Concussion, a type of mild traumatic brain injury (TBI) induced by biomechanical forces, often results in the temporary impairment of neurological function.1 An estimated 1.1 million to 1.9 million sports- and recreational-related concussions occur in US children 18 years or younger each year.2 Concussions may present with a wide array of signs and symptoms including impairments in cognitive, behavioral, physical, emotional, or sleep health.1,3,4 An untreated or improperly managed concussion can lead to intensified symptoms, prolonged recovery, as well as subsequent and more severe injury.5–8 Evidence also suggests that concussion can lead to long-term health consequences such as decreased cognitive function, increased rates of depression, and dementia.7,9
Given the morbidity associated with concussion, a national conversation has commenced regarding what can be done to increase concussion awareness and reduce the prevalence and severity of this injury, especially among young athletes. One approach to combat this public health issue is the passage of youth sports concussion laws. In 2009, Washington State enacted the nation's first statewide law regarding concussion safety (ie, the Lystedt law).10,11 Between 2009 and 2014, all US states and Washington, District of Columbia, followed suit and enacted some variation of the Lystedt law. The goal of these laws is to increase awareness about concussion among young athletes, parents, and coaches; improve recognition and management of concussion; and ultimately reduce the incidence and potentially severe consequences of concussion.11,12 Although specific concussion law provisions vary by state, the vast majority of laws include the following 3 tenets: (1) immediate removal from play or practice after an actual or suspected concussion; (2) medical clearance from a licensed health professional in order for an athlete to return to play (RTP); and (3) concussion education for parents, young athletes, and/or coaches.13
Despite minimal variation in the core tenets of concussion laws across states, these laws allow for a substantial degree of interpretation and discretion at the school level, often resulting in inconsistencies in the implementation of the 3 core tenets.14,15 There is a dearth of studies on the school-level implementation of these laws,16 including whether and how schools have been able to implement these laws to their fullest extent. However, none of these studies evaluated law implementation by US high schools using a nationally representative sample. Early research reveals significant differences in the content and quality of school concussion policies and the strategies utilized to implement concussion laws across schools; such differences may have a direct impact on the effectiveness of these laws.15–17 Furthermore, despite the documented importance of law compliance,18–20 no study to date has assessed school written concussion policy compliance with prescriptive state mandates, nor the relationship between policy compliance and school-level implementation. The current study therefore aimed to (1) analyze the degree of school written concussion policy compliance with the respective state law and (2) examine the relationships between researcher-rated concussion policy compliance and school-level implementation of the concussion law as reported by school officials. In this study, compliance is defined as the degree to which a written school concussion policy reflects the prescriptive elements of the respective state law whereas school-level implementation is defined as the degree to which schools take action(s) to implement their respective state law. We hypothesized that there would be a positive correlation between researcher-rated concussion policy compliance and school-reported level of law implementation. Examining whether school written concussion policies comply with state prescriptive mandates and how concussion policy compliance is related to the implementation of state concussion law requirements within schools could help school officials improve their school written concussion policies and implement strategies that facilitate the successful implementation of state concussion laws within schools.
This study assessed school written concussion policy compliance with and school-reported implementation of the respective state concussion law using policy content analysis and interviews with school officials (ie, athletic trainers (ATs) and athletic directors (ADs)). An invitation to participate in this study, a description of the study, and contact information for the research team were sent to all high schools active in High School Reporting Information Online (RIO) during the 2014-2015 (n = 240) and 2015-2016 (n = 203) academic years through the High School RIO listserv.21 Interested school officials (1 per school) who were involved in the development and implementation of their school's written concussion policy were asked to contact our research team to schedule and complete a telephone interview. The first 71 school officials (64 ATs and 7 ADs) were enrolled and completed a semistructured telephone interview between April and October 2015. Following completion of the interviews, all participating school officials were requested to provide an electronic copy of their school's written concussion policy. A more detailed description of the study and recruitment process has been published elsewhere.15,17 The institutional review board of the authors' primary institution approved this study.
Interviews with school officials
Semistructured telephone interviews were conducted with school officials (ie, ATs and ADs) to explore school-level implementation of the core tenets of state concussion laws. Each interview was structured into 6 parts: (1) demographics; (2) concussion policy: general; (3) concussion policy: education; (4) concussion policy: removal from play; (5) concussion policy: RTP; and (6) concussion policy: liability. All interviews were conducted by the same researcher and lasted 30 to 40 minutes. The interviewer, who had extensive experience in qualitative methods, was trained on the study protocol and telephone interviewing procedures. Interviews were audio recorded with the consent of the interviewees and transcribed verbatim after each interview.
The interview guide, described in Coxe et al,15 explores the implementation procedures of the 3 core tenets of state concussion laws by participating high schools. For each tenet, participants were first asked whether the tenet was included in their school's written concussion policy (ie, “Does your school have a policy that requires a student-athlete with a suspected concussion be removed from play?”). For tenets receiving “yes” responses, participants ranked their school's level of implementation of each of the core tenets and their associated requirement(s) on a Likert scale ranging from “very poor” (1) to “very well” (5) (ie, “When the policy requiring mandatory concussion training for coaches was first officially implemented at your school, how well was it put into practice?”). The respondents were then asked to report the percentage of time their school enforces each of the core tenets and associated requirement(s) on a scale ranging from 0 to 100 (ie, “Since the policy requiring mandatory concussion training for coaches was first officially implemented, what percentage of time was it followed?”).
Policy content analysis
A policy content analysis was conducted to determine the degree of compliance of the school's written concussion policy with the respective state law (School Written Policy Compliance). We used a high school concussion policy content analysis codebook developed based on public health law research methods,22 existing literature on concussion laws,9,12,23,24 and methodology for policy content analysis (described in Coxe et al15).25,26 Two trained research staff members independently coded the content of the 71 high schools' written concussion policies. For each tenet, the written school concussion policy language specificity (ie, policy description, enforcement, and implementation steps) was analyzed and coded into one of 3 categories based on the policy's compliance with the respective state law's prescriptive mandates specified in the Youth Sports Traumatic Brain Injury Laws Codebook22: weaker than the respective state's prescriptive mandates (eg, absent in the school policy but present in the state law), equal to the respective state's prescriptive mandates (eg, present or absent in both the school policy and the state law), or stronger than the respective state's prescriptive mandates (eg, present in the school policy but absent in the state law).15 We further collapsed the coding into 2 categories for analysis: (1) weaker than the respective state's prescriptive mandates and (2) equal to or stronger than the respective state's prescriptive mandates.
Descriptive analyses were conducted on participating high schools' demographics, school written concussion policy compliance, and school-level implementation of the respective state concussion laws. Fisher's exact tests were conducted to examine the relationship between school written concussion policy compliance and school-level law implementation. All analyses were conducted using SPSS version 25.0 (IBM Corporation, Armonk, New York). An α level of .05 was set a priori as the threshold for statistical significance in all analyses.
High school demographic and policy information
Seventy-one high schools from 26 states and Washington, District of Columbia, participated in this study. Most were public schools (91.5%) with a student enrollment of 1000 or more (54.9%). All 71 schools employed at least 1 certified AT, with about one-third employing more than 1 AT (n = 24; 33.8%). The majority of school written concussion policies (57.7%) went into effect before January 1, 2012. Athletic trainers were involved in the development of the majority of policies (76.1%), whereas ADs participated in the development of more than one-third of policies (n = 25; 35.2%). Most school written concussion policies (63.4%) only applied to interscholastic sports. The majority of policies (n = 60; 84.5%) had not been revised or updated since their initial development (data not tabled).
Researcher-rated school written concussion policy compliance relative to their state concussion law
Seven (9.9%) of the 71 high schools' written concussion policies did not include specific language complying with the respective state law requirement that an athlete must be removed immediately from play when a concussion is suspected. All schools' policies (n = 71; 100.0%) complied with the state-mandated provision that a parent/guardian be notified of a suspected concussion (Table 1). One policy (1.4%) did not comply with the minimum 24-hour waiting period requirement before an athlete could RTP. Two policies (2.8%) did not comply with the requirement that athletes must be cleared by a health professional prior to RTP, whereas one-fourth of policies (n = 18; 25.4%) did not comply with the requirement that medical clearance be provided by a health professional trained in concussion management. Approximately one-fourth (n = 17; 23.9%) of policies did not comply with the state law requirement that coaches receive concussion training (n = 19; 26.8%) or that a concussion information sheet be distributed to parents or student-athletes (n = 20; 28.2%) (Table 1).
School-reported implementation of the concussion law by tenet
All 71 participants reported that their school's concussion policy included the removal-from-play tenet. The majority of schools (91.5%) implemented the removal-from-play tenet well or very well, with more than three-fourths of schools (n = 57) reporting that implementation of this tenet was followed more than 90.0% of the time (Table 2). All participants reported that the school's AT(s) was responsible for removing athletes from play when a concussion was suspected (Figure, panel A). Sixty-four participants (90.1%) reported that their school required parents/guardians be notified about their child's suspected or diagnosed concussion. Of these 64 schools, 87.5% (n = 56) reported that their school implemented this requirement well or very well (Table 2). Most schools (93.8%) designated the school's AT as the person responsible for notifying the student-athlete's parent/guardian concerning a suspected or diagnosed concussion (Figure, panel B). The most common way to notify parents was by phone (96.9%), followed by an in-person conversation (59.4%), and/or an e-mail (14.1%) (data not tabled).
All 71 participants reported that their school required a minimum 24-hour waiting period before athletes could RTP following a concussion (Table 2). Most (n = 66; 93.0%) indicated that their school implemented this law tenet well or very well. All 71 participants reported that the RTP tenet at their school was implemented most of the time (range, 80%-100%; mean = 98.9, standard deviation = 3.6). Seventy participants (98.6%) reported that their school required that student-athletes be cleared by a certified health professional (eg, physician, nurse practitioner, AT) before returning to play, and of these, 98.6% reported that their school implemented this requirement well or very well (Table 2). More than one-third (n = 26; 36.6%) of the 71 schools required that health professionals providing RTP clearance be trained in concussion management, and of these, only 46.2% (12/26) reported that their school implemented this requirement well or very well. Sixty-six schools (93.0%) required clearance for RTP be in the form of a written document, with the majority of these schools (93.9%) reporting that they implemented this requirement well or very well (Table 2).
Concussion education tenet
Most schools (n = 67; 94.4%) required mandatory concussion training for coaches, of which, 80.6% (n = 54) reported that this requirement was implemented well or very well (Table 2). Of the 67 schools that mandated training for coaches, more than two-thirds (n = 46; 68.7%) required that the training be completed on an annual basis (data not tabled). Sixty-two schools (87.3%) required that a concussion information sheet be distributed to parents/guardians at least annually (Table 2), and more than one-fourth of these (27.4%) required the distribution of the information sheet to parents before each sport season (that their child played) (data not tabled). Of these 62 schools, 48 (77.4%) indicated that they implemented this requirement well or very well. The majority of schools with this requirement (88.7%) also required parents to sign the concussion information sheet. Most schools (n = 58; 81.7%) required that a concussion information sheet be distributed at least annually to student-athletes, of which, 86.2% (n = 50) implemented this requirement well or very well (Table 2). Of these 58 schools, 84.5% (n = 49) required the student-athlete to sign the information sheet. Only 42.3% of schools (n = 30) required the concussion information sheet be updated with new information on concussion prevention and management recommendations (Table 2). Of these 30 schools, 70.0% (n = 21) reported that this requirement was implemented well or very well.
Relationship between researcher-rated school concussion policy compliance and school-reported law implementation within schools
We observed several discrepancies between researcher-rated (assessed via the policy content analysis) and school-reported (assessed via interviews with school officials) concussion policy elements. For example, all 71 participants reported that their school's concussion policy included the policy element “Removal from play when a concussion is suspected,” whereas only 90.1% of written school concussion policies included specific language mandating removal from play when a concussion is suspected. Fisher's exact tests were also conducted to examine the relationships between researcher-rated school concussion policy compliance and school-reported concussion law implementation within schools. No significant relationships were observed (Table 3).
This study documented the degree of school written concussion policy compliance with the respective state concussion law and assessed the relationship between policy compliance and school-level implementation of these laws as reported by school officials. We found that most written school concussion policies complied with their respective state law. The majority of survey participants reported that their school implemented the state law requirements and associated practices well or very well. However, participants revealed that more resource-intensive policy requirements and/or requirements outside of the school's control, such as the requirements that student-athletes be cleared by a health professional trained in concussion management, were not implemented as well as other requirements. The results of this study suggest that compliance with prescriptive state mandates at the school level is a critical step in achieving intended outcomes of state concussion laws. However, school policy compliance alone is not sufficient for achieving targeted outcomes. Schools need to have the resources and capacity as well as effective implementation strategies to carry out concussion law requirements. Future research should identify implementation challenges common across schools as well as develop and evaluate strategies that promote wide-scale adoption, implementation, and enforcement of concussion law requirements at the school level.
We observed high compliance of school policies with their respective state law's removal-from-play and RTP requirements. We found that the majority of schools, even schools with policies that did not meet state law standards, reported that they implemented their state law requirements well or extremely well. These findings are very encouraging, but not surprising, because all the schools in our sample employed at least 1 AT. Athletic trainers often play an important role in the management of concussion, including responding to concussion when it occurs in student-athletes and supervising concussed student-athletes throughout the RTP process.27,28 Additional research is needed to examine compliance with and enforcement of state concussion laws among schools without an AT in order to determine whether these schools have sufficient resources for successful implementation. Future studies should also examine the implementation of state concussion laws within middle schools and recreational sports leagues.
While most schools complied with their state law's removal-from-play and RTP requirements, compliance with the concussion education tenet requirements was less common. Specifically, approximately one-fourth of school policies did not comply with the requirement that coaches receive concussion training or that a concussion information sheet be distributed to parents or student-athletes. Schools also reported that the education requirements were not implemented as well as the other law requirements. These findings are consistent with previous research12,17 and suggest that law requirements that are more resource-intensive (ie, requiring financial resources, staff support, or other school resources) are more challenging to implement than those that are less resource-intensive. Previous studies found that despite concussion educational materials being provided to schools, many schools do not have the capacity to implement comprehensive concussion education for coaches, athletes, and parents.12,16 It is possible that state laws may not include specific language or clear guidelines on how to implement the concussion education requirements, which may influence the interpretation and implementation of these requirements at the school level. These results call for more specific guidance or resources to implement these requirements when states mandate concussion education for coaches, parents, and/or student-athletes.
Consistent with prior studies,16 we found that law requirements outside of the school's control (ie, those that relied on individuals outside of the school's authority) were not implemented as well as law requirements within the school's control. For instance, we found that only a relatively small number of schools (n = 26; 36.6%) mandated that medical clearance be obtained from a health professional trained in concussion management; less than half of these 26 schools reported that they implemented this requirement well or extremely well. This finding is concerning because student-athletes may be seeking care from health care providers who are not properly trained or prepared to treat concussion. As others have noted,15,16 schools cannot directly implement these requirements (ie, schools cannot force student-athletes to seek care with specific providers), making the implementation of these requirements challenging. Barriers to the school-level implementation of these law requirements need to be identified and addressed to facilitate successful implementation of concussion laws.
Previous research20 in other areas suggests that school policies that exceed state law standards are correlated with higher levels of law implementation. This study, however, did not find statistical significance in such relationships. This may reflect the fact that most school policies examined in this study complied with their respective state law requirements or be the result of a “ceiling effect” as most schools reported that they implemented the law requirements well or very well. It is also possible that the school policy content did not reflect schools' actual law implementation practices at the time of study completion, given that most schools (n = 60; 84.5%) had not updated their written concussion policies since their initial development. Our results call for more research to better understand how school written concussion policy compliance with prescriptive state mandates may support high levels of implementation and enforcement of concussion laws by high schools. Such research may have important implications for the development and implementation of strong, comprehensive school policies aimed to increase concussion awareness among student-athletes, parents, and coaches; improve concussion management; and ultimately reduce the prevalence and potentially severe consequences of concussion among student-athletes.
This study had several limitations. First, despite drawing from a national sample, this sample was relatively small, consisted of schools from only 26 states and Washington, District of Columbia, and all schools employed at least 1 AT. Therefore, these results may not be generalizable to all US high schools or high schools without an AT. Participating schools may be different from nonparticipating schools, given their efforts and engagement in High School RIO, a national injury surveillance system. For example, participating schools may be more interested in injury prevention and concussion management, may have policies that are more compliant with or exceed state law standards, and may be more likely to implement these laws than their counterparts. Nonetheless, lessons learned from these schools may be valuable for the development of effective strategies that facilitate the implementation of state law requirements into practice at the school level. Second, we did not observe implementation of these policies directly but relied on participant self-report. Reports on the degree of school-level implementation of law requirements may have been biased by a social desirability response tendency of school officials; thus, our results may be overestimated. Third, we did not examine how the level of compliance with these laws affected rates of reported concussion. Future studies should link policy data with injury data to further our understanding of how law implementation may affect rates of reported concussion among high school athletes. It is also important to acknowledge that at the time of data collection many of the school policies examined in this study had not been revised or updated since their initial development, whereas more than one-third of state concussion laws had been revised at least once since their enactment at the time of data collection. As such, the school policies examined may not have reflected their state's concussion law at the time of data collection.
To our knowledge, this is the first comprehensive study to evaluate the implementation of state concussion laws at the school level. Our results indicated that the majority of school written concussion policies comply with the respective state law. Study participants reported that schools implemented the core tenets of the respective state law well or extremely well, though participants noted that law requirements that are more resource-intensive and outside of the school's control are more challenging to implement. We did not identify a relationship between researcher-rated compliance of the school written concussion policy with prescriptive state mandates and self-reported school-level law implementation; additional research is warranted. Further research should also be conducted to identify facilitators and barriers to the implementation of state concussion laws at the school level.
Implications for Policy & Practice
- While most schools complied with and implemented their respective state law's removal-from-play and RTP requirements well, compliance with and implementation of the concussion education requirements were less common. Policy makers should take these findings into consideration when revising and updating state concussion laws.
- Our findings suggest that specific guidance and implementation resources are vital to the successful implementation of state concussion law requirements, especially concussion education requirements, at the school level.
- Policy compliance is a key step in successful implementation of state concussion law requirements within schools. Additional efforts are needed to identify implementation challenges common across schools and develop effective strategies to address these challenges.
- Lessons learned from this study may facilitate the implementation and enforcement of state concussion law requirements into practice at all US high schools, including those without an AT.
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