Abstract
Concerns over the short- and long-term health implications of concussions has led to a surge in concussion education materials, resources, and modalities to educate youth athletes as a first line of defense in injury prevention. In this paper, we argue that this over-emphasis on concussion education–and a reliance on static, sensationalized, and culturally disconnected messaging–fails to consider the sociocultural implications of concussion education and the subsequent uptake and impact of this information by/on youth athletes. To do so, we present research involving semi-structured interviews with youth athletes in Ontario, Canada (N = 28; aged 13-18-years-old) focused on understanding experiences with concussion knowledge and education. Through our analysis, we highlight three important domains related to athletes’ experiences with concussion education concerning (1) sufficient education, (2) scare tactics in education efforts, and (3) equity, access, and responsibility. By problematizing education as an effective mode of injury prevention, we draw attention to a gap within current sport-related concussion literature concerning knowledge uptake, education, and behaviour with the social and cultural realities of concussion experiences.
Keywords
Introduction
The concern surrounding sport-related concussions (SRCs) continues to gain attention both within and beyond the sport community and is recognized as a growing public health concern. Funding and resources allocated to the concussion ‘crisis’ (Malcolm, 2018) through both municipal, secondary and federal government agencies speak to the issue’s prominence at local, national and international levels. Youth athletes have been identified as a population that may experience more complexity surrounding concussion recovery (Howell et al., 2020), risk of recurrent concussion (van Ierssel et al., 2021), and reporting behaviours (Ferdinand Pennock et al., 2023). In Canada, approximately one in nine high school athletes sustain a concussion through sports and recreation (Black et al., 2021). In response to these concerning trends, researchers have sought to address shortcomings specific to youth concussion, including developing injury recognition tools (e.g., the Sport Concussion Assessment Tool 6 (SCAT6); Echemendia et al., 2023), evaluating knowledge sources (see Mallory et al., 2020), and establishing consistent management approaches (Collins et al., 2014; Rivara et al., 2014). Taken together, the concerns surrounding youth athlete health and efforts to ensure that athletes have access to updated, accurate information has resulted in the proliferation of concussion education materials as a means of injury prevention. Though, as we highlight in this paper, stressing the importance of education does not adequately account for the difficulty of ensuring knowledge uptake surrounding what is an invisible and complex injury. In response to the increased emphasis on concussion education as a means of injury prevention, the purpose of this paper is to examine the effectiveness of current concussion education approaches, including the subsequent uptake and impact of this information by/on youth athletes in a Canadian sport context. Specifically, we address two objectives related to youth athletes’ concussion education. In part A, we interrogate the framing and shortcomings of education as a mode of prevention; throughout the section, we review relevant literature and define and justify (mis)education as a useful analytical tool in health-related disciplines. Subsequently, in part B, we build on this foundation by presenting findings of primary research conducted in Ontario, Canada, highlighting youth athletes’ experiences with education related to concussion prevention.
Part A: Education as a Mode of Prevention
The prominence of sport’s concussion issue has coincided with an increased emphasis on various forms of prevention. Similar to prevention frameworks seen in the broader public health literature concerning injury or health behaviours, concussion prevention is typically structured into primary, secondary, and tertiary efforts. Primary prevention is concerned with strategies to prevent injury occurrence, secondary prevention addresses early detection and injury management, whereas tertiary prevention focuses on minimizing long-term complications and reoccurrence (Black et al., 2018; Kerr et al., 2018). Although calls have been made for risk reduction to be targeted at primary prevention strategies such as rule changes (e.g., Emery et al., 2006), Kroshus and Chrisman (2019) argue that education as a means of secondary prevention remains a focal point of concussion policies in the United States. Notably, we have seen a shift in messaging away from promoting education as a primary means of prevention among prominent concussion groups and/or organizations (e.g., the Concussion in Sport Group (CISG), Parachute Canada, etc.). For instance, CISG shifted from championing education as a mode of prevention (fifth consensus statement) to advocating for more robust prevention avenues like rule and/or policy changes (sixth consensus statement) (Patricios et al., 2023). Despite high-level progress like this, such changes have yet to be implemented in practical and widely accessible ways across youth sport in Canada and the United States. Indeed, there continues to be a tension where education represents the most frequently relied upon method of responding to the concussion issue for both governments and sport organizations despite calls among researchers for more emphasis on primary modes of prevention in the form of rule changes or culture reform (see Malcolm, 2018).
We contend that when prevention efforts over-emphasize education as the dominant mode of prevention in this manner, several noteworthy issues occur which may, in fact, hinder overarching prevention efforts. First, the over-reliance on education as a mode of prevention has resulted in a knowledge landscape that is simply overflowing with information—scientific, scholarly, popular, and otherwise—and, in some cases, lacks accuracy (Mallory et al., 2020). To describe the impacts of this knowledge and information reality, we have coined the phrase (mis)education. Importantly, misinformation and related terms (e.g., disinformation) have been defined inconsistently throughout public health literature and, as a result, lack clarity and an ability to operationalize (see El Mikati et al., 2023). Additionally, in reviewing misinformation-related literature, the realities we were observing within the context of concussion education could not be reasonably understood using existing conceptualizations. Whereas misinformation does not necessarily focus on behaviour change, (mis)education operates from the perspective that the purpose of educational initiatives is often directly tied to promoting behavior change. To address these shortcomings, we define (mis)education as an outcome of an over-reliance on education as a mode of prevention, where the real-world impact of a given educational approach is unknown, ineffective, or based on inaccurate information. Within the context of concussion education then, the framing of (mis)education allows for a critical analysis of the true impact of current approaches on youth athletes and those that support them, including specific behaviours related to reporting (or underreporting) injury, concussion management, and risk-related decision making.
Notably, the proliferation of online resources, as well as people’s tendency to rely on online information as an accessible way to stay informed, has created conditions which may ultimately foster concussion (mis)education (Tonsaker et al., 2014). As Mallory and colleagues (2020) suggest, while “[o]nline concussion resources have the potential to provide the end user with current concussion guidelines and information including concussion prevention, identification and management,” the quality, accuracy, and reliability of the information available online remains “largely unknown” (p. 171). Indeed, in their recent review of online concussion resources for youth, the authors note that 59% of key Canadian stakeholder sites did not contain or link to research-informed concussion resources. This “alarming” percentage highlights a significant shortcoming concerning online educational approaches to date, where youth athletes themselves may be equipped with potentially inaccurate, out-of-date information (Mallory et al., 2020, p. 171). The results of concussion (mis)education in this manner may then contribute to the underreporting of injuries or injury mismanagement among other issues (Ferdinand Pennock et al., 2023).
The second major implication of an over-reliance on education as the dominant mode of injury prevention revolves around the role of neoliberal health environments and their influence on understandings and perceptions of risk. Importantly, neoliberal approaches to health suggest that the individual actor is ultimately responsible for risk decisions involving their own health and well-being by emphasizing autonomy over collective influence (Peacock et al., 2014). In this context, individuals can come to uphold intense and often insidious thoughts about the role of personal responsibility in poor health, injury, or death for both themselves and others (Peacock et al., 2014; see also Sweet, 2018). Conceptualizations of risk then emphasize informed decision-making to avoid harmful or negative outcomes. As a result, secondary prevention in the form of education becomes the favoured approach for those seeking to manage, mitigate, or shift responsibility of different risk circumstances. In a real-world example of this dynamic, the Stop Concussions Foundation – an international organization “designed to educate players, administrators, physicians, coaches and officials on the cause, effects and consequences of concussions and neurotrauma injuries” – promotes their work using the hashtag #ChangeTheMindSetNotTheGame. While only seven words in length, this phrase captures the essence of neoliberal risk in several noteworthy ways. First, by shifting responsibility to the individual and placing specific emphasis on education, Stop Concussions discourages any conversations regarding cultural realities within sport and leisure that have been shown to be major contributing factors to the current concussion issue (e.g., Bridel et al., 2020; Malcolm, 2018; Ventresca & MacDonald, 2020). In other words, for Stop Concussions, the concussion crisis is an individual problem, not a sport problem. Secondly, the messaging produces a defacto assumption that any policy or rule changes that may make sport safer are simply not worth exploring. Again, if the responsibility for risk management is on the individual (the mindset) and critique of sport itself is actively discouraged (not the game), then discussions surrounding any policy or rule changes are set to begin on the back foot. In this instance, the growing body of research conducted by social scientists on the social, cultural, and historical factors of concussion is ignored, and, more ironically, primary modes of prevention (e.g., rule changes) that have been successfully instituted at the highest level of sport (e.g., the NHL’s rule 48, banning hits to the head) are disregarded entirely.
Closely connected to perceptions of risk, the third and final implication of an over-reliance on concussion education as the dominant mode of injury prevention centres the question of who is ultimately responsible for injury, including within concussion-related legislation. One of the most significant examples of this dynamic is Rowan’s Law (Bill 193, Rowan’s Law – Concussion Safety, 2018) in the province of Ontario, Canada. Rowan’s Law was drafted in response to the 2013 death of Ontario teenage rugby player Rowan Stringer following two concussions in short succession. The legislation mandates that schools and sport organizations across Ontario have established return-to-school and return-to-play concussion protocols and increases emphasis on concussion awareness and education resources. As McCradden and Cusimano (2019) highlight, however, the law stops short of mandating medical clearance before return-to-school or play. While this stipulation potentially limits the burden on parents/guardians in terms of the logistics and practicality of accessing a medical professional (Frémont et al., 2015), it also decidedly shifts the burden of responsibility away from medical expertise and onto the individual’s knowledge (and, thus, education) concerning injury prevention. Indeed, as McCradden and Cusimano (2019) suggest, “proper concussion management will require all persons involved in sport to take it upon themselves to prioritize brain health and act to protect those who are vulnerable” (p. 167). While Rowan’s Law takes important steps forward in equalizing approaches to concussion management across the province, its impact is still reliant on uptake by not only sport organizations, school boards, and other governing bodies, but also individual decision-makers like parents, coaches, and athletes themselves. Importantly, volunteers in Canada play a key role in the delivery of sport programming at all levels of competition (Canadian Fitness and Lifestyle Research Institute, 2022); thus, concussion legislation places undue burden on unpaid and over-tasked individuals, requiring them to navigate the world of concussion education to support prevention efforts.
Taken together, these implications highlight how concussion (mis)education creates circumstances that may hinder knowledge uptake and the appropriate management of concussions by those involved. These impacts may be felt more acutely by youth athletes who have demonstrated incongruencies between the SRC knowledge and subsequent behaviours (Pennock et al., 2024). Therefore, when youth athletes report experiencing frustration, feelings of isolation, and a loss of identity throughout injury management (Bridel et al., 2020), we must situate those experiences in the reality of SRC education where social and cultural influences relating to injury are too-often ignored (e.g., race, socioeconomic status, access to education, access to treatment, etc.). To that end, in part B, we introduce primary research with youth athletes to explore their experiences with approaches to concussion education and its impact on knowledge uptake and behaviours within youth sport.
Part B: Youth athletes’ experiences with concussion education
Methodology
Procedure, Materials, and Participants
Participants were recruited as part of two larger projects approved by the institutional research ethics board. Both projects, conducted within the Greater Toronto Area, focused on understanding concussion knowledge, education, experiences, and behaviours within youth sport populations.
The first and second author conducted semi-structured interviews with eligible participants. Interview guides focused on athletes’ experiences in sport as well as relationships with peers, family members and coaches. Participants were asked to share their knowledge and any formal education regarding concussion, including sources of knowledge, and their understanding of concussion protocols and procedures within their sport organization. Participants were provided with pseudonyms and details were changed if needed to protect the anonymity of the individuals. Interviews ranged from 1-2 hours in length and were transcribed verbatim prior to analysis.
A total of 28 (19 girls and 9 boys) youth athletes participated across both projects. Ages spanned from 13-18 years-old; there was also a range in level of play, primary sport (inclusive of contact and collision sports, performative/aesthetic sports, and individual sports), and previous experience with a concussive injury.
Analysis
Data was analyzed using reflexive thematic analysis (RTA), which as Braun and Clarke (2019) describe, emphasizes the researchers’ intentional role in the knowledge production process. Importantly, the authors note that “different approaches to TA […] reflect different philosophical assumptions about, and orientations to, qualitative research” (p. 592). Stemming from the critical interpretivist paradigm that underpins the collective work, we sought an analysis process that would allow us to centre researcher subjectivity while engaging in “organic and recursive” thematic generation (Braun & Clarke, 2019, p. 593). For our purposes then, RTA allowed us to balance our subjective experiences collecting the data with the philosophical and paradigmatic tensions we feel/have felt in relation to the vast majority of concussion-related work (i,e., work that centres biomedical, post/positivist orientations to research; see Malcolm, 2018 for a detailed description of this). As a result, engaging with the data meant reorienting ourselves to the assumptions we carry about the importance of embracing critical, social knowledges in the context of the concussion issue.
To accomplish this, we applied the idea of critical friends – or “a process of critical dialogue between people, with researchers giving voice to their interpretations in relation to other people who listen and offer critical feedback” (Smith & McGannon, 2018, p. 113) – both before and during the analysis process. In engaging in this fashion, we sought to hold space for the tensions that arose between our approach and the stories relayed to us through interacting with participants. In doing so, we recognized a need to approach the data with a shared understanding of the importance of participant stories and their influence on the way in which we would ultimately analyze and present the analysis. The presented themes then, as Bruan and Clarke (2019) describe, “are creative and interpretive stories about the data, produced at the intersection of the researcher’s theoretical assumptions, their analytic resources and skill, and the data themselves” (p. 594). Practically speaking, this meant a constant re-engagement with collection tools, interview notes, reviewed literature, and the experiences which enabled our involvement in this work throughout our critical friend meetings. The analysis process involved collaboratively and recursively interpreting the stories within the data and our own assumptions which had informed our approach to the work. Through this process grounded in reflexivity, we sought to construct themes that moved beyond the descriptive – or, as Braun and Clarke (2019) describe it, an overreliance on domain summary themes – and are instead developed and discussed in relation to their meaning and the substantive knowledge they provide with respect to concussion knowledge and education.
Results and Discussion
By problematizing education as the principal mode of injury prevention, we have highlighted a gap within current SRC literature concerning the intersection of education, knowledge, behaviour, and personal experience with the social and cultural realities of concussion in youth sport. Specifically, we highlight three important themes related to athletes’ experiences concerning (1) sufficient education, (2) scare tactics in education efforts, and (3) equity, access, and responsibility within education. In keeping with our RTA approach, each theme is presented and discussed in relation to the context of participant stories, relevant literature, and our own assumptions as concussion scholars interested in the social dynamics of the concussion crisis. The combined results and discussion section is structured with the intention of achieving a better balance in theme description and critical interpretation of the data, which was fundamental to the overarching methodological approach.
Athletes Are Sufficiently Educated
The first theme highlights how athletes perceive, take up, and navigate concussion education and the subsequent impact on their concussion knowledge and behaviour. Concussion education as sufficient refers to the process by which athletes are exposed to educational outputs in a manner that meet the minimum standard required by sport organizations and that seem to satisfy perceptions that athletes are equipped to make informed concussion decisions. However, we argue this sufficiency is merely a prop to upholding concussion education as an effective form of injury prevention, in that this level of education is not sufficient to inform change regarding concussion prevention measures. Put more simply, more knowledge and information shared through educational approaches does not necessarily equate to meaningful behaviour change with respect to injury reporting decisions or style of play (see Chrisman et al., 2013; Cusimano et al., 2017; Pennock et al., 2024).
Athletes as sufficiently educated was expressed by athletes’ concussion knowledge recall. Youth athletes in the study indicated they had been exposed to concussion education through their sport and reflected at least a perfunctory level of concussion knowledge. Most participants were able to identify various signs and symptoms with relative ease; as Amara rhymed off, “oh like, seeing stars, [I’ve] heard of people throwing up… dizziness, nausea.” Participants were also able to explain their sport organization’s concussion management protocols, most commonly focusing on who to report a suspected concussion to and the requisite rest and return-to-play period following a diagnosed concussion. For instance, Kerry was able to detail the stepwise procedure for athletes returning to artistic swimming, starting with flutter kicks and progressing to underwater movements. As a modality of improving athletes’ knowledge concerning signs and symptoms, many education platforms and materials could be considered effective. However, previous studies suggest youth athletes demonstrate sufficient concussion knowledge, yet their behaviours are inconsistent with what would be considered best practice (Chrisman et al., 2013; Cusimano et al., 2017; Pennock et al., 2024). Therefore, whether current levels and/or approaches to education translate to effective concussion prevention or management solutions is less clear. In this regard, when asked if he felt like going through multiple levels of online concussion training prior to the season was effective in changing athlete behaviour, Hugh bluntly responded: “No. Like, I feel like they [athletes] just have to do it to say they did it”. This reflects the reality that being sufficiently educated can also simply mean completing the required modules in order to participate with no guarantee of meaningful engagement with the presented information and, therefore, no incentive to change behaviours.
The way concussion information is disseminated and promoted by the sport organization also highlights the ways in which education is taken up, and at times, resisted by youth athletes. A key consideration for the uptake of education lies in the delivery mode. Some of the most popular methods of dissemination–including handouts, brochures, infographics and videos– present concussion information in the form of static knowledge delivery. These fixed forms of information, whether print or digital, often do not require or facilitate engagement between the participants and the material. Hugh describes his experience receiving written concussion materials: Do I read them all? Yeah, I read some of them. But if it’s on, like the one on concussion, I think I know a good amount, like sure I’ll read it, skim read it. It’s not like I’m reading it, studying it, really absorbing it. And I don’t, the rugby coaches aren’t going to have a test on that stuff kind of thing.
Participants found that concussion materials varied in terms of their perceived quality, where athletes expressed limited interest or questioned the information source. Sonya, a dancer, noted they had to watch a concussion documentary, but that “everything we mainly watch is football-based”. Russ described his experience taking a pre-season concussion module: “you have to read the slides and then answer the questionnaire at the end of each [module]. And [I’ve] done it so many times now that I don’t even read the slides, like I know the answers”. In addition to issues around quality, athletes pointed to a lack of engagement around concussion materials, with communication often occurring at a superficial level from the sport organization. As Alex states, “I’ve never really even talked to anyone about it. This is like my first time actually talking to someone about concussions. When the team talks to you about it, they’re like yeah, if your head hurts come to us, we want to help and all this, but it’s like, I’ve never even talked about concussions”. This dissemination gap, fueled by a lack of engagement from the organization and the mode of information delivery, can often leave athletes with only a minimum level of knowledge (see Caron, 2019). Thus, while static knowledge delivery offers many strengths, including low cost, efficiency, and lower levels of upkeep and engagement, we argue that many of the most relied on modalities serve to only fulfill the sufficiency requirement of concussion education and may have little impact on behaviour change.
Findings indicate concussion education is also deemed sufficient in terms of its one-size-fits-all approach to concussion management, as it often fails to consider the social relationships and cultural realities that exist within athletes’ sport environments. For some, playing in an important game is the cumulation of months or years of dedication; as Sandrine recalls, “I was like, I think I have a concussion, and then I was like no, no, I can’t, I have a big tournament this weekend, so I just let it go. And then it just disappeared”. Hilary suggested that “… context matters, you know? Like, what’s the score in the game? What are the stakes?“. As it currently stands, most education tools are not designed to acknowledge athletes facing these types of decisions. Promoting athletes to report injuries immediately without recognizing the existing sporting culture that celebrates (and often demands) sport above all else (e.g., an athlete’s health and wellbeing: see Atkinson, 2019) represents a significant contradiction in our current approach to facilitating concussion-related behaviour change.
Thus, despite being sufficiently educated in the eyes of sport organizations, and indeed, governing bodies via legislation, findings reveal little emphasis on either concussion-related behaviour change, prevention strategies, or situated risk practices. Knowledge sufficiency does not adequately address the sport culture that pervades much of youth sport and emphasizes playing through pain or toughing it out. Indeed, embedded social and cultural risk practices within sport demonstrate youth athletes’ reluctance to report potential injury despite knowledge of signs and symptoms (Pennock et al., 2024). This propensity to engage in risk practices indicates that current concussion education approaches may rely too heavily on sign and symptom knowledge as a prop, rather than addressing the ongoing cultural and situational practices with sport organizations that continuously undercut messages concerning athlete safety. Knowledge sufficiency, then, upholds education as the dominant mode of injury prevention by downplaying the importance of the broader risk culture that influences athletes’ decision-making processes concerning concussion reporting and management. Athletes themselves are then framed as informed actors solely responsible for navigating, managing, or mitigating risk within diverse sport environments. Overall, education as sufficient emphasizes the limitations of many current educational approaches to concussion education, whereby the prevention of injury is limited or ignored, and the inability to address behaviour change towards the desired concussion management behaviours of reporting and removal.
‘Scare the Hell Out of These Kids'
Participants also expressed support for and an interest in fear-based education methods. Notably, adolescents are typically subjected to risk-related communication or education that spans across multiple facets, settings, and mediums in their lives (Society for Adolescent Health and Medicine, 2017). Historically, these efforts have revolved around prominent issues like drinking and driving, smoking, or a lack of physical activity. The role of communication or education in these contexts then is to grab the attention of the intended audience in a manner which evokes an emotional response in the form of fear or shock which, theoretically, should result in meaningful behaviour change (see Strively & Field-Springer, 2021).
Support for fear-based tactics within concussion education among participants in this research aligned with this reality; participants argued that athletes must be convinced of the severity of concussions and the long-term implications of injury to change behaviour and improve health outcomes. Understandably, associating concussion as generally very bad makes categorizing and interpreting it far easier. As Stephanie alluded to when asked about some of the SRC examples that she provided, “I just think seeing those really really bad cases helps to clear things up for me… it just makes understanding concussions and the risks and all that a little bit easier”. Similarly, for Holden, there’s a disconnect between the way in which concussions are discussed when compared to other injuries or health conditions. Specifically, he highlighted: I feel like the advertisement for concussion maybe has to be a lot more serious. Like when you look at smoking commercials, I think concussion commercials should be the same, if not worse. Because, again, it’s your brain. Your lungs, okay. But it’s your brain. So, you have to... make people scared of it.
Perhaps unsurprisingly given this reality, within their descriptions of effective education, several participants drew on worst-case scenario examples to ground their understanding. Stacy, a 14-year-old rugby player, described suffering a concussion as, “hitting your head like really really hard… like smashing the ground, getting kicked, or taking a knee… It’s always really really bad contact and, like, you get knocked out and stuff like that”. Similarly, Geraint suggested that it is the stories of athlete suicide, depression, and anxiety that really stick out for him: “Yeah, the stories of them [former professional athletes] committing suicide but keeping their brains intact so that they could be studied. That’s pretty meaningful, I think”. Responses like this highlight an underlying tension within concussion education work; that is, when advertised as a mode of injury prevention, efforts to improve concussion education’s effectiveness become ethically problematic and tied to notions of fear and risk. In such cases, other forms of concussion prevention efforts which seek to move beyond the reactive approach of most concussion education (e.g., a pre-game safety chat, social support networks in schools, etc.) are scrutinized for their inability to, as Charlotte described, “scare the hell out of these kids”. This then has a real, practical impact on how young athletes are exposed to fear-based communication within sporting environments. For instance, when ask if he worried about concussions in rugby, Michael described the way in which his coaches prepare his team before each game: Before every game, it’s... I don’t think this is the best way my coach put it, but imagine a message like, ‘expect yourself to go into that game and be hurt’. And it's not just him, like I've heard that from four different coaches now. Well, one of them, was more like ‘expect to go into a game and die’. But that's a little extreme.
Notably, within these reflections, the line between failing to report a concussive injury and life-altering long-term impacts is linear—mismanagement of concussions when you are young means long-term complications later in life. Whether or not this sentiment bears any truth was not important or considered in conversations with research participants, revealing important ethical questions about attempting to manipulate behaviour through fear, risk and/or shame. Indeed, the effectiveness and ethical implications of such approaches are not necessarily as intended. Scare-tactics, fear-appeal, and fear-inducing stigmatization have all been studied extensively with health-based behaviour change issues (e.g., Brookes & Harvey, 2015; Thompson et al., 2009). On smoking cessation, for instance, Thompson and colleagues (2009) assert that a more comprehensive approach to education “challenges simplistic understandings of risky behaviours and subjects, and significantly reworks how we respond to these risk positions” (p. 193). Similarly, Brookes and Harvey (2015) suggest that the use of scare-tactics in health promotion is “ethically problematic” and operationally ineffective (p. 76). As statements that ring true for educational approaches to concussion, we contend that we must reorient our priorities concerning promoting secondary prevention throughout concussion management.
For some participants in this research, the impact of fear-based approaches as potentially harmful was evident. For instance, for Luke, a 14-year-old rugby player, the use of such tactics within concussion education stands to leave a lasting impact: “I don’t know. That stuff makes you think. The anxiety and depression and that mental stuff… It just really scares the shit out of me to be honest”. Geraint reiterated Luke’s feelings, suggesting that the concussion education he has received – in combination with the sensationalization of the long-term implications of injury within the media – has made him rethink his involvement in collision sports all together: “I used to think I’d play rugby for, like, ever. But I just don’t know if I can justify that anymore, you know? The stuff [long-term implications of injury] really makes you think”. Given these findings, athletes’ support for the use of scare or fear-based education tactics must be situated within the context of the broader dialogue concerning SRCs within both mediated discourses and academic research. On the one hand, employing such strategies to educate young athletes about SRC and the risk of injury may be more detrimental than not in the pursuit of enhancing knowledge uptake and meaningful behaviour change. At the same time, it’s clear that fear, alarm, and panic are already large aspects of the circulating dialogue concerning concussions. Intentionally or not, education’s role in facilitating the centering of fear and risk must be critically examined, especially within the context of an injury that can cause feelings of social isolation and frustration (see Bridel et al., 2020). We argue that this context must be dealt with within more comprehensive approaches to education and alternative efforts concerning prevention as this work moves forward.
Bottom of the (Brain Injury) Heap: Concussion Access, Equity, and Responsibility
The third theme addresses concussion education as a point of interest concerning issues of access, equity, and the scope of responsibility for those involved in youth concussion management. Here, we define bottom of the (brain injury) heap as evidence for the inequitable access to concussion resources and the varied burden of responsibility in seeking materials out across populations. Throughout the research, some participants recognized the reality that access to education and/or care was dependent on their subjective circumstances. In this case, the words of two participants speak volumes to the potential disconnects within our current education and treatment approaches. First, from Geraint, who has attended private school his whole life: … I know that not many schools are as good as mine with concussion awareness and education, so I think that players in other situations will kind of go back before they’re ready. I think that with the schools that I’ve gone to and the programs that I’ve gone through, I’ve been really fortunate to get the kind of education about concussions that I needed; and, when I actually got one, I know the treatment I received was world-class. … I don’t know. When I got my concussion, I just went to the walk-in clinic and the doctor there told me to rest and sit in the dark if the light hurt my eyes. My mom asked the school if there were any resources available for me during my recovery, but they weren’t very helpful, so I just ended up skipping class.
The results of these dynamics once again reshape the question of who ultimately becomes responsible for injury prevention. In Bachynki’s (2019) historical analysis of helmet manufacturing, she highlights that the evolution of risk responsibility in sport has coalesced broader conceptualizations of personal health, suggesting that messaging surrounding preventing sport injuries has consistently reinscribed the burden on parents and athletes. Once one has “voluntarily chosen to assume the risks of the sport” (Bachynski, 2019, p. 41; see also Morrison, 2020), they alone are culpable for any negative outcomes. We argue that this line of neoliberal thinking has created the conditions in which concussion education can be reasonably accepted as the approach to injury prevention, while also deepening pre-existing inequities across diverse social locations. Indeed, when individual parents or athletes bear the responsibility for injury prevention, subjective experiences of access, management, and/or treatment vary greatly and may impact the care and attention one receives. Danielle described this reality in her reflections on the impact her parents’ perspective had had on her own knowledge uptake: Unless you have people, who, like my parents, are really nailing down the importance of telling someone about your concussion, or even a minor head injury, I think they would just think everything’s fine; and if their head hurts, they just have to push through it. You know? I think that’s kind of dangerous.
As Danielle implies, those parents or guardians who are able to be more involved/engaged in knowledge uptake may play a fundamental role in their child’s understanding of concussions; this then leads to important questions surrounding differences in one’s ability to navigate the world of concussion education – one which we have already identified as complex, inconsistent and unreliable – across populations (e.g., socioeconomic status, race, geographic location, etc.). Indeed, work by Wallace and colleagues (2022) highlights significant health inequities for Black athletes concerning access to concussion resources and/or concussion care when compared to white athletes. The authors suggest that race, in combination with other demographic factors, can “perpetuate disparities in care for SRCs” (p. 353). Importantly, other authors have reiterated these findings, suggesting that race and ethnicity play a significant role in the current framing of concussion and, thus, our collective response to it (see Kalman-Lamb & Silva, 2024; St Amant, 2024). Practical effects of this racial bias have been observed in processes related to baseline testing (Wallace et al., 2022) and concussion settlement pay-outs (Young et al., 2023). In the context of this manuscript, we contend that perceptions of who (i.e., which populations) is impacted by the concussion issue undoubtedly shape understandings of responsibility for injury; inequities in access to concussion resources or treatment must therefore be further examined through a critical, intersectional approach.
Moving beyond recognizing signs and symptoms invites opportunity to identify those who experience risk through sport in distinct and diverse ways; this then lends itself to engaging in important conversations surrounding the complexity of athlete identity and its intersection with injury and knowledge uptake (see Bridel et al., 2020). Ultimately, a holistic approach to concussion education creates space for more robust conversations about existing inequities. For instance, working with specific subsets of athlete populations (e.g., racialized athletes) to understand specific and subjective needs related to concussion education may help to ensure the information they receive is specific to their experience. Collectively, policy and legislation designed to support sport organizations and governing bodies in the development and implementation of comprehensive and population-specific approaches to the education they provide may help to facilitate space to discuss sport-specific issues. While such shifts may be perceived as counterintuitive within a neoliberal public health system that prioritizes individual responsibility and efficiency, we contend that they represent actionable, tangible steps for researchers and policy makers operating within the concussion space seeking to address the inequities that plague current approaches.
Concluding Thoughts
The findings presented above depict the complexity of the risk–knowledge intersection which forms the foundation of the concussion issue. Currently, dominant approaches to injury prevention which centre education shift the responsibility of navigating this complexity to the individual actor (e.g., parents/guardians, athletes, coaches, etc.) while, in some cases, actively discouraging discussions surrounding primary prevention methods (e.g., policy or rule changes). Across the three themes explored above, the research demonstrates the reality that more knowledge and information communicated through education is not an effective form of concussion injury prevention and/or behaviour change. Specifically, current approaches to education centre questions of sufficiency, which ultimately prioritize an athlete’s ability to simply list concussion signs and symptoms as effective education. Similarly, support for fear-based education throughout existing research reflects the sensationalization of injury that has dominated the public discourse surrounding concussion but fails to consider important ethical questions concerning influencing concussion behaviour change through an embrace of fear. Finally, inequities related to access, population-specific information, and concussion treatment point to current shortcomings of approaches to education and the subsequent disproportionate impact on specific populations (e.g., racialized athletes, athletes with disabilities, etc.). Taken together, the intersection of these themes reflects the reality of (mis)education, where an uncritical over-reliance on education as a mode of injury prevention carries far-reaching impacts on concussion research and work, including how education continues to develop. Importantly, the framing of (mis)education has allowed us to critically assess the current landscape of concussion knowledge and dissemination, shifting the lens of analysis from dominant neoliberal approaches to more subjective understandings of knowledge uptake and concussion-related behaviour. In doing so, we suggest (mis)education as an analytical public health tool may potentially be impactful across other prominent health-related issues. For instance, applying (mis)education to understanding so-called deviant behaviours in sport (see Hughes & Coakley, 1991) involving hyper-commitment and over-conformity to the sport ethic may be particularly insightful.
Given this, we call for a continued shift towards prioritizing primary prevention efforts, including rule and policy changes, which seek to address long-embedded normative values and behaviours in sport that center unsafe concussion management practices. This call for the championing of primary prevention must coincide with a critical reorientation to how we promote meaningful knowledge uptake and engagement through education efforts. Approaches to education must avoid employing blunt tools that simply list common signs and symptoms of injury and, instead, engage the multifaceted nature of concussive injuries within sport and recreation environments. For example, co-constructing knowledge with users may be a more promising avenue for enhancing concussion prevention. Mah and colleagues (2022) highlight the importance of “thinking otherwise” with young people and their experiences of concussion (p. 105); specifically, the authors suggest that young people themselves are experts of their own experience, meaning that they must be involved in the construction of concussion knowledge within clinical and research settings. We argue that approaches to concussion education must also recognize and engage with this subjective expertise. In circumstances where researchers have done so (e.g., Caron et al., 2019; Mah et al., 2022), the impacts of (mis)education have been effectively considered. Therefore, actionable work to address concussion (mis)education must continue to acknowledge and centre participatory and/or individuated approaches to knowledge production and uptake.
Importantly, other researchers have also begun to reshape concussion education through an embrace of more participant-oriented materials and methods. Examples include educational practices that are more dynamic and specifically designed to draw athletes in, such as pre-game concussion safety huddles (Kroshus et al., 2019). Others acknowledge the cultural realties of the sport by developing creative education materials that are based on athletes’ experiences (e.g., Lassman et al., 2022). Addressing the social relationship, work by Kita and colleagues (2020) centres the importance of peer support as a vital aspect of any intervention aimed at tackling the concussion issue. The work addresses the gap between clinical knowledge of symptoms and the need to consider the experiences of youth athletes struggling with concussions. Finally, considerations for intervention and resources for prevention must be equity-driven (Kerr et al., 2018; Wallace et al., 2022); any barriers to knowledge uptake across populations must be identified and addressed to ensure the impacts of concussion are not disproportionately felt by those with less access to resources. At a broader level, sport organizations and government agencies can address these barriers by ensuring that education approaches are grounded in theoretically- and ethically sound resources. In doing so, critical discussions can move beyond fear-based communication by addressing the wide-spread use of worst-case scenario examples through critical and contextual applications of participatory approaches discussed above.
With these contributions, among others, the framing of concussion education is beginning to shift beyond its long-standing role as a dominant mode of injury prevention. We suggest, however, that this evolution is primarily situated within research and has yet to be extended to practical and applied solutions across youth sport environments. Doing so must involve comprehensive advocacy approaches that engage sport organizations and those responsible for developing policy and legislation. Within these efforts, we contend that the experiences and subjective expertise of youth athletes themselves must be prioritized.
Supplemental Material
Supplemental Material - Risk, Responsibility, and Prevention in Injury Management: Implications of Concussion (mis)education on Youth Athlete Knowledge Uptake
Supplemental Material for Risk, Responsibility, and Prevention in Injury Management: Implications of Concussion (mis)education on Youth Athlete Knowledge Uptake by Kaleigh Pennock and Braeden McKenzie in Communication and Sport
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Social Sciences and Humanities Research Council of Canada.
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References
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