Physical sensors that are applied either to the surface of the body or at a distance and do not involve input of significant amounts of energy into the subject or an invasion of the subject's privacy. (b) Weighing or testing sensory acuity. (c) Magnetic resonance imaging. (d) Electrocardiography, electroencephalography, thermography, detection of naturally occurring radioactivity, electroretinography, ultrasound, diagnostic infrared imaging, doppler blood flow, and echocardiography. (e) Moderate exercise, muscular strength testing, body composition assessment, and flexibility testing where appropriate given the age, weight, and health of the individual.

119

5) Research involving materials (data, documents, records, or specimens) that have been collected, or will be collected solely for non-research purposes (such as medical treatment or diagnosis). Note: Some research in this category may be exempt from the HHS regulations for the protection of human subjects. 45 CFR 46.101(b)(4). This listing refers only to research that is not exempt.

6) Collection of data from voice, video, digital, or image recordings made for research purposes.

7) Research on individual or group characteristics or behavior (including, but not limited to, research on perception, cognition, motivation, identity, language, communication, cultural beliefs or practices, and social behavior) or research employing survey, interview, oral history, focus group, program evaluation, human factors evaluation, or quality assurance methodologies. Note: Some research in this category may be exempt from the HHS regulations for the protection of human subjects. 45 CFR 46.101(b)(2) and (b)(3). This listing refers only to research that is not exempt.

Use the attached approved informed consent document(s).

You have been granted a Waiver of Documentation of Consent according to 45 CFR 46.117 and/or 21 CFR 56.109(c)(1).

You have been granted a Waiver of Informed Consent according to 45 CFR 46.116(d).

Responsibilities of the Principal Investigator:

1. Report immediately to the IRB any unanticipated problems.

2. Submit for review and approval by the IRB all modifications to the protocol or consent form(s). Ensure the proposed changes in the approved research are not applied without prior IRB review and approval, except when necessary to eliminate apparent immediate hazards to the subject. Changes in approved research implemented without IRB review and approval initiated to eliminate apparent immediate hazards to the subject must be promptly reported to the IRB, and will be reviewed under the unanticipated problems policy to determine whether the change was consistent with ensuring the subjects continued welfare.

3. Report any significant findings that become known in the course of the research that might affect the willingness of subjects to continue to participate.

4. Ensure that only persons formally approved by the IRB enroll subjects.

5. Use only a currently approved consent form, if applicable. Note: Approval periods are for 12 months or less.

6. Protect the confidentiality of all persons and personally identifiable data, and train your staff and collaborators on policies and procedures for ensuring the privacy and confidentiality of subjects and their information.

120

7. Submit a Continuing Review Application for continuing review by the IRB. Federal regulations require IRB review of on-going projects no less than once a year a reminder letter will be sent to you two months before your expiration date. If a reminder is not received from Office of Research Support (ORS) about your upcoming continuing review, it is still the primary responsibility of the Principal Investigator not to conduct research activities on or after the expiration date. The Continuing Review Application must be submitted, reviewed and approved, before the expiration date.

8. Upon completion of the research study, a Closure Report must be submitted to the ORS.

9. Include the IRB study number on all future correspondence relating to this protocol. If you have any questions contact the ORS by phone at (512) 471-8871 or via e-mail at [email protected].

Sincerely,

James Wilson, Ph.D. Institutional Review Board Chair

121

APPENDIX A.2: PERMISSION LETTER FOR DIRECTORY USE FROM TSATA

122

123

APPENDIX B.2: PERMISSION LETTER FOR EMAIL USE FROM CEA

124

125

APPENDIX C.2: APPROVAL FROM THE INSTITUTIONAL REVIEW BOARD

OFFICE OF RESEARCH SUPPORT

THE UNIVERSITY OF TEXAS AT AUSTIN

P.O. Box 7426, Austin, Texas 78713 · Mail Code A3200 (512) 471-8871 · FAX (512) 471-8873

FWA # 00002030

Date: January 2013 PI: Carisa M Raucci Dept: Kinesiology and Health Education Title: Examination of the knowledge, attitudes, self-efficacy, and treatment practices of athletic trainers and physicians regarding concussions in the high school athlete (RoCKAS)

Re: IRB Expedited Approval for Protocol Number

Dear Carisa M Raucci

In accordance with the Federal Regulations the Institutional Review Board (IRB) reviewed the above referenced research study and found it met the requirements for approval under the Expedited category noted below for the following period of time: to . Expires 12 a.m. [midnight] of this date. If the research will be conducted at more than one site, you may initiate research at any site from which you have a letter granting you permission to conduct the research. You should retain a copy of the letter in your files.

Expedited category of approval:

126

the subjects, the collection procedure, the amount of blood to be collected, and the frequency with which it will be collected. For these subjects, the amount drawn may not exceed the lesser of 50 ml or 3 ml per kg in an 8 week period and collection may not occur more frequently than 2 times per week.

3) Prospective collection of biological specimens for research purposes by non-invasive means. Examples:

(a) Hair and nail clippings in a non-disfiguring manner. (b) Deciduous teeth at time of exfoliation or if routine patient care indicates a need for extraction; (c) Permanent teeth if routine patient care indicates a need for extraction. (d) Excreta and external secretions (including sweat). (e) Uncannulated saliva collected either in an un-stimulated fashion or stimulated by chewing gumbase or wax or by applying a dilute citric solution to the tongue. (f) Placenta removed at delivery. (g) Amniotic fluid obtained at the time of rupture of the membrane prior to or during labor. (h) Supra- and subgingival dental plaque and calculus, provided the collection procedure is not more invasive than routine prophylactic scaling of the teeth and the process is accomplished in accordance with accepted prophylactic techniques. (i) Mucosal and skin cells collected by buccal scraping or swab, skin swab, or mouth washings. (j) Sputum collected after saline mist nebulization.

5) Research involving materials (data, documents, records, or specimens) that have been collected, or will be collected solely for non-research purposes (such as medical treatment or diagnosis).

127

Note: Some research in this category may be exempt from the HHS regulations for the protection of human subjects. 45 CFR 46.101(b)(4). This listing refers only to research that is not exempt.

6) Collection of data from voice, video, digital, or image recordings made for research purposes.

Use the attached approved informed consent document(s).

You have been granted a Waiver of Documentation of Consent according to 45 CFR 46.117 and/or 21 CFR 56.109(c)(1).

You have been granted a Waiver of Informed Consent according to 45 CFR 46.116(d).

Responsibilities of the Principal Investigator:

1. Report immediately to the IRB any unanticipated problems.

3. Report any significant findings that become known in the course of the research that might affect the willingness of subjects to continue to participate.

4. Ensure that only persons formally approved by the IRB enroll subjects.

5. Use only a currently approved consent form, if applicable. Note: Approval periods are for 12 months or less.

7. Submit a Continuing Review Application for continuing review by the IRB. Federal regulations require IRB review of on-going projects no less than once a year a reminder

128

letter will be sent to you two months before your expiration date. If a reminder is not received from Office of Research Support (ORS) about your upcoming continuing review, it is still the primary responsibility of the Principal Investigator not to conduct research activities on or after the expiration date. The Continuing Review Application must be submitted, reviewed and approved, before the expiration date.

8. Upon completion of the research study, a Closure Report must be submitted to the ORS.

9. Include the IRB study number on all future correspondence relating to this protocol. If you have any questions contact the ORS by phone at (512) 471-8871 or via e-mail at [email protected].

Sincerely,

James Wilson, Ph.D. Institutional Review Board Chair

129

APPENDIX D.2: RECRUITMENT LETTER

Dear Health Care Professional,

You are invited to participate in a research study, entitled “Examination of the knowledge, attitudes, self-efficacy, and treatment practices of athletic trainers and physicians regarding concussions in the high school athlete (RoCKAS).” This study is being conducted by Carisa Raucci from the Department of Kinesiology and Health Education, Dr. Mark Chassay, assistant team physician, and her faculty advisor Dr. Mary Steinhardt of The University of Texas at Austin (see contact information below).

Purpose of Study The purpose of this study is to 1) examine areas in need of concussion education by examining knowledge, attitudes and treatment practices regarding concussions; and 2) determine what systems and guidelines health care professionals are using to improve best concussion practices. If you agree to participate:  The optional online survey will take approximately 15 minutes of your time.  You will complete an activity about your personal demographics and your knowledge, attitudes, and treatment practices regarding concussion management.  Either type a response or select from multiple-choice options. The survey items will solicit your beliefs, training and management of concussions.  Participants completing the survey are eligible to enter a series of drawings for a $25 VISA gift card.

Risks, Benefits, and Confidentiality of Data We do not anticipate any risk or discomfort as you complete the survey. Participation involves no costs; however, your feedback will be used to identify knowledge gaps or misconceptions as well as attitudes leading to behavioral patterns that may facilitate unsafe actions regarding concussion management efforts. These results may, to some extent, help explain why people practice certain health management styles. The benefits may assess key sources to defining effective interventions in concussion management efforts. The minimal risk to participants in relation to the potential benefits to future athletes supports the current study. Only your email address will be kept during the data collection phase. A limited number of research team members will have access to the data during data collection.

130

Contacts If you have any questions about this study or need to update your email address, contact the investigators listed below. This study has been approved by The University of Texas at Austin Institutional Review Board; the study number is 2013-03-0071. If you have questions about your rights as a research participant or are dissatisfied at any time with any part of this study, you may contact (anonymously if you wish) the Institutional Review Board by phone at (512) 471-8871 or email at [email protected]. You will receive a follow-up participant consent form in your mailbox in one week. Thank you for your time and contribution toward this important study.

Sincerely,

C. Mark Chassay, MD, FAAFP, FASCM Assistant Team Physician The University of Texas at Austin Intercollegiate Athletics P.O. Box 7399, Austin, TX 78713-7399 Phone: (512) 471-5513

131

APPENDIX E.2: CONSENT TO PARTICIPATE IN INTERNET RESEARCH

Identification of Investigator and Purpose of Study

You are invited to participate in a research study, entitled “Examination of the knowledge, attitudes, self-efficacy, and treatment practices of athletic trainers and physicians regarding concussions in the high school athlete (RoCKAS)”. The study is being conducted by Carisa Raucci from the Department of Kinesiology and Health Education, Dr. Mark Chassay, assistant team physician, and her faculty advisor Dr. Mary Steinhardt of The University of Texas at Austin (see contact information below).

The purpose of this research study is to 1) examine areas in need of concussion education by examining knowledge, attitudes and treatment practices regarding concussions; and 2) determine what systems and guidelines health care professionals are using to improve best concussion practices. Your participation in the study will contribute to a better understanding of knowledge gaps or misconceptions as well as attitudes leading to behavioral patterns that may facilitate unsafe actions regarding concussion management efforts. You are free to contact the investigator(s) to discuss the study. You must be at least 18 years old to participate.

If you agree to participate:  The optional online survey will take approximately 15 minutes of your time.  You will complete questions about your personal demographics and your knowledge, attitudes and treatment practices regarding concussion management.  Either type a response or select from multiple-choice options. The survey items will solicit your beliefs, training and management of concussions.  Participants completing the survey are eligible to enter a series of drawings for a $25 VISA gift card.

Risks/Benefits/Confidentiality of Data

We do not anticipate any risk or discomfort as you complete the survey. Participation involves no costs. The benefits may assess key sources to defining effective interventions in concussion management efforts. The minimal risk to participants in relation to the potential benefits to future athletes supports the current study. Only your email address will be kept during the data collection phase. A limited number of research team members will have access to the data during data collection.

Participation or Withdrawal

Your participation in this study is voluntary. You may decline to answer any question and you have the right to withdraw from participation at any time. Withdrawal will not affect your relationship with The University of Texas in anyway. If you do not want to participate either simply stop participating or close the browser window.

132

If you do not want to receive any more reminders, you may email us at [email protected].

Contacts

If you have any questions about the study or need to update your email address contact the researchers listed below. This study has been reviewed by The University of Texas at Austin Institutional Review Board and the study number is 2013-03-0071.

Questions about your rights as a research participant. If you have questions about your rights or are dissatisfied at any time with any part of this study, you can contact, anonymously if you wish, the Institutional Review Board by phone at (512) 471-8871 or email at [email protected].

If you agree to participate, click on the following link https://www.surveymonkey.com/s/GHKRTZK.

Thank you,

C. Mark Chassay, MD, FAAFP, FASCM Assistant Team Physician The University of Texas at Austin Intercollegiate Athletics P.O. Box 7399, Austin, TX 78713-7399 Phone: (512) 471-5513

Please print a copy of this document for your records.

133

APPENDIX F.2: INTERNET SURVEY INSTRUMENT FOR ATHLETIC

TRAINERS

To view the actual online version, please go to: https://www.surveymonkey.com/s/GHKRTZK

Survey modifications from Rosenbaum’s original survey (Rosenbaum & Arnett, 2010) included the addition of 8 knowledge questions (survey item Appendix F.2 #165, 167, 180, 181, 182, 183, 184, and 185 for the athletic trainer questions and Appendix G.2 #279, 281, 294, 295, 296, 297, 298, and 299 for the physician questions). Additional treatment practice questions were asked in section 6 that were not asked in the original survey (G.2 #208-218 and H.2 #322-332). Variations of this survey were created for the populations of this study. The athletic trainers (RoCKAS-AT; see Appendix F.2) and the physicians (RoCKAS-DR; see Appendix G.2) survey forms were slightly different in regards to substituting terminology in the questions, and the physicians were specifically asked if they take care of concussed patients; of which it can be assumed that high school athletic trainers inherently treat concussed patients. Physicians were also asked the classification of their medical specialty and whether they treated high school or middle school athletes. The athletic trainers had two additional questions regarding who referred concussed student-athletes to them and whether or not their affiliated school had procedures in place to manage concussions.

134

135

136

137

138

139

140

141

142

143

144

145

146

147

148

149

150

151

152

153

154

(End)

155

APPENDIX G.2: INTERNET SURVEY INSTRUMENT FOR PHYSICIANS

To view the actual online version, please go to: https://www.surveymonkey.c om/s/GHKRTZK

156

157

158

159

160

161

162

163

164

165

166

167

168

169

170

171

172

173

174

175

176

177

178

(End)

179

APPENDIX H.2: FINAL FOLLOW-UP EMAIL

Dear Health Care Professional,

You have recently been invited to participate in a research study, entitled “Examination of the knowledge, attitudes, self-efficacy, and treatment practices of athletic trainers and physicians regarding concussions in the high school athlete (RoCKAS)”. The study is being conducted by Carisa Raucci from the Department of Kinesiology and Health Education, Dr. Mark Chassay, assistant team physician, and her faculty advisor Dr. Mary Steinhardt of The University of Texas at Austin (see contact information below).

The purpose of this research study is to 1) examine areas in need of concussion education by examining knowledge, attitudes and treatment practices regarding concussions; and 2) determine what systems and guidelines health care professionals are using to improve best concussion practices. Your participation in the study will contribute to a better understanding of knowledge gaps or misconceptions as well as attitudes leading to behavioral patterns that may facilitate unsafe actions regarding concussion management efforts. You are free to contact the investigator at the below address and phone number to discuss the study. You must be at least 18 years old to participate.

Risks/Benefits/Confidentiality of Data

Participation or Withdrawal

180

If you do not want to receive any more reminders, you may email us at [email protected].

Contacts

If you agree to participate, click on the following link https://www.surveymonkey.com/s/GHKRTZK.

This survey is due to expire on December 15, 2013.

Thank you,

C. Mark Chassay, MD, FAAFP, FASCM Assistant Team Physician The University of Texas at Austin Intercollegiate Athletics P.O. Box 7399, Austin, TX 78713-7399 Phone: (512) 471-5513

Please print a copy of this document for your records.

181

APPENDIX I.2: PERMISSION LETTER FOR ROCKAS SURVEY USE

Hi Carisa, No problem. Go ahead and add the items to the survey. I would recommend that you follow the same validation procedure that I included in the paper showing the development of the survey. I would be curious about the extent to which the new items are consistent w/ the old items.

Your study sounds interesting, and I’d be interested to see what you all find!

Thanks and good luck.

Best, Aaron

On Thu, Feb 28, 2013 at 10:20 AM, Raucci, Carisa M wrote:

Hello Aaron,

My name is Carisa Raucci and I am doctoral candidate at The University of Texas at Austin working with Dr. Mark Chassay. We are in the process of getting ready to distribute your RoCKAS survey and I wanted to touch base with you. Per your conversation with Mark (I have attached below), you gave him permission to utilize your survey. With the changes in the literature over the past several years, we have made a few additions to questions in the knowledge section. Would you be OK with us adding a few questions to that part regarding concussion knowledge? If it helps, I can send you the questions.

Thank you for your time and input,

182

REFERENCES

Aiken, L. S., & West, S. G. (1991). Multiple regression: Testing and interpreting

interactions. Newbury Park: Sage.

Alla, S., Sullivan. S.J., Hale, L., McCrory, P. (2009). Self-report scales/checklists for

the measurement of concussion symptoms: a systematic review. British Journal of

Sports Medicine, 43 (i3-12).

Almasi S.J., & Wilson, J.J. (2012). An update on the diagnosis and management of

concussion. WMJ, 111(1), 21-27.

Anchondo, I., Berkeley, L., Mulla, Z.D., Byrd, T., Nuwayhid, B., Handal, G., & Akins,

R. (2012). Pediatricians’, obstetricians’, gynecologists’, and family medicine

physicians’ experiences with and attitudes about breast-feeding. Southern Medical

Journal, 105(5), 243-249.

Arbogast, K.B. McGinley, A.D., Master, C.L, Grady, M.F., Robinson, R.L., Zonfrillo,

M.R. (2013). Cognitive rest and school-based recommendations following pediatric

concussion: the need for primary care support tools. Clinical Pediatrics, 52(5), 397-

402.

Aubry, M., Cantu, R., Dvorak, J., et al. (2002). Summary and agreement statement of

the First International Conference on Concussion in Sport, Vienna 2001:

recommendations for the improvement of safety and health of athletes who may

suffer concussive injuries. British Journal of Sports Medicine, 36(1), 6–7.

Baillargeon, A., Lassonde, M., Leclerc, S., & Ellemberg, D. (2012).

Neuropsychological and neurophysiological assessment of sport concussion in

children, adolescents and adults. Brain Injury, 26(3), 211-220.

183

Bakhos, L.L., Lockhart, G.R., & Myers, R., Linakis, J.G. (2010). Emergency

department visits for concussion in young child athletes. Pediatrics, 126, e550-6.

Balbach, E.D., Smith, E.A., & Malone, R.E. (2006). How the health belief model helps

the tobacco industry: individuals, choice, and “information”. Tobacco Control, 15,

s4, iv37-43.

Bandura, A. (1977). Self-efficacy: toward a unifying theory of behavioral change.

Psychological Review, 84(2), 191-215.

Bandura, A. (2006). Toward a psychology of human agency. Perspectives on

Psychological Science, 1(2), 164-180.

Bassett, L.W., Bunnell, D.H., Cerny, J.A., & Gold, R.H. (1986). Screening

mammography: Referral practices of Los Angeles physicians. American Journal of

Roentgenology, 147, 689-692.

Becker, M.H., & Maiman, L.A. (1975). Sociobehavioral determinants of compliance

with health and medical care recommendations. Medical Care, 13(1), 10-24.

Betz, M.E., Sullivan, A. F., Manton, A.P., Espinola, J.A., Miller, I., Camargo, Jr., C.A., &

Boudreaux, E.D. (2013). Knowledge, attitudes, and practices of emergency department

providers in the care of suicidal patients. Depression and Anxiety, 30(10), 1005-1012.

Boden, B.P., Tacchetti, R.L., Cantu, R.C., Knowles, S.B., & Mueller, F.O. (2007).

Catastrophic head injuries in high school and college players. American Journal of

Sports Medicine, 35(7), 1075-1081.

Bogden, R.C., & Biklen, S.K. (1998). Qualitative research for education: An

introduction to theory and methods. Needham Heights, MA: Ally & Bacon.

184

Boggild, M., & Tator, C.H. (2012). Concussion knowledge among medical students and

neurology/neurosurgery residents. The Canadian Journal of Neurological Sciences,

39(3), 361-368.

Bompadre, V., Jinguji, T.M., Yanez, D., Satchell, E.K., Gilbert, K., Burton, M., Conrad

III, E.U., & Herring, S.A. (2014). Washington state’s Lystedt Law in concussion

documentation in Seattle public high schools. Journal of Athletic Training, 49(4),

486-492.

Boriboon, K. (2013). Concussion management in football: Don’t shake it off. PT in

Motion, 5(1), 18-25.

Brain Injury Association of America (2014). Affiliate Policy Brief – State Sports

Concussion Legislation. Retrieved from

file:///C:/Users/Carisa/Downloads/Affiliate+Policy+Brief+State+Sports+Concussion+

Legislation.pdf

Brinsley, K.J., Sinkowitz-Cochran, R.L., Cardo, D.M., & the CDC Campaign to Prevent

Antimicrobial Resistance Team, (2005). Assessing motivation for physicians to

prevent antimicrobial resistance in hospitalized children using the Health Belief

Model as a framework. American Journal of Infection Control, 33, 175-181.

Broglio, S.P., Cantu, R.C., Gioia, G.A., Guskiewicz, K.M., Kutcher, J., Palm, M., &

Valovich McLeod, T.C. (2014). National Athletic Trainers’ Association position

statement: Management of sport concussion. Journal of Athletic Training, 49(2),

245-265.

Brown, T.T., Proctor, S.E, Sinkowitz-Cochran, R.L., Smith, T.L., Jarvis, W.R., & Society

for Healthcare Epidemiology of America, Inc. (2001). Physician preferences for

185

continuing medical education with a focus on the topic of antimicrobial resistance.

Infection Control and Hospital Epidemiology, 22, 656-60.

Burglehaus, M.J., Smith, L.A., Sheps, S.B., & Green, L.W. (1997). Physicians and

breastfeeding: beliefs, knowledge, self-efficacy and counselling practices. Canadian

Journal of Public Health, 88(6), 383-387.

Cabana, M.D., Ebel, B.E., Cooper-Patrick, L., Powe, N.R., Rubin, H.R., & Rand, C.S.

(2000). Barriers pediatricians face when using asthma practice guidelines. Archives

of Pediatrics & Adolescent Medicine, 154(7), 685-693.

doi:10.1001/archpedi.154.7.685

Cabana, M.D., Rand, C.S., Powe, N.R., Wu, A.W., Wilson, M.H., Abboud, A.C., &

Rubin, H.R. (1999). Why don’t physicians follow clinical practice guidelines? A

framework for improvement. Journal of the American Medical Association, 282(15),

1458-1465.

Canbulat, N., & Uzun, O. (2008). Health beliefs and breast cancer screening behaviors

among female health workers in Turkey. European Journal of Oncology Nursing, 12,

148-156.

Cantu, R.C., & Voy, R. (1995). Second impact syndrome: a risk in any contact sport.

Physician and Sportsmedicine, 23(6), 27–34.

Cao, Z., Chen, Y., & Wang, S. (2014). Health belief model based evaluation of school

health education programme for injury prevention among high school students in the

community context. BioMed Central Public Health, 14(1), 1-15.

Carpenter, C.J. (2010). A meta-analysis of the effectiveness of Health Belief Model

variables in predicting behavior. Health Communication, 25, 661-669.

186

The Center on Brain Injury Research and Training (2015). Max’s and Jenna’s Laws.

Retrieved from http://cbirt.org/ocamp/max-jenna-laws/

Centers for Disease Control and Prevention (2013). Facts for Physicians. Retrieved from

http://www.cdc.gov/concussion/headsup/pdf/Facts_for_Physicians_booklet-a.pdf

Centers for Disease Control and Prevention (2015). Injury Prevention &

Control: Traumatic Brain Injury. Retrieved from

http://www.cdc.gov/concussion/signs_symptoms.html

Chriqui, J.F., Resnick, E.A., Schneider, L., Schermbeck, R., Adcock, T., Carrion, V., &

Chaloupka, F.J. (2013). School district wellness policies: evaluating progress and

potential for improving children’s health five years after the federal mandate. School

years 2006–07 through 2010-11. Volume 3. Chicago, IL: Bridging the Gap Program,

Health Policy Center, Institute for Health Research and Policy, University of Illinois

at Chicago.

Choe, M.C., & Giza, C.C. (2015). Diagnosis and management of acute concussion.

Seminars in Neurology., 35(1), 29-41. doi: 10.1055/s-0035-1544243.

Coe, R.M., & Wessen, A. (1965). Social-psychological factors influencing the use of

community health resources. American Journal of Public Health., 55, 1024.

Cohen, J. (1992). A power primer. Psychological Bulletin, 112, 155-159.

Conner, M. & Norman, P. (1996). Predicting Health Behavior. Search and Practice

with Social Cognition Models. Open University Press: Ballmore: Buckingham.

Corbin, J. & Strauss, A. (2008). Basics of Qualitative Research (3rd ed.). Thousand

Oaks, CA: Sage Publications.

187

Covassin, T., Elbin III, R., & Stiller-Ostrowski, J.L. (2009). Current sport-related

concussion teaching and clinical practices of sports medicine professionals. Journal

of Athletic Training, 44(4), 400-404.

Creighton, D.W., Shrier, I., Shultz, R, Meeuwisse, W.H., Matheson, G.O. (2010).

Return-to-play in sport: a decision-based model. Clinical Journal of Sport Medicine,

20(5), 379-385.

Creswell, J. W. (1998). Qualitative inquiry and research design: Choosing among five

traditions. Thousand Oaks, CA: Sage Publications.

Cronin, S.N. (1986). Health beliefs in compliant and noncompliant hypertensive clients.

Journal of Community Health Nursing, 3(2), 87-97.

Cusimano, M.D., Sharma, B., Lawrence, D.W., Llie, G., Silverberg, S., Jones, R.

(2013). Trends in North American newspaper reporting of brain injury in ice hockey.

PLOS One. 8 (4), e61865.

Daneshvar, D.H., Nowinski, C.J., McKee, A. & Cantu, R.C. (2011). The epidemiology

of sport-related concussion. Clinics in Sports Medicine, 30(1), 1–17.

Davis, M.S. (1968). Variations in patients’ compliance with doctors’ advice: an

empirical analysis of patterns of communication. American Journal of Public

Health., 58, 274.

Dean, P.J., O'Neill, D., & Sterr, A. (2012). Post-concussion syndrome: prevalence after

mild traumatic brain injury in comparison with a sample without head injury. Brain

Injury, 26(1), 14-26.

188

Deschesnes, M., Martin, C., & Hill, A.J. (2003). Comprehensive approaches to school

health promotion: how to achieve broader implementation? Health Promotion

International, 18(4), 387-396.

Donadiki, E.M., Jimenez-Garcia, R., Hernandez-Barrera, V., Sourtzi, P., Carrasco-

Garrido, P., Lopez, A., Jimenez-Trujillo, I., & Velonakis, E.G. (2014). Health Belief

Model applied to non-compliance with HPV vaccine among female university

students. Public Health, 128(3), 268-273.

Doolan, A.W., Maerlender, A.C., Gorforth, M., & Gunnar, B.P. (2012). A review of

return to play issues and sports-related concussion. Annals of Biomedical

Engineering, 40(1), 106-113.

Echemendia, R.J., Putukian, M. Mackin, R.S., Julian, L., & Shoss, N. (2001).

Neuropsychological test performance prior to and following sports-related mild

traumatic brain injury. Clinical Journal of Sport Medicine: Official Journal Of

The Canadian Academy Of Sport Medicine, 11(1), 23-31.

Echlin, P.S., Grady, M.S., & Timmons, S.D. (2012). Concussion: pathophysiology and

sequelae. Neurosurgical Focus, 33(6), 1-2.

Eisenberg, M.A., Andrea, J., Meehan, W., & Mannix, R. (2013). Time interval between

concussions and symptom duration. Pediatrics, 132(8), 8-17.

Eriksen, I.I., Melberg, H.O., & Bringedal, B. (2013). Norwegian physicians’ knowledge

of the prices of pharmaceuticals: a survey. PLOS One, 8(9), e7521.

Esbensen, F., Melde, C., Taylor, T.J., & Peterson, D. (2008). Active parental consent in

school-based research. How much is enough and how do we get it? Evaluation

Review, 32(4), 335-362.

189

Evenson, K., Ballard, K., Lee, G., & Ammerman, A. (2009). Implementation of a

school-based state policy to increase physical activity. Journal of School Health,

79(5), 231-238.

Faul, M., Xu, L., Wald, M.M., & Coronado, V.G. (2010). Traumatic Brain Injury in the

United States: Emergency Department Visits, Hospitalizations and Deaths 2002-

2006. US Department of Health and Human Services. Retrieved from

http://www.cdc.gov/traumaticbraininjury/pdf/blue_book.pdf

Faure, C. (2010). Creating concussion management policy: How school leaders,

coaches and parents can work together to ensure kids stay safer in sport. American

Secondary Education, 39(1), 5-14.

Fishbein M, & Ajzen I. (1975). Belief, Attitude, Intention, and Behavior: An

Introduction to Theory and Research. Reading, MA: Addison-Wesley Publishing

Company.

Fjordbak, B.S. (2011). Protecting student athletes: growing number of states pass

concussion-related legislation. The ASHA Leader.

Fox, S.A., Klos, D.S., & Tsou, C.V. (1988). Underuse of screening mammography by

family physicians. Radiology, 166, 431-433.

Gessel, L.M., Fields, S.K., Collins, C.L., Dick, R.W., & Comstock, R.D. (2007).

Concussions among United States high school and collegiate athletes. Journal of

Athletic Training, 42(4), 495-503.

Gilchrist, J., Thomas, K.E., Xu, L., McGuire, L.C., & Coronado, V.G. (2011). Nonfatal

sports and recreation related traumatic brain injuries among children and

190

adolescents treated in emergency departments in the United States, 2001-2009.

Morbidity and Mortality Weekly Report, 60(39), 1337-42.

Giza, C.C., & Hovda, D.A. (2001). The neurometabolic cascade of concussion. Journal

of Athletic Training, 36(3), 228-35.

Giza, C.C., Kutcher, J.S., Ashwal, S., Barth, J., Getchius, T.S., Gioia, G.A., Gronseth,

G.S., Guskiewicz, K., Mandel, S., Manley, G., McKeag, D.B., Thurman, D.J., &

Zafonte, R. (2013). Evidence-based guideline update: evaluation and

management of concussion in sports report of the guideline development

subcommittee of the American Academy of Neurology. Neurology, 80(24),

2250-2257.

Glaser, B. G., & Strauss, A.L. (1967). The Discovery of Grounded Theory: Strategies

for Qualitative Research. New York: Aldine De Gruyter.

Gonzalez, J.M., Alegria, M., Prihoda., T.J., Copeland, L.A., & Zeber, J.E. (2011). How

the relationship of attitudes toward mental health treatment and service use differs

by age, gender, ethnicity/race and education. Social Psychiatry and Psychiatric

Epidemiology, 46(1), 45-57.

Grebow, P.M., Greene, B.Z., Harvey, J., & Head, C.J. (2000). Shaping health policies.

Educational Leadership, 57(6), 63-66.

Grilli, R., Ramsay, C., Minozzi, S. (2004). Mass media interventions: effects on health

services utilisation. Cochrane Review, Update Software, Issue 2: Oxford.

Guilmette, T. J., & Paglia, M. F. (2004). The public’s misconception about traumatic

brain injury: A follow-up survey. Archives of Clinical Neuropsychology, 19(2),

183-192.

191

Guilmette, T.J., Malia, L.A., & McQuiggan, M.D. (2007). Concussion understanding

and management among New England high school football coaches. Brain

Injury, 21(10), 1039–1047.

Guskiewicz, K.M., Bruce, S.L., Cantu, R.C., et al. (2004). National Athletic Trainers’

Association position statement: management of sport-related concussion. Journal

of Athletic Training, 39(3), 280–297.

Guskiewicz, K.M., McCrea, M., Marshall, S.W., Cantu, R.C., Randolph, C., Barr, W.,

Onate, J.A., & Kelly, J.P. (2003). Cumulative effects associated with recurrent

concussion in collegiate football players: the NCAA concussion study. The

Journal of the American Medical Association. 290(19), 2549-2555.

Halstead, M. E., & Walter, K.D. (2010). Sports-related concussion in children and

adolescents. Pediatrics, 126(3), 597-615.

Haran, H.P., Bressan, S., Oakley, E., Davis, G.A., Anderson, V., & Babl, F.E. (in press).

On-field management and return-to-play in sports-related concussion in children:

are children managed appropriately. Journal of Science and Medicine in Sport.

Harkins, P.J., Lundgren, J.D., Spresser, C.D., & Hampl, S.E. (2012). Childhood

obesity: survey of physician assessment and treatment practices. Childhood

Obesity, 8(2), 155-161.

Harmon, K.G., Drezner, J.A., Gammons, M., Guskiewicz, K.M., Halstead, M., Herring,

S.A., Kutcher, J.S., Pana, A., Putukian, M., & Roberts, W.O. (2013). American

Medical Society for Sports Medicine position statement: concussion in sport.

British Journal of Sports Medicine, 47(3), 15-26.

192

Harper, M., & Cole, P. (2012). Member checking: Can benefits be gained similar to

group therapy? The Qualitative Report, 17(2), 510-517.

Head injuries in football (2014). The New York Times. Retrieved from

http://topics.nytimes.com/top/reference/timestopics/subjects/f/football/head_injuri

es/index.html

Herring, S.A., Cantu, R.C., Guskiewicz, K.M., Putukian, M., & Kibler, W.B. (2011).

Concussion (mild traumatic brain injury) and the team physician: A concussion

statement – 2011 update. Medicine & Science in Sports & Exercise, 43(12),

2412-2422.

Hochbaum, G.M., (1958). Public participation in medical screening programs: A socio-

psychological study. Washington, D.C.; U.S. Dept. of Health, Education, and

Welfare.

Hux, K., Schram, C. D., & Goeken, T. (2006). Misconceptions about brain injury: A

survey replication study. Brain Injury, 20(5), 547-553.

Hyman, R.B., Baker, S., Ephraim, R., Moadel, A., & Philip, J. (1994). Health Belief

Model variables as predictors of screening mammography utilization. Journal of

Behavioral Medicine, 17(4), 391-406.

IBM Corp. (2010). IBM SPSS Statistics for Windows, Version 19.0. Armonk, NY:

IBM Corp.

Ibrahim, I., Chew, B.L., Zaw, W.W., & Bever, H.P. (2014). Knowledge of anaphylaxis

among Emergency Department staff. Asia Pacific Allergy, 4, 164-171.

Irwin, A. (2001). Constructing the scientific citizen: science and democracy in the

biosciences. Public Understanding of Science, 10, 1-18.

193

James, D.C., Pobee, J.W., Oxidine, D., Brown, L., & Joshi, G. (2012). Using the Health

Belief Model to develop culturally appropriate weight-management materials for

African-American women. Journal of the Academy of Nutrition and Dietetics,

112 (5), 664-670.

Jinguji, T.M., Krabak, B.J., & Satchell, E.K. (2011). Epidemiology of youth sports

concussion. Physical Medicine and Rehabilitation Clinics of North America, 22,

565-575.

Kahanov, L., Loebsack, A.R., Masucci, M.A., & Roberts, J. (2010). Perspectives on

parenthood and working of female athletic trainers in the secondary school and

collegiate settings. Journal of Athletic Training, 45(5), 459-66.

Kann, L., Telljohann, S.K., & Wooley, S.F. (2007). Health education: Results from the

school health policies and programs study 2006. Journal of School Health, 77,

408-34.

Karbach, U., Schubert, I. Hagemeister, J., Ernstmann, N., Pfaff, H., & Hopp, H. (2011).

Physicians’ knowledge of and compliance with guidelines an exploratory study in

cardiovascular diseases. Deutsches Arzteblatt International, 108(5), 61-69.

Kelly, J. P., & Rosenberg, J.H. (1998). The Development of Guidelines for the

Management of Concussion in Sports. Journal of Head Trauma Rehabilitation,

13(2).

Kerr, Z.Y., Register-Mihalik, J.K., Marshall, S.W., Evenson, K.R., Mihalik, J.P., &

Guskiewicz, K.M. (2014). Disclosure and non-disclosure of concussion and

concussion symptoms in athletes: Review and application of the socio-ecological

framework. Brain Injury, 28(8), 1009-1021.

194

Kim, H., Ahn, J., & No, J. (2012). Applying the health belief model to college students’

health behavior. Nutrition Research and Practice, 6(6), 551–558.

King, K.A., Virourek, R.A., English, L., & Merianos, A.L. (2014). Vigorous physical

activity among college students: using the health belief model to assess

involvement and social support. Archives of Exercise in Health and Disease,

4(2), 267-279.

Kissick, J., & Johnston, K.M. (2005). Return to play after concussion: principles and

practice. Clinical Journal of Sport Medicine, 15(6), 426-31.

Kvamme, E., Catlin, M., Banta-Green, C., Roll, J., & Rosenblatt, R. (2013). Journal of

Substance Abuse Treatment, 44(3), 355-360.

Lai, J.C.L., Hamid, P.N., & Cheng, S. (1999). Health beliefs, optimism, and preventive

health decisions in Hong Kong Chinese. Journal of Social Behavior and

Personality, 14(1), 147-158.

Langlois, J.A., Rutland-Brown, W., & Wald, M.M. (2006). The epidemiology and

impact of traumatic brain injury: a brief overview. Journal of Head Trauma and

Rehabilitation, 21(5), 375–378.

Lavigne, P. (2012). Concussion news worries parents. ESPN. Retrieved from

http://espn.go.com/espn/otl/story/_/id/8297366/espn-survey-finds-news-coverage-

concussions-leads-majority-parents-less-likely-allow-sons-play-youth-football-

leagues

Lebrun, C.M., Mrazik, M., Prasad, A.S., Tjarks, B.J., Dorman, J.C., Bergeron, M.F.,

Munce, T.A., & Valentine, V.D. (2013). Sport concussion knowledge base,

clinical practises, and needs for continuing medical education: a survey of family

195

physicians and cross-border comparison. British Journal of Sports Medicine, 47,

54-59.

Lin, P.L., Oram, R.J., Lauderdale, D.S., Dean, R., & Daum, R.S. (2000). Knowledge of

Centers for Disease Control and Prevention guidelines for the use of vancomycin

at a large tertiary care children’s hospital. Journal of Pediatrics, 137, 694-700.

Lincoln, A.E., Casell, S.V., Almquist, J.L., Dunn, R. E., Norris, J. R., & Hinton, R.Y.

(2011). Trends in concussion incidence in high school sports. The American

Journal of Sports Medicine, 39(5), 958-963.

Lo, S.W., Chair, S.Y., & Lee, F.K. (2014). Factors associated with health-promoting

behavior of people with or at high risk of metabolic syndrome: based on the

Health Belief Model. Applied Nursing Research. Advance Online Publication.

doi: 10.1016/j.apnr.2014.11.001.

Lytle, L.A., & Achterberg, C.L. (1995). Changing the diet of America’s children: what

works and why? Journal of Nutritional Education, 27, 250-260.

Mackenzie, J.A., & McMillan. T.M. (2005). Knowledge of post-concussional

syndrome in naı¨ve lay-people, general practitioners and people with minor

traumatic brain injury. British Journal of Clinical Psychology, 44, 417-424.

Makdissi, M. (2009). Is the simple versus complex classification of concussion a valid

and useful differentiation? British Journal of Sports Medicine, 43, i23-i27.

Makdissi, M., Darby, D., Maruff, P., Ugoni, A., Brukner, P., & McCrory, P.R. (2010).

Natural history of concussion in sport markers of severity and implications for

management. The American Journal of Sports Medicine, 38(3), 464-471.

196

Makowsky, M.J., Guirguis, L.M., Hughes, C.A., Sadowski, C.A., & Yuksel, N. (2013).

Factors influencing pharmacists’ adoption of prescribing: qualitative application

of the diffusion of innovations theory. Implementation Science, 8, 109-120.

Mantano, D. E., & Phillips, W. R. (1995). Cancer screening by primary care physicians:

a comparison of rates obtained from physician self-report, patient survey, and

chart audit. American Journal of Public Health, 85, 795-800.

Marar, M., McIlvain, N.M., Fields, S.K., & Comstock, R.D. (2012). Epidemiology of

concussions among United States high school athletes in 20 sports. American

Journal of Sports Medicine, 40(4), 747-755.

Maroon, J.C., & Bost, J. (2011). Concussion management at the NFL, college, high

school, and youth sports levels. Clinical Neurosurgery, 58, 51-56.

Marteau, T.M., & Johnston, M. (1990). Health professionals: A source of variance in

health outcomes. Psychology & Health, 5, 47–58.

Mathur, V., Dwivedi, S., Hassan, M.A., & Misra, R.P. (2011). Knowledge, attitude, and

practices about biomedical waste management among healthcare personnel: a

cross-sectional study. Indian Journal of Community Medicine, 36(2), 143-5.

Maylone, M.M., Ranieri, L., Griffin, M.T., McNulty, R., & Fitzpatrick, J.J. (2011).

Collaboration and autonomy: perceptions among nurse practitioners. Journal of

the American Academy of Nurse Practitioners 23(1), 51–57.

Mazerolle, S.M., Scruggs, I.C., Casa, D.J., Burton, L.J., McDermott, B.P., Armstrong,

L.E., Maresh, C.M. (2010). Current knowledge, attitudes, and practices of

certified athletic trainers regarding recognition and treatment of exertional heat

stroke. Journal of Athletic Training, 45(2), 170-80.

197

McCrea, M., Hammeke, T., Olsen, G., Leo, P., Guskiewicz, K. (2004). Unreported

concussion in high school football players: implications for prevention. Clinical

Journal of Sport Medicine, 14(1), 13-7.

McCrory, P. (2001). Does second impact syndrome exist? Clin J Sport Med., 11(3),

144-9.

McCrory, P., Meeuwisse, W., Johnston, K., Dvorak, J., Aubry, M., Molloy, M., & Cantu,

R. (2009). Consensus statement on concussion in sport: the 3rd international

conference on concussion in sport held in Zurich, November 2008. Journal of

Athletic Training, 44 (4), 434–48.

McCrory, P., Meeuwisse, W.H., Aubry, M., Cantu, B., Dvorak, J., Echemendia, R.J.,

…Turner, M. (2013). Consensus statement on concussion in sport: the 4th

International Conference on Concussion in Sport held in Zurich, November 2012.

British Journal of Sports Medicine, 47(5), 250-258. doi:10.1136/bjsports-2013-

092313

McFarland, E.G. (2004). Return to play. Clinical Journal of Sports Medicine, 23, xv-

xxiii.

McGraw, S.A., Sellers, D., Stone, E., Resincow, K.A., Kuester, S., Fridinger, F., &

Wechsler, H. (2000). Measuring implementation of school programs and policies

to promote healthy eating and physical activity among youth. Preventive

Medicine, 31, S86-97.

McKee, A.C., Cantus, R.C., Nowinski, C.J., Hedley-Whyte, E.T., Gavett, B.E., Budson,

A.E., Santini, V.E., Lee, H., Kubilus, C.A., & Stern, R.A. (2009). Chronic

traumatic encephalopathy in athletes: progressive tauopathy following repetitive

198

head injury. Journal of Neuropathology and Experimental Neurology, 68(7),

709-35.

McKinlay, A., Bishop, A., & McLellan, T. (2011). Public knowledge of ''concussion''

and the different terminology used to communicate about mild traumatic brain

injury (MTBI). Brain Injury, 25(7/8), 761-6.

McRee, A.L., Gilkey, M.B., & Dempsey, A.F. (2014). HPV vaccine hesitancy: findings

from a statewide survey of health care providers. Journal of Pediatric Health

Care, 28(6), 541-549.

Meehan, W.P., d’Hemecourt, P., & Comstock, R.D. (2010). High school concussions in

the 2008-2009 academic year: mechanism, symptoms, and management. The

American Journal of Sports Medicine, 38(12), 2405–9.

Meehan, W.P., d’Hemecourt, P., Collins, C.L., & Comstock, R.D. (2011). Assessment

and management of sport-related concussions in United States high schools. The

American Journal of Sports Medicine, 39(11), 2304-10.

Milio ,N. (1998). Priorities and strategies for promoting community-based prevention

policies. Journal of Public Health Management & Practice, 4(3).

Morgan, O., Kuramoto, F., Emmet, W., Stange, J.L., & Nobunaga, E. (2014). The

impact of the Affordable Care Act on behavioral health care for individuals from

racial and ethnic communities. Journal of Social Work in Disability &

Rehabilitation, 13(1/2), 139-61.

Naftel, K .G., Yust, E. M., Nichols, M. H., King, W. D., & Davis. D. (2014). Knowledge

and management of sports concussions among coaches and certified athletic

trainers in Alabama. Southern Medical Journal, 107(7), 418-23.

199

National Athletic Trainers’ Association (2015). Terminology. Retrieved from

http://www.nata.org/athletic-training/terminology

National Collegiate Athletic Association (2014). Concussion guidelines diagnosis and

management of sport-related concussion guidelines. Retrieved from

http://www.ncaa.org/health-and-safety/concussion-guidelines

Nationwide Children’s (2013). An Educator's Guide to Concussions in the Classroom

(2nd ed.). Retrieved from http://www.nationwidechildrens.org/concussions-in-

the-classroom

Newton, J.D., White, P.E., Ewing, M.T., Makdissi, M., Davis, G.A., Donaldson, A.,

Sullivan, S.J., Seward, H., Finch, C.F. (2014). Intention to use sport concussion

guidelines among community-level coaches and sports trainers. Journal of

Science and Medicine in Sport, 17(5), 469–473.

Ngo-Metzger, O., Sorkin, D., Billimek, J., Greenfield, S., & Kaplan, S. (2012). The

effects of financial pressures on adherence and glucose control among

racial/ethnically diverse patients with diabetes. Journal of General Internal

Medicine, 27(4), 432-7.

Noble, J.M., & Hesdorffer, D.C. (2013). Sport-related concussions: a review of

epidemiology, challenges in diagnosis, and potential risk factors.

Neuropsychological Review, 23, 273–84.

Nørgaard, B., Ammentorp, J., Ohm Kyvik, K., Kofoed, P. (2012). Communication

skills training increases self-efficacy of health care professionals. Journal of

Continuing Education in the Health Professions, 32(2), 90–97.

200

Notebaert, A.J., & Guskiewicz, K.M. (2005). Current trends in athletic training practice

for concussion assessment and management. Journal of Athletic Training, 40,

320-5.

Nujum, Z.T., Remadevi, S., Nirmala, C., Rajmohanan, K., Indu, P.S., & Nair, S.M.

(2012). Factors determining noncompliance to mass drug administration for

lymphatic filariasis elimination. Tropical Parasitology, 2(2), 109-115.

Omalu, B., Bailes, J., Hammers, J.L., & Fitzsimmons, R.P. (2010). Chronic traumatic

encephalopathy, suicides and parasuicides in professional American athletes: the

role of the forensic pathologist. American Journal of Forensic Medicine &

Pathology, 31(2), 130-2.

Osbourne, B. (2001). Principles of liability for athletic trainers: Managing sport-related

concussion. Journal of Athletic Training, 36(3), 316–21.

Oyeyemi, A.Y., Oyeyemi, B.O., & Bello, I.S. (2007). Physicians and AIDS care: does

knowledge influence their attitude and comfort in rendering care? African Journal

of Health Sciences, 14(1-2), 37-43.

Pallant, J. (2010). SPSS survival manual: A step by step guide to data analysis using the

SPSS program (4th ed.). New York, NY: Open University Press.

Patel, D.R., Shivdasani, V., & Baker, R.J. (2005). Management of sport-related

concussion in young athletes. Journal of Sports Medicine, 35(8), 671-84.

Pennington, B. (2013). A new way to care for young brains. The New York Times.

Retrieved from http://www.nytimes.com/2013/05/06/sports/concussion-fears-

lead-to-growth-in-specialized-clinics-for-young-

athletes.html?pagewanted=all&_r=0

201

Perez-Rodrigo, C., Klepp, K., Yngve, A., Sjostrom, M., Stockley, L., & Aranceta, J.

(2001). The school setting: an opportunity for the implementation of dietary

guidelines. Public Health Nutrition, 4(2B), 717-24.

Pitney, W.A., Mazerolle, S.M., & Pagnotta, K.D. (2011). Work-family conflict among

athletic trainers in the secondary school setting. Journal of Athletic Training,

46(2), 185-93.

Potosky, A.L., Han, P.K., Rowland, J., Klabunde, C.N., Smith, T., Aziz, N., Earle, C.,

Avanian, J.Z., Ganz, P.A., & Stefanek, M. (2011). Differences between primary care

physicians’ and oncologists’ knowledge, attitudes and practices regarding the care of

cancer survivors. Journal of General Internal Medicine, 26(12), 1403-1410.

Presseau, J., Johnston, M., Francis, J.J., Hrisos, S., Stamp, E., Steen, N., Hawthorne, G.,

Grimshaw, J.M., Elovainio, M., Hunter, M., & Eccles, M.P. (2014). Theory-based

predictors of multiple clinician behaviors in the management of diabetes. Journal

of Behavioral Medicine, 37(4), 607–620.

Rager, K.B. (2005). Self-care and the qualitative researcher: when collecting data can

break your heart. Educational Researcher, 34(4), 23-27.

Reiner, Z., Sonicki, Z., & Tedeschi-Reiner, E. (2010). Physicians’ perception,

knowledge and awareness of cardiovascular risk factors and adherence to

prevention guidelines: the PERCRO-DOC survey. Atherosclerosis, 213(2), 598-

603.

Rigby, J., Vela, L., & Housman, J. (2013). Understanding athletic trainers’ beliefs

toward a multifaceted sport-related concussion approach: application of the

Theory of Planned Behavior. Journal of Athletic Training, 48(5), 636-644.

202

Ritchie, J., & Lewis, J. (2003). Qualitative Research Practice. Thousand Oaks, CA:

Sage Publications.

Rogers, E.M. (2003). Diffusion of Innovations (5th ed.). New York: Free Press.

Rosenbaum, A. M., & Arnett, P. A. (2010). The development of a survey to examine

knowledge about and attitudes toward concussion in high-school students.

Journal of Clinical and Experimental Neuropsychology, 32(1), 44-55.

Rosenbaum, A.M. (2007). An examination of the knowledge about and attitudes toward

concussion in high school athletes, coaches, and athletic trainers. (Doctoral

dissertation). Retrieved from ProQuest Dissertations and Theses. (Accession

Order No. 3299046).

Rosenstock, I. M., Strecher, V. J., & Becker, M. H. (1988). Social learning theory and

the health belief model. Health Education & Behavior, 15(2), 175.

Ruiz-Moral, R., Rodriguez, P., Perula de Torres, A., de la Torre, J. (2006). Physician–

patient communication: A study on the observed behaviours of specialty

physicians and the ways their patients perceive them. Patient Education and

Counseling, 64, 242–248.

Sabin, J.A., Nosek, B.A., Greenwald, A.G., & Rivara, F.P. (2009). Physicians’ implicit

and explicit attitudes about race by md race, ethnicity, and gender. Journal of

Health Care for the Poor and Underserved, 20(3), 896–913.

Sady, M.D., Vaughan, C.G., & Gioia, G.A. (2011). School and the concussed youth:

recommendations for concussion education and management. Physical Medicine

and Rehabilitation Clinics of North America, 22(4), 701-719.

203

Saunders, G. H., Dann, S.M., Griest, S.E., & Frederick, M.T. (2014). Development and

evaluation of a questionnaire to assess knowledge, attitudes, and behaviors

towards hearing loss prevention. International Journal of Audiology, 53(4), 209–

218.

Schneider, K.J., Iverson, G.L., Emery, C.A., McCrory, P., Herring, S.A., & Meeuwisse,

W.H. (2013). The effects of rest and treatment following sport-related

concussion: a systematic review of the literature. British Journal of Sports

Medicine, 47, 304-307.

Shirreffs, A., Lee, D.P., Henry, J., Golden, M.R., & Stekler, J.D. (2012). Understanding

barriers to routine HIV screening: knowledge, attitudes, and practices of

healthcare providers in King County, Washington. PLOS One, 7(9), 1-6.

Signoretti, S. Lazzarino G., Tavazzi, B., & Vagnozzi, R. (2011). The pathophysiology

of concussion. American Academy of Physical Medicine and Rehabilitation,

3(S359-68).

Slobounov, S., Bazarian, J., Bigler, E., Cantu, R., Hallett, M., Harbaugh, R., Hovda, D.,

Mayer, A.R., Nuwer, M.R., Kou, Z., Lazzarino, G., Papa, L., & Vagnozzi, R.

(2013). Sports-related concussion: ongoing debate. British Journal of Sports

Medicine, 0, 1-2.

Spector, P.E. (2006). Method variance in organizational research. Organizational

Research Methods, 9(2), 221-232.

Spinos, P., Sakellaropoulos, G., Georgiopoulos, M., Stavridi, K., Apostolopoulou, K.,

Ellul, J., & Constantoyannis, C. (2010). Postconcussion syndrome after mild

204

traumatic brain injury in Western Greece. The Journal of Trauma., 69(4), 789-

794.

Sullivan, S.J., Bourne, L., Choie, S., Eastwood, B., Isbister, S., McCrory, P., & Gray, A.

(2009). Understanding of sport concussion by the parents of young rugby

players: a pilot study. Clinical Journal of Sports Medicine, 19(3), 228-30.

Sullivan, S.J., Schneiders, A.G., Cheang, C., Kitto, E., Lee, H., Redhead, J., Ward, S.,

Ahmed, O., & McCrory, P.R. (2012). ‘What’s happening?’ A content analysis of

concussion-related traffic on Twitter. British Journal of Sports Medicine, 46,

258-263.

Sunami, K., Nakamura, T., Ozawa, Y., Kubota, M., Namba, H., & Yamaura, A. (1989).

Hypermetabolic state following experimental head injury. Neurosurgical Review,

12(suppl 1), 400-411.

Texas State Athletic Trainers’ Association. (2015). H.B. No. 2038. Retrieved from

http://www.tsata.com/wp-content/uploads/2013/12/HB-2038.pdf

The Kaiser Family Foundation. (2002). National survey of physicians part 1: doctors on

disparities in medical care. Washington, DC: The Kaiser Family Foundation.

Retrieved from http://www.kff.org/minorityhealth/20020321a-index.cfm

United States Department of Labor (2012). Bureau of Labor Statistics – Occupational

Outlook Handbook. Athletic trainers. Retrieved from

http://www.bls.gov/ooh/healthcare/athletic-trainers.htm

United States Department of Labor (2014). Bureau of Labor Statistics – Occupational

Outlook Handbook. Retrieved from http://www.bls.gov/ooh/healthcare/athletic-

trainers-and-exercise-physiologists.htm

205

University Interscholastic League. (2014). UIL alignment. Retrieved from

http://www.uiltexas.org/alignments/category/align-football

Visser, F., Hiddink, G., Koelen, M., van Binsbergen, J., Tobi, H., & van Woerkum, C.

(2008). Longitudinal changes in GPs’ task perceptions, self-efficacy, barriers and

practices of nutrition education and treatment of overwight. Family Practice,

i105-i112.

Weber, M., & Edwards, M.G. (2012). Sport concussion knowledge in the UK general

public. Archives of Clinical Neuropsychology, 27(3), 355-361.

Weistart, J.C., Lowell, C.M. (1979). The Law of Sports. Indianapolis, IN: Bobbs-

Merrill Co.

Wells, E.M., Goodkin, H.P., & Griesbach, G.S. (2015). Challenges in determining the

role of rest and exercise in the management of mild traumatic brain injury.

Journal of Child Neurology, 1-7.

Wheat, M.E., Kunitz, G., & Fisher, J. (1990). Cancer screening in women: A study of

house staff behavior. American Journal of Preventive Medicine, 6, 130-136.

Wickner, A. (2013). Concussion laws by state. Education Week. Retrieved from

http://www.edweek.org/ew/section/infographics/37concussion_map.html

Willer, B., Johnson, W. E., Rempel, R. G., & Linn, R. (1993). A note concerning

misconceptions of the general public about brain injury. Archives of Clinical

Neuropsychology, 8(5), 461-465.

Williams, R.M., Welch, C.E., Weber, M.L., Parsons, J.T., & Valovich McLeod, T.C.

(2014). Athletic trainers’ management practices and referral patterns for

206

adolescent athletes after sport-related concussion. Sports Health: A

Multidisciplinary Approach, 6(5), 434-439.

Yard, E.E., & Comstock, D. (2009). Compliance with return to play guidelines

following concussion in US high school athletes, 2005-2008. Brain Injury,

23(11), 888-98.

Yates, R.R. (1999). New intervention strategies for reducing antibiotic resistance.

Chest, 115, S24-S27.

Yoshino, A., Hovda, D.A., Kawamata, T., Katayama, Y., & Becker, D.P. (1991).

Dynamic changes in local cerebral glucose utilization following cerebral

concussion in rats: evidence of a hyper- and subsequent hypometabolic state.

Brain Research, 561(1), 106-119.

Zemper, E.D. (1994). Analysis of cerebral concussion frequency with the most

commonly used models of football helmets. Journal of Athletic Training, 29(1),

44-50.

Zonfrillo, M.R., Master, C.L., Grady, M.F., Winston, F.K., Callahan, J.M., & Arbogast,

K.B. (2012). Pediatric providers’ self-reported knowledge, practices, and

attitudes about concussion. Pediatrics, 130(6), 1120-1125.

207