United States Air Force Academy Cadets’ Perceived Costs of Concussion Disclosure

Abstract

Introduction Concussion is unique among sport-related injuries as effective clinical diagnosis and treatment often rely on symptom-report for clinician diagnosis and treatment. However, at-risk populations such as collegiate athletes and military academy cadets often have been shown to under-report concussions and symptoms, complicating diagnosis, treatment, and policy-based interventions. The purpose of this study was to explore factors influencing concussion reporting in United States Air Force Academy (USAFA) cadets. Materials and Methods Semi-structured interviews were conducted on 34 cadets (18 with concussion history; 16 without concussion history). This study was approved by the USAFA Institutional Review Board. Analysis included a five-cycle process of clarifying the topic at hand through an introduction, conducting a literature review, data collection and summarization, relating current findings to current literature, and making final interpretations. Data were summarized by creation of a codebook after reading five transcripts and identifying meaningful units. A four-person research team read and identified meaningful units individually, then met to discuss common meaningful units and codebook creation. Once the codebook was created, the lead researcher used the codebook to code all transcripts. Results Eight themes were generated from interview transcripts. This manuscript focuses on the perceived costs following a concussion theme and the following subthemes: perceived costs to physical fitness, military career aspirations, pilot qualifications, sport, reputation, academics, and lack of time. Conclusions Cadet interviews described a complex environment where concussions were often viewed as costly to future career ambitions and provided potential reasons for non-disclosure largely including disruption in daily life. Reduction in perceived and actual harms due to concussion disclosure will require not only improving clinical care, but also addressing barriers to self-disclosure. Additionally, research suggests the sooner one reports a concussion, the sooner they return to physical or military activity. Educational interventions should be designed to address the perceived costs identified from our study and educate cadets that while some costs may be reality, others may not. Secondly, it should also be stressed to cadets that the sooner one seeks medical attention following a concussion, the sooner they may return to activity. Messaging around these themes may decrease the costs associated with time removed from academics, athletics, or military activities therefore minimizing attempts at concussion self-management. Lastly, if efforts are made to improve the overall concussion disclosure stigma, cadets may increase seeking care after injury because their reputation may not be as impacted.

United States Air Force Academy Cadets' Unprompted Knowledge of Concussions and “Bell Ringers” or “Dings”: Perceived Differences and Similarities

“…Two scripts were developed for data collection by three concussion and qualitative researchers: one for cadets with a concussion history, one for cadets without a concussion history (Table 1). Interview scripts were designed with a phenomenological philosophical framework, 14 and began with two introductory questions, then specific questions relating to the topic, and then closing questions. 15 In study design phase, we anticipated individuals with a concussion history and those without concussion history may answer interview questions differently, specifically recalling a particular concussion event and their experience, however the two scripts were mostly similar.…”

“…We used a five-cycle process to analyze the transcripts as described by Anderson Anderson 16 , Wertz, et al 17 , and in Weber Rawlins, et al 14 . Cycles one and two include an initial view into the topic which are usually completed in an introduction and literature review.…”

“…Five transcripts from both interview scripts were randomly selected and read by a four-person research team. 14 The four-person research team then met to deliberate and create an initial codebook. During the initial meeting, the research team determined both interview scripts elicited similar response and thus may be analyzed together.…”

Progress and Future Directions of the NCAA-DoD Concussion Assessment, Research, and Education (CARE) Consortium and Mind Matters Challenge at the US Service Academies

“…Additional advances have been made toward understanding the culture of concussion disclosure at the USAFA and indicate that non-disclosure can develop in any population where disclosure is perceived as having undesirable consequences, such as missing practice or game time in athletes or negative career repercussions such as medical disqualification in future pilots ( 39 ). Furthermore, perceived costs to physical fitness, military career aspirations, pilot qualifications, sport, reputation, academics, and lack of time in the cadet schedule are emerging as themes as to why USAFA and USMA cadets may choose not to disclose a concussion ( 40 ). At USAFA, Mind Matters lessons have been integrated into concussion care and outreach and are annually assessed through school-wide surveys.…”

A social dilemma model of information self-disclosure, applied to the concussion domain

“…Likewise, athletes and non-athletes might conceal concussions because they perceive disclosure as being financially or occupationally harmful. 17,18 Employees, for example, might conceal concussions if they believe that disclosure will result in lost earnings. Disclosure also creates emotional outcomes depending on whether self-disclosure violates or supports potential disclosers' conceptions of their ideal selves.…”