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For Research Question 1, both original study hypotheses concerning associations between coach knowledge and attitude and athlete knowledge and attitude at the school level (average of coaches at the school) were rejected. We hypothesized that there would be a positive relationship between these variables. No association was observed. Although at the

time of study origination, it seemed intuitive a relationship may exists, the way these

variables were examined, may have contributed to this lack of association. Coach influence was examined at the school level and not the team level. Many of the athletes in the current study participated in multiple sports leading to multiple coaches influencing these young athletes. As a result, it was difficult to assess which coach may primarily influence athlete characteristics. Therefore, the school level seemed the most appropriate level of analysis for the variables of knowledge and attitude. Future studies may need to ask questions to gain a better understanding of which coach or set of coaches an athlete most respects. In addition, as mentioned in the discussion for this aim, throughout the study period, it became evident that many coaches do not discuss concussion concepts with his/her athletes. Furthermore, this study occurred at a time when athletes and coaches were inundated by media and social attention to the problem of concussion, which may have also influenced these findings.

Research Question 2 encompassed a variety of factors both intrinsic and extrinsic to the athlete that may influence reporting with various outcomes relative to the original study hypotheses. Originally, context was not factored into these hypotheses, but throughout the study period more thought was given to how this may influence reporting and more specific reporting outcomes were investigated. We initially hypothesized that being female, higher athlete knowledge and attitude scores, higher coach knowledge and attitude scores, and access to a Certified Athletic Trainer (AT) would be positively associated with concussion reporting. Gender was found to be associated with reporting of events during games, practices, and participating while symptomatic during games. Contrary to our original hypothesis males were more likely to report during games. However, females were more likely to report during practices and less likely to participate during games while

symptomatic, which is supportive of our original hypotheses. The other 5 reporting outcome measures were not associated with gender.

In accordance with our original hypotheses, athlete knowledge score was positively associated with reporting during practices and for bell ringer only events. As discussed, this may be related to better knowledge allowing athletes to recognize bell ringers as needing to be reported. In addition, the majority of events during practices were bell ringer events. However, the other 6 reporting outcomes were not associated with athlete knowledge.

The findings concerning coach knowledge and attitude influence were perplexing upon first review. We observed an estimated decrease in reporting for people reporting 50% of bell ringer only events, game events, practice events, and concussion only events with increased coach knowledge, which are in contradiction to our original hypotheses. There are multiple plausible explanations for these findings. As mentioned earlier, coach influence was examined at the school level and may not be directly associated with when these athletes reported/did not report these events. Furthermore, athletes with more conservative coaches may be more likely to conceal possible concussive events for fear of being removed from play and more conservative management. In support of our hypotheses higher coach

knowledge scores were associated with decreased participation in both games and practices while symptomatic. This may seem contradictory to the previous findings. However, coaches with higher knowledge scores may have recognized the signs and symptoms of concussion in athletes and removed them from play. Perhaps these findings are more of a reflection of coach behavior than athlete reporting behavior. We did not assess coach behavior in this capacity in the current study. Therefore this is only speculation. Only 2 reporting variables were not associated with coach knowledge.

In support of the original study hypotheses, increased coach attitude was associated with increased reporting during games and decreased participation in both games and practices while symptomatic. Contrary to the original hypotheses increased coach attitude was associated with decreased reporting in practice and bell ringer only events. These findings may be associated with the fear of removal from activity. As mentioned, the coach variables were at the school level and not assessed for the sport in which the athletes recalled suffering the concussive event, as we did not collect this specific data. To truly understand the influence of coach knowledge and attitude on reporting, the knowledge and attitude of the coach(es) specific to the sport in which the concussive event(s) were experienced would need to be aligned with reporting of these same events. Although the current study may lend some idea to overall coach influence, the reason for some of these perplexing findings may be this lack of alignment between coaches and the concussive event. Future research should focus on reporting at the end of a specific season relative to the coaches of the sport in which the events occurred.

The significant findings concerning AT access were in direct contradiction to the original hypotheses, with individuals with no AT access reporting a greater proportion of game related events, and being less likely to participate in games and practices while symptomatic. The other 5 reporting variables were not associated with AT access. Many factors may have influenced these findings. To begin, AT access was determined by at the time of study the school having daily access to an AT. To truly understand the influence of access to an AT, knowing if at the time of “injury” the individuals had access to an AT would need to be known. Individuals without access may have also been more likely to report and less likely to participate symptomatic as a result of fewer “consequences” related

to reporting. As this study occurred at a time when policies were changing concerning return to play following concussions, many of the schools in our sample both in and outside of North Carolina have implemented policies not allowing athletes to return the same day. In addition, the current attention concerning concussion may have also played a role.

With the exception of indirect perceived behavioral control, the original study hypotheses for Research Question 3a-b were accepted as all 3 direct measures and 2 of the indirect measures (attitude and subjective norm) were found to be positively associated with intention to report. In addition, intention to report was associated with not participating in games and practices while symptomatic. The questions concerning participation with symptoms were more aligned with the questions concerning intention, which may be why these 2 variables were associated with intention and the other 6 reporting variables were not associated. Overall these findings related to the Theory of Reasoned Action and Planned Behavior emphasize the importance of a culture shift concerning the reporting problem among high school athletes.

Both study hypotheses concerning AT influence on coach and athlete knowledge and attitude were rejected with no associations observed. This finding may be the result of many different sources of concussion knowledge, previous experience, and the time in which these individuals had access to an AT. In addition, the current social and media attention to

concussion may influence knowledge and attitudes. Furthermore, as mentioned, only 2 of the ATs in the study sample conducted any type of concussion education session with athletes and coaches.

More extensive analyses were done than originally proposed to better understand the many aspects concerning reporting ranging from context to the spectrum (“bell ringer’ vs.

“concussion”) of events. Through this examination the variables of participating while symptomatic emerged as 2 of the most meaningful variables as they encompassed the behaviors of the entire sample, not just those 89 individuals who recalled experiencing a “concussive” event. Moreover, the discrepancies across these variables illustrate the many variables, people, and factors that may play a role in concussion reporting among high school athletes. There is not one simple solution to addressing concussion in this population. To better address these issues, multiple facets and people need to be involved.