Lack of concussion symptom knowledge impacts diagnosis in Black athletes

Black college athletes demonstrated less knowledge of concussions than white college athletes, despite NCAA requirements for concussion education among athletes, according to results from a cross-sectional study.

The results indicated a need for “equitable strategies” in the dissemination of concussion information to diverse populations, according to the researchers, who published the findings in The Journal of Head Trauma Rehabilitation and described care-seeking for concussions as “a complex clinical and behavioral issue.”

“Previous work indicates that upward of 50% to 80% of concussions may go unreported across various age groups of participation. Studies suggest factors associated with care-seeking decisions fit within the socioecological framework, which may indicate that influences exist at multiple levels (eg, intrapersonal, interpersonal, environment, policy) and also that interventions must be cognizant of such influences and their relationships with one another,” Jessica Wallace, PhD, MPH, LAT, ATC, and colleagues wrote. “Within this framework, the intrapersonal factor of the athlete’s concussion knowledge has been raised as an area of importance.”

Specifically, individuals may go without seeking care for a concussion because of uncertainty about whether or not the injury is a concussion and not feeling as though the injury is serious enough to report, according to Wallace and colleagues. Wallace is an assistant professor in the department of health science at the University of Alabama’s College of Human Environmental Sciences.

Wallace and colleagues conducted a cross-sectional study using a convenience sample of NCAA athletes from seven institutions in three geographic regions to examine racial differences between Black and white athletes in their knowledge of concussion symptoms and use of concussion information sources. Athletes completed questionnaires that examined personal and sports-related demographic information, knowledge of concussion symptoms and use of concussion information sources. The researchers analyzed the differences in outcome measures among Black vs. white athletes as well as the relationship between race and concussion symptom knowledge scores, accounting for sex, sports contact level, NCAA division, concussion history and sources of information about concussions.

The analysis included 768 collegiate athletes (82.6% white) who completed the questionnaire.

Wallace and colleagues found that Black athletes were more likely to have lower concussion symptom knowledge scores compared with white athletes (P < .001). A multivariable regression model that controlled for covariates maintained this finding (incidence rate ratio = 0.97; 95% CI, 0.94-0.997).

The researchers also found that white athletes were more likely to report school-based professionals (P < .001), online medical sources (P = .02) and the NCAA (P = .008) as sources of concussion information, while Black athletes were more likely to report referees (P = .03).

“Approximately 16% fewer Black athletes gained concussion knowledge from school-based professionals including a teacher, school nurse, or gym/health teacher than white athletes, and roughly 13% fewer Black athletes gained concussion knowledge from the NCAA than white athletes,” Wallace and colleagues wrote. “Despite NCAA mandates requiring concussion education for athletes, the differences in CSK and information seeking highlight the need for equitable strategies to disseminate concussion information to diverse populations.”

According to the researchers, the NCAA requires that all institutions enact concussion safety procedures to “better protect the health and safety of collegiate athletes,” indicating that all athletes — regardless of institution, sex, sport or race — should have access to, and receive, education about concussions. Their findings indicated that “varying levels of knowledge exist” between Black and white athletes.

Wallace and colleagues noted several limitations of their research, including the fact that the findings may not be generalizable to individuals or institutions who did not participate in the current study, as well as the fact that they had less information about other racial/ethnic groups, which impacted their ability “to make other ethnic or culturally justified comparisons.” Future studies that examine health literacy regarding concussions, including knowledge, symptom identification, attitudes and reporting behaviors, “would benefit from contextualizing targeted communities and the demographic makeup of athletes and families,” according to the researchers.

“Such racial differences observed in this study underline an unacceptable disparity worthy of attention and underscore the need to identify strategies to ensure equitable access to concussion education and prevention,” Wallace and colleagues wrote. “Moving forward, a conscious attempt is needed to redevelop concussion education initiatives as racially, culturally and linguistically inclusive, addressing the needs of all collegiate-athletes equally and equitably.”