Youth intentions to provide social support to a peer with a concussion

ABSTRACT

Objectives

1) To describe demographic factors, concussion knowledge, attitudes, subjective norms, self-efficacy and intentions to provide social support to a peer with a concussion and 2) to examine if demographic factors and concussion knowledge are associated with components of the Theory of Planned Behavior.

Methods

The survey was completed between October 2018 and February 2019 by 200 youth (M = 15.30 years, SD = 1.52). Questions were designed for athletes and non-athletes and inquired about various types of social support. Data analysis included descriptive statistics, Wilcoxon Rank Sum Tests and Spearman’s Rank-Order Correlation Coefficients.

Results

More favorable attitudes and intentions to provide social support were observed among females (W = 2576, p ≤ 0.001; W = 2411, p ≤ 0.001), older youth (rho = 0.32, p ≤ 0.001; rho = 0.41, p ≤ 0.001) and those with higher concussion knowledge (rho = 0.29, p ≤ 0.001; rho = 0.22; p ≤ 0.001). Participating in sports with a high-risk of concussion was associated with lower attitudes and intentions to provide social support (W = 6677; p ≤ 0.001; W = 6721; p ≤ 0.001). Self-reported concussion history or knowing someone with a concussion history was not significantly associated with social support intentions.

Conclusion

This study identified characteristics of youth who had positive intentions to provide social support. These findings identify individuals who may model providing social support to a peer, as well as opportunities for future concussion education.

KEYWORDS:

• concussion
• social support
• youth
• theory of planned behavior
• brain injury

Introduction

Concussion is an increasing public health concern. From 2003 to 2013, diagnosed cases of pediatric concussion increased by 4.4-fold in Ontario, Canada, with concussion rates highest among those aged 13–18 years old (1). Pediatric concussion is a particular concern, as the highest prevalence rates are among those 10–14 and 15–19 years old (2). High school-aged youth (referred to as youth) also take longer than adults (3) and younger children (aged 5–12 years) to recover from concussion (4) which can result in disruptions in academic (5), social and extracurricular activities (6). Most youth will recover from a concussion within 4 weeks, however about 30% of youth experience persistent concussion symptoms meaning it takes longer than 4 weeks to recover (4). Among youth, concussion can be caused by various mechanisms including falls, sports, motor vehicle collisions, injury at school or on the playground, and exposure to force (1).

Youth can experience a variety of symptoms after a concussion, including physical (e.g., headache), cognitive (e.g., difficulty remembering), emotional/behavioral (e.g., sadness and irritability) and sleep (e.g., sleep disturbances) (3). One suggestion for mitigating emotional and behavioral concussion symptoms is through the provision of social support (7–10). Social support is defined as sharing resources between two individuals to increase the recipient’s well-being (11). Key types of social support include emotional (i.e., providing reassurance or ensuring an individual feels cared about), tangible (i.e., direct aid or physical support) and informational (i.e., providing guidance or advice) support (12).

A study exploring youths’ experiences with social support found that many youth felt isolated from their peers and friends during concussion recovery due to recommendations for rest and persisting symptoms (9). These youth valued emotional support provided primarily by close friends and tangible support provided primarily by parents during their concussion recovery (9). This sentiment is reinforced by a study with young adult athletes, which found that individuals with a concussion primarily relied on family and friends for social support after a concussion (8). Despite the reliance on family and friends, compared to an orthopedic injury group, individuals with a concussion reported less satisfaction with the social support they received (8). Emerging evidence from current studies demonstrates the potential impact of social support on concussion recovery by enhancing quality of life, mitigating feelings of social isolation, and decreasing emotional and behavioral symptoms (8–10).

Existing concussion surveys used with youth populations primarily include questions about concussion knowledge and attitudes (13,14) and how these factors impact individuals’ intentions to report a concussion (15–17) or actual reporting of a concussion (13,17). Additionally, most surveys are focused on sport-related concussions and scenarios (13–17) despite the numerous mechanisms of sustaining a concussion and the fact that concussions occur in non-athlete populations. To date, there has been limited investigation into the relationship between concussion knowledge and attitudes on intended or actual concussion-related behaviors other than concussion reporting, including no such investigation specific to the behavior of providing social support to a peer with a concussion.

Within the concussion literature, the use of theories, models and frameworks has been suggested to inform the development of concussion education and the resulting instruments, surveys and evaluation methods (3,18). Past concussion studies have developed surveys using the Theory of Planned Behavior (TPB) to better understand concussion-related behavior (15–17,19). The TPB is a broad and generalizable theory (20) that helps to predict human behavior (21,22) using few variables (23). The TPB proposes that an individual’s intentions to perform a behavior are highly indicative of their likelihood to perform the behavior (21). These intentions to perform a behavior are informed by three factors: 1) attitudes – an individual’s perceived evaluation of the outcome from performing the behavior; 2) subjective norms – an individual’s perception of the social pressure to perform the behavior; and 3) perceived behavioral control – an individual’s perceived ability to perform the behavior (21). Ajzen (21) has also suggested that perceived behavioral control is similar to the construct of self-efficacy which has been used in a past concussion survey (19).

Based on previous concussion surveys developed using the TPB, the importance of social support after a concussion, and the lack of investigation specific to the behavior of providing social support to a peer with a concussion, a novel survey exploring youths’ intentions to provide social support to a peer with a concussion was developed. This survey was based on the TPB and designed for athletes and non-athletes. For this study, peer was a broad term used to describe individuals similar in age such as a friend, classmate or teammate. Therefore, the objectives of this study were to deliver the novel survey: 1) to describe demographic factors, concussion knowledge, attitudes, subjective norms, self-efficacy and intentions to provide social support to a peer with a concussion and 2) to examine if there is a relationship between demographic factors and concussion knowledge on youths’ attitudes, subjective norms, self-efficacy and intentions to provide social support to a peer with a concussion.

Methods

Survey development

A novel concussion survey based on TPB and focused on social support and concussion reporting was developed as part of a larger study. This study focused on the development of questions theorized as being relevant to the provision of social support, including demographic factors, concussion knowledge, attitudes, subjective norms, self-efficacy and social support intentions. For each construct of interest, existing concussion surveys were identified to generate an initial pool of questions (13,14,19). Existing knowledge questions were modified, and new questions were added to be written for youth and to include many ways of sustaining a concussion, various concussion symptoms, and scenarios within and outside of sports and athletics. For example, the knowledge question, ‘Concussions can sometimes lead to emotional disruptions’ (14) was modified to ‘Concussions can sometimes lead to sadness and difficulty sleeping’ to be more relevant and easily understood by youth. Additionally, language in some scenarios was modified from athlete or player to student or friend. There are no existing surveys related to intentions to provide social support to a peer with a concussion, and therefore, a novel survey exploring this concept was developed. Questions about providing social support to a peer with a concussion were developed to include scenarios about emotional, tangible and informational support. Finally, questions were modified based on consultation with individuals with pediatric concussion expertise or experience working with youth. These individuals consisted of clinicians, researchers, trainees, research staff, school staff and community members (see Appendix A for survey).

Cognitive interviewing

This study was approved by the Holland Bloorview Research Ethics Board (REB#18–792). To ensure that the questions were applicable to youth, cognitive interviews (24) were completed with five participants (all female participants) aged 14–18 years (M = 15.80 years, SD = 1.79 years). Youth were recruited using flyers distributed throughout the hospital and at a post-concussion education group. Youth were eligible to participate in cognitive interviews if they were: 1) between 12 and 19 years of age, 2) currently enrolled in high school (or attended high school within the past 2 months), 3) able to read and understand English and 4) able to provide informed consent. This eligibility criteria was selected to reflect individuals who would be completing the survey.

Cognitive interviews were completed to inquire about the context, difficulty and relevance of questions, as well as better understand how participants selected answers to questions. Cognitive interviews allow end users to provide verbal feedback about the survey with the goal of evaluating and updating questions (24). Cognitive interviews were completed using a combination of thinking-aloud and probing methods (24). The thinking-aloud method involves participants verbalizing their thoughts and actions as they complete the survey with minimal intervention from the interviewer, whereas the probing method involves more specific discussion, prompts and questions from the interviewer (24). Interviews from the sessions were audio recorded, transcribed verbatim and reviewed by two members of the research team. Feedback and responses were grouped by question and if a participant had difficulty answering or understanding a question or had feedback or suggestions on the wording it was updated prior to delivering the survey (25).

After cognitive interviewing, updates were made to the phrasing, wording and context of questions. For example, suggestions to increase the clarity and conciseness of questions were made, such as rephrasing ‘Do you consider yourself knowledgeable about concussions?’ to ‘Do you think you know a lot about concussions?’ and updating ‘collides with’ to ‘runs into.’ Updates made after cognitive interviewing resulted in a decrease in average readability score (Flesch-Kincaid Grade Level) of 0.16, with a final survey readability level of 5.35 indicating a reading level of approximately grade 5 (26,27).

Survey delivery

Survey

The survey was comprised of seven sections and 65 standard questions with an additional three tailored branching question.

Section 1 and 2: Participant details

Section 1 included questions about participant identification to create an anonymous identification code (e.g., ‘The third letter of your full first name’). Section 2 included eight standard and three tailored branching questions about participant demographics. These demographics included questions about grade, gender, age, sports participation, self-reported diagnosed concussion history, knowing someone with a concussion history, perceived concussion knowledge and prior concussion education at school.

Section 3: Concussion knowledge

Section 3 assessed concussion knowledge using 10 true-false questions (e.g., ‘A concussion can only occur if there is a direct hit to the head’) and knowledge of concussion symptoms using a checklist comprised 12 accurate (e.g., headache or difficulty remembering) and eight distractor symptoms (e.g., black eye or hair loss). The concussion knowledge section included questions about concussion identification (e.g., how a concussion occurs, and signs and symptoms) and concussion management (e.g., returning to school and sports after sustaining a concussion). Questions in this section inquired about concussion knowledge that would be relevant to self-identifying a concussion and relating to peers’ concussion experience. The true-false knowledge section also contained two attention check questions (i.e., ‘You cannot get an injury while playing sports’ and ‘Students in grade 3 and grade 12 are always the same age’) to ensure participants were answering honestly. For the true-false knowledge questions, 1 point was given for a correct response and 0 points for an incorrect response. One point was also given for each accurate symptom that was checked and distractor symptom left unchecked. The true-false questions were scored out of 10, and the checklist symptom question was scored out of 20 for a maximum concussion knowledge score of 30.

Sections 4 to 7: Social support

Sections 4 through 7 queried participants’ attitudes, subjective norms, self-efficacy and intentions related to providing social support to a peer with a concussion. Each statement was answered on a 4-point Likert scale from strongly disagree to strongly agree. Questions were scored from 1 to 4, with more favorable responses receiving a higher score. An example of a question about participant attitudes was ‘If my friend has a concussion I would tell them why it is important to be seen by a doctor’. Questions about subjective norms included a scenario and asked participants to answer about how their close friends and most students at their school would respond. An example of a question about self-efficacy asked, ‘If my friend has a concussion, I am confident in my ability to help them study for a test, even if I had my own studying to do’. Finally, an example of a question about intentions related to providing social support inquired about ‘If my friend has a concussion I would listen to them describe how they are feeling’. Attitudes were scored out of 48, subjective norms out of 16, self-efficacy out of 40 and intended behaviors out of 40 for a maximum social support score of 144 (see Table 1 for a breakdown of the number of questions per survey section). Internal consistency was calculated for each section. Internal consistency was adequate for attitudes (Cronbach α = 0.70) and subjective norms (Cronbach α = 0.79), and high for self-efficacy (Cronbach α = 0.92) and intentions to provide social support (Cronbach α = 0.80).

Table 1. Number of questions per survey section.

Survey Section	Number of Survey Questions
Section 1: Anonymous identification code	8
Section 2: Participant demographics	8 + 3
Section 3: Concussion knowledge	13
Section 4: Attitudes	12
Section 5: Subjective norms	4
Section 6: Self-efficacy	10
Section 7: Intentions to provide social support to a peer	10
Total	65 + 3

Participants

Youth were recruited using various methods including flyers, community message boards, partnered schools, social media and events. Participants were eligible for inclusion if they were: 1) between the ages of 12–19 years, 2) currently enrolled in high school (or attended high school within the past 2 months), 3) able to read and understand English and 4) able to provide informed consent.

Procedure

Participants completed the survey in-person or online via REDCap (28,29). Responses were anonymous. The survey included screening questions to ensure that participants met eligibility criteria and were interested in completing the survey. The survey took approximately 10 to 20 min to complete. Data collection took place between October 2018 and February 2019.

Data analysis

To be included in the analysis, participants had to answer more than 90% of all questions and answer both attention check questions correctly. Responses were grouped and scored by section including concussion knowledge and TPB questions related to social support. Based on the highest pediatric concussion risk as reported by Zemek et al. (4), sport participation was grouped into high (hockey, soccer, basketball and football) or low (all other sports) risk. Descriptive statistics were generated and relationships between variables were explored using Wilcoxon Rank Sum Tests and Spearman’s Rank-Order Correlation Coefficient. P-values were adjusted for the false discovery rate using the Benjamini–Hochberg correction (30). In order to be aligned with sample sizes of past concussion survey literature, between 150 and 300 participants were required for data analysis (13,19).

Results

The survey was opened or attempted 371 times. Across the 371 surveys, 63 surveys were excluded for not answering or passing the screening questions, 5 surveys were excluded as participants did not meet eligibility criteria and 13 participants did not answer the attention check questions correctly. All other surveys were excluded as sections of the survey were incomplete. A total of 200 surveys completed by youth were included in the analysis.

Participants ranged in age from 13 to 19 years with an average of 15.30 years (SD = 1.52 years). Participants included 99 males (49.5%) and 96 females (48.0%). Additionally, 58 participants (29.0%) had a self-reported concussion history and 167 (83.5%) knew someone with a concussion history. See Table 2 for additional demographic information.

Table 2. Participant demographic information (N = 200).

Demographic	Participants
Age, mean (SD)	15.30 (1.52)
Grade, N (%)
9	92 (46.00)
10	21 (10.50)
11	20 (10.00)
12	64 (32.00)
Other	3 (1.50)
Gender, N (%)
Male	99 (49.50)
Female	96 (48.00)
Prefer not to specify	2 (1.00)
Other	2 (1.00)
Did not respond	1 (0.50)
Age, N (%)
13	10 (5.00)
14	82 (41.00)
15	23 (11.50)
16	25 (12.50)
17	46 (23.00)
18	11 (5.50)
19	3 (1.50)
In the last 12 months, what organized sports (i.e. on a school team, or in a league or club) have you participated in(individually or on a team)? (check all that apply) N (%)
Ball Hockey	25 (12.50)
Baseball	25 (12.50)
Basketball*	54 (27.00)
Badminton	27 (13.50)
Boxing	4 (2.00)
Cheerleading	2 (1.00)
Cross Country Running	28 (14.00)
Cycling (Road)	8 (4.00)
Curling	4 (2.00)
Dance	18 (9.00)
Diving	3 (1.50)
Downhill Skiing	27 (13.50)
Equestrian	6 (3.00)
Field Hockey	7 (3.50)
Figure Skating	4 (2.00)
Football*	19 (9.50)
Golf	27 (13.50)
Gymnastics	3 (1.50)
Hockey*	53 (26.50)
Kickball	4 (2.00)
Lacrosse	7 (3.50)
Martial Arts (e.g. Karate, Tae Kwon Do, Judo etc.)	6 (3.00)
Mountain Biking	5 (2.50)
Nordic (Cross-Country) Skiing	0 (0.00)
Ringette	0 (0.00)
Roller Derby	0 (0.00)
Rowing	4 (2.00)
Rugby	18 (9.00)
Running	33 (16.50)
Snowboarding	15 (7.50)
Soccer*	41 (20.50)
Softball	19 (9.50)
Speed Skating	2 (1.00)
Spikeball	10 (5.00)
Swimming	43 (21.50)
Synchronized Swimming	4 (2.00)
Tennis	30 (15.00)
Track and Field	34 (17.00)
Ultimate Frisbee	18 (9.00)
Volleyball	27 (13.50)
Waterpolo	1 (0.50)
Weightlifting	11 (5.50)
Wrestling	2 (1.00)
I don’t play organized sports	23 (11.50)
I play sports recreationally	25 (12.50)
Other	11 (5.50)
Have you ever been diagnosed with a concussion? N (%)
Yes	58 (29.00)
No	127 (63.50)
Not sure	15 (7.50)
Prefer not to answer	0 (0.00)
If yes, how many? N (%)
1	26 (13.00)
2	18 (9.00)
3	8 (4.00)
4	0 (0.00)
5 or more	4 (2.00)
Did not respond	2 (1.00)
Has somebody close to you, like a friend, teammate or family member ever been diagnosed with a concussion? N (%)
Yes	167 (83.50)
No	22 (11.00)
Not sure	11 (5.50)
Do you think you know a lot about concussions? N (%)
Yes	90 (45.00)
No	110 (55.00)
If yes, how did you learn about concussions? (select all that apply) N (%)
Information from an adult	69 (34.50)
Information from a course	36 (18.00)
Looked up information on your own	33 (16.50)
Information from a friend or sibling	26 (13.00)
Other	8 (4.00)
During the past year, did you learn about concussions at school? N (%)
Yes	102 (51.00)
No	98 (49.00)

*Highest pediatric concussion risk sports, as reported by Zemek et al (4).

Concussion knowledge scores ranged from 13 to 30 (M = 25.73, SD = 3.46, maximum possible score of 30). See Table 3 for breakdown of knowledge questions.

Table 3. Knowledge question responses (N = 200).

Knowledge Question	Frequency of Correct Response N (%)
These questions contain statements about concussions that may or may not be true. To the best of your knowledge, please select true or false for each statement.
In order to be diagnosed with a concussion, you have to be knocked out (false)	197 (98.50)
A concussion can only occur if there is a direct hit to the head (false)	166 (83.00)
Immediately returning to play after experiencing a suspected concussion can delay getting better (true)	184 (92.00)
Symptoms of a concussion can sometimes last for several weeks (true) (Missing: N = 1)	197 (98.50)
Concussions can sometimes lead to sadness and difficulty sleeping (true)	194 (97.00)
You can tell if someone has a concussion by looking at them (false)	187 (93.50)
A person may feel lonely when recovering from a concussion (true)	188 (94.00)
Sometimes students need to be away from school for a couple days after being diagnosed with a concussion (true)	194 (97.00)
A concussion can only occur during sports (false)	199 (99.50)
All youth experience sensitivity to light and nausea after being diagnosed with a concussion (false)	132 (66.00)
Section score (out of 10), mean (SD)	9.20 (0.98)
Think about someone who has had a concussion. Check off the following signs and symptoms that you believe are common to experience AFTER a concussion.
Hives (false)	195 (97.50)
Headache (true)	183 (91.50)
Skin Rash (false)	195 (97.50)
Drowsiness (true)	158 (79.00)
Sensitivity to Light (true)	182 (91.00)
Difficulty Remembering (true)	158 (79.00)
Black Eye (false)	182 (91.00)
Fever (false)	169 (84.50)
Balance Problems (true)	151 (75.50)
Nausea (true)	162 (81.00)
Feeling in a ‘Fog’ (true)	134 (67.00)
Sadness (true)	135 (67.50)
Feeling Slowed Down (true)	145 (72.50)
Reduced Breathing Rate (false)	162 (81.00)
Excessive Studying (false)	192 (96.00)
Difficulty Concentrating (true)	157 (78.50)
Dizziness (true)	173 (86.50)
Joint Stiffness (false)	184 (92.00)
Irritability (true)	94 (47.00)
Hair Loss (false)	196 (98.00)
Section score (out of 20), mean (SD)	16.54 (3.07)
Total knowledge score (out of 30), mean (SD)	25.73 (3.46)

The following sections inquired about participants’ attitudes, subjective norms, self-efficacy and intentions related to providing social support to a peer with a concussion. Attitude scores ranged from 24 to 48 (M = 37.45, SD = 4.43, maximum possible score of 48), subjective norms scores from 6 to 16 (M = 12.75, SD = 2.10, maximum possible score of 16), self-efficacy scores from 16 to 40 (M = 33.27, SD = 5.25, maximum possible score of 40) and intentions scores from 22 to 40 (M = 35.52, SD = 4.73, maximum possible score of 40). Total social support scores ranged from 75 to 143 (M = 115.98, SD = 13.84, maximum possible score of 144). See Table 4 for individual social support questions and section scores.

Table 4. Social support question responses (N = 200).

Question	Score Mean (SD)	Frequency of Favorable Response N (%)
Social Support Attitudes
If my friend has a concussion …
I would let them know where they can get more information about concussions (Missing: N = 1)	3.37 (0.66)	183 (91.50)
I would tell them why it is important to be seen by a doctor	3.57 (0.62)	188 (94.00)
I would tell them to sit in a dark room and rest*	2.06 (0.84)	61 (30.50)
I wouldn’t ask them about their experience*	2.79 (0.90)	130 (65.00)
I’d check to see how they’re feeling	3.58 (0.57)	194 (97.00)
I’d make sure they know that I’m thinking about them (Missing: N = 1)	3.24 (0.77)	170 (85.00)
I’d make sure to leave them alone while they’re recovering* (Missing: N = 1)	2.44 (0.81)	97 (48.50)
I would text them to make sure they still feel part of the team while they’re recovering (Missing: N = 1)	2.93 (0.90)	141 (70.50)
I would make fun of them for talking about their concussion symptoms*	3.60 (0.76)	178 (89.00)
I would help them study for an upcoming test after they missed days of school	3.26 (0.78)	176 (88.00)
I’d ask them how I can help them make up for missed school work	3.36 (0.66)	185 (92.50)
I’d offer to take notes for them	3.32 (0.74).	178 (89.00)
Section score (out of 48), mean (SD)	37.45 (4.43)
Social Support Subjective Norms
Scenario A: A student runs into another student during a sport competition and complains of a headache, dizziness and difficulty concentrating. The student is diagnosed with a concussion and misses the next day of school
My close friends would provide the student with notes and handouts from classes they missed	3.37 (0.60)	187 (93.50)
Most students at my school would provide the student with notes and handouts from the classes they missed	2.93 (0.72)	154 (77.00)
Scenario B: A student slips in the stairwell at school, hitting their head against the wall. The student does not black out, but cannot remember exactly what happened. They do not have dizziness or nausea but complain of difficulty concentrating in class
My close friends would explain why it is important that the student sees a doctor as they have signs of a concussion (Missing: N = 1)	3.42 (0.62)	187 (93.50)
Most students at my school would explain why it is important that the student sees a doctor as they have signs of a concussion	3.06 (0.70)	163 (81.50)
Section score (out of 16), mean (SD)	12.75 (2.10)
Social Support Self-Efficacy
If my friend has a concussion, I am confident in my ability to …
Direct them where to go at school for concussion support, even if I have never had a concussion	3.34 (0.68)	187 (93.50)
Explain why they may need to switch seats in the classroom, even if it was in front of our classmates	3.16 (0.79)	162 (81.00)
Explain common concussion symptoms to them, even if I have never had a concussion	3.24 (0.71)	174 (87.00)
Treat them the same as before their concussion, even if they cannot participate in practice (Missing: N = 1)	3.45 (0.65)	188 (94.00)
Reassure them of not playing in our final game, even if our teammates feel that they are letting the team down	3.42 (0.61)	189 (94.50)
Make sure they still feel part of the group, even if they missed a couple days of school	3.46 (0.62)	191 (95.50)
Bring them homework from school, even though I will have to walk or be driven to their house	3.25 (0.77)	170 (85.00)
Walk with them to class, even though it might take away from time with other friends	3.35 (0.62)	184 (92.00)
Eat lunch with them in a quiet place, even if all my other friends are eating somewhere loud	3.37 (0.67)	183 (91.50)
Help them study for a test, even if I had my own studying to do	3.26 (0.71)	177 (88.50)
Section score (out of 40), mean (SD)	33.27 (5.25)
Intentions to Provide Social Support
If my friend has a concussion, I would …
Tell them to talk to their parent/guardian if they were feeling in a fog after falling off a bike	3.49 (0.56)	194 (97.00)
Encourage them to play in a sports competition if they were still experiencing symptoms* (Missing: N = 1)	3.05 (1.04)	138 (69.00)
Encourage them to talk to their teacher if they were having trouble concentrating at school	3.47 (0.56)	196 (98.00)
Listen to them describe how they are feeling	3.44 (0.61)	187 (93.50)
Text them to check on them if they weren’t at school	3.28 (0.73)	177 (88.50)
Tell them that I thought they were faking their symptoms to get out of school*	3.12 (1.07)	138 (69.00)
Take their shift at work if they needed time off (Missing: N = 1)	3.25 (0.65)	179 (89.50)
Be unlikely to give them notes from the classes they missed*	2.97 (1.06)	135 (67.50)
Bring them updates from the school club they are involved with	3.31 (0.68)	179 (89.50)
Take their role in a group presentation if they were unable to come to class (Missing: N = 2)	3.23 (0.74)	170 (85.00)
Section score (out of 40), mean (SD)	32.52 (4.73)
Total social support score (out of 144), mean (SD)	115.98 (13.84)

*The most favorable response was strongly disagree and therefore, questions were reversed scored.

Demographic variables including gender, age, participation in high-risk sports, having a self-reported concussion history and knowing someone with a concussion history had no significant relationship with overall concussion knowledge. However, participants who thought they were knowledgeable about concussions scored significantly higher on the symptom checklist (W = 3324, p ≤ 0.001) and overall concussion knowledge (W = 3269, p ≤ 0.001). Participants with higher overall concussion knowledge scored significantly higher on attitudes (rho = 0.29, p ≤ 0.001) and intentions to provide social support (rho = 0.22, p = 0.008).

Compared to males, females scored significantly higher on all constructs including attitudes (W = 2567, p ≤ 0.001), subjective norms (W = 3690, p ≤ 0.018), self-efficacy (W = 3298, p ≤ 0.001) and intentions to provide social support (W = 2411, p ≤ 0.001). Additionally, older youth scored significantly higher on attitudes (rho = 0.32, p ≤ 0.001), self-efficacy (rho = 0.19, p ≤ 0.024) and intentions to provide social support (rho = 0.41, p ≤ 0.001) compared to younger youth. Participating in sports at a high-risk for a concussion was associated with significantly lower attitudes (W = 6677, p ≤ 0.001) and intentions to provide social support (W = 6721, p ≤ 0.001) compared to participants who do not play these sports. Finally, participants who thought they were knowledgeable about concussions scored significantly higher on attitudes (W = 4039, p ≤ 0.035), self-efficacy (W = 3757, p ≤ 0.007) and intentions to provide social support (W = 3959, p ≤ 0.024). No significant relationship to any social support constructs was found between those who had a self-reported concussion history and those who did not, as well as those who knew someone with a concussion history and those who did not. See Table 5 for bivariate associations.

Table 5. Bivariate associations between demographic variables and survey sections (N = 200).

Demographic Variable	Concussion Knowledge	Attitudes	Subjective Norms	Self-Efficacy	Intentions to Provide Social Support
Wilcoxon Rank Sum Test (W)
Gender	4571	2567***	3690*	3298***	2411***
Participation in High-Risk Sports	5199	6677***	5264	5797	6721***
Self-Reported Concussion History	3397	3892	3822	3674	3893
Knowing Someone with a Concussion History	1556	1668	1666	1604	1659
Perceived Concussion Knowledge	3269***	4039*	4299	3757**	3959*
Spearman Rank-Order Correlation Coefficient (rho)
Age	− 0.115	0.321***	0.051	0.187*	0.411***

*p ≤ 0.05, ** p < 0.01 and *** p < 0.001

Discussion

This study found that not all youth have positive intentions to provide social support to a peer with a concussion. Females, older youth and participants with increased concussion knowledge had higher intentions to provide social support to a peer with a concussion. It is well documented in the literature that compared to males, females have larger support networks (31) and are more satisfied with the support they receive (31,32) which may influence the greater intentions to provide social support in this context. Additionally, these findings align with previous work exploring social support with youth, where participants identified that having appropriate concussion knowledge was a facilitator to providing social support (9). However, in this previous work, individuals with a concussion history were found to be key providers of social support (9), a finding that contradicted the current study. One potential reason that youth with a concussion history may not have been key providers of social support within this study is that the questions did not align with their personal concussion experience. For example, if an individual had few symptoms and a quicker concussion recovery, it may have been difficult for them to relate to feeling left out or desiring social support after a concussion.

As higher concussion knowledge may increase the provision of social support, these findings highlight opportunities for concussion education focused on increasing social support to create a more supportive environment. These findings may also identify individuals who would be more likely to model providing social support to a peer with a concussion such as females and older youth. Although this study identified individuals who may be more likely to provide social support to a peer with a concussion, future studies could look at whether intentions to provide social support to a peer with a concussion vary based on the type of social support. Past studies have identified that emotional support is often sought out, however it is one of the least likely types of social support received (10). In order to create a more supportive environment for youth with a concussion, these findings may also inform targeted updates to existing guidelines for youth with a concussion (33,34) to emphasize the potential role of social support in concussion recovery.

Additionally, playing a sport at high-risk for a concussion (hockey, soccer, basketball and/or football) was associated with lower intentions to provide social support. Lower intentions to provide social support to a peer may result from the higher rate of concussions occurring in these sports. In a Canadian study, across all sports, the highest incidence rates for concussion were found in hockey, soccer, basketball and football (4) and, therefore, participants who play these sports may be more familiar with concussions. Having teammates with concussions may be more common among these high-risk sports, and participants may not be able or willing to provide as much social support to each individual (e.g., due to the higher number of concussions). Another reason for these lower intentions may be related to sport culture and the environment. For example, one study found that pressure from individuals including teammates, coaches, parents and fans negatively impacted athletes’ intentions to continue playing their sport after a head impact (35). The provision of social support to peers after a concussion may be one way to counteract the potential impact of sport culture. Future studies and initiatives could implement targeted concussion education focused on social support and creating a more supportive environment within sport settings, as this study found that an increase in concussion knowledge was associated with positive intentions to provide social support to a peer.

This study outlined the delivery of a novel survey based on the TPB to explore the relationship between demographic factors and concussion knowledge on youths’ attitudes, subjective norms, self-efficacy and intentions to provide social support to a peer with a concussion. Despite the many concussion surveys that have been developed for youth athletes and that are focused on sport-related concussion (13–15), the novel survey developed and delivered in this study aimed to be more inclusive of all youth who experience a concussion and is the one of the first surveys developed for a broader audience that includes both athletes and non-athletes. This was done by including survey questions that incorporated references to various ways of sustaining a concussion, diverse postconcussion symptoms and many areas of life that may be impacted during concussion recovery (e.g., school, extracurricular activities, etc.). This inclusivity is essential given that concussions can occur from a variety of situations such as falls, motor vehicle collisions, injury at school or on the playground and exposure to force, with sport-related concussion only comprising about 30% of all concussions among children and youth (1). By including non-sport specific language and a variety of scenarios, this survey has the potential to be appropriate for delivery in many settings.

In addition to being developed for a broader audience, this survey is the first to focus on providing social support to a peer with a concussion. Although youth can experience emotional and behavioral symptoms after a concussion (3) which can result in feelings of isolation and loneliness, only one study has explored the concept of social support among youth who experience concussion (9). This study was qualitative and focused on the individual with a concussion receiving social support (9), as opposed to providing social support to a peer and creating a more supportive environment. Although research exploring the concept of social support specific to concussion is limited, the importance of social support has been demonstrated in other populations such as LGBTQ youth (36) and youth exposed to parental intimate partner violence (37). LGBTQ youth who received social support were more likely to experience decreased incidence of depression, school avoidance, violence and anxiety (36). Additionally, for youth who experienced parental intimate partner violence, receiving social support helped to prevent these youth from experiencing intimate partner violence themselves (37). Since social support is a novel concept within the field of concussion and has the potential to mitigate negative outcomes, additional exploration into the relationship between variables and the impact of social support on concussion recovery should be explored in larger youth populations.

Practice implications

This study provides initial exploration of youths’ intentions to provide social support to a peer with a concussion and identified youth who may be more likely to provide social support to a peer with a concussion such as females, older youth, youth that do not participate in high-risk sports and youth with higher concussion knowledge. These findings may be of interest to youth and those who interact with and support them, such as their parents, families, school staff and coaches. As not all youth have positive intentions to provide social support to a peer with a concussion, next steps could involve identifying opportunities where youth with higher intentions to provide social support to a peer with a concussion are able to model positive social-support related behaviors. This may promote a more supportive culture around concussion and be done through leadership positions in various settings such as at school, in the community or on sports teams.

Strengths and limitations

This is one of the first studies to deliver a concussion survey designed for all youth and include questions based on sport and non-sport scenarios. This allows the survey to be inclusive, applicable and appropriate for delivery in various settings with youth, such as schools, community settings and sports organizations. In addition, this survey explores intentions to provide social support to a peer with a concussion, an essential and largely unexplored area of concussion research.

Another strength of this work is that this survey is based on the TPB, which has been used in past concussion surveys and is a commonly used behavior change theory. Despite this, the relationship between intention and behavior may be impacted by additional constructs outside of the TPB such as an individual’s skill related to the behavior and environmental considerations (38), and therefore, there are limitations to its use (39). Future research could explore the relationship between intention toward providing social support to a peer and actual performance of this behavior, as well as additional factors that may influence this relationship. Specifically, further understanding of why some youth may be less likely to provide social support to a peer could be explored.

To ensure the survey was relevant to youth and to gain feedback, cognitive interviews were conducted. Despite the strengths of this approach, only female participants completed cognitive interviews and, therefore, additional perspectives were not included. The responses provided in the survey were self-report, cross-sectional and in some cases retrospective. As this study described the initial delivery of the survey, full measurement development, and reliability and validity statistics were not conducted. Therefore, the relationships between variables are suggestive and should be interpreted with caution as these relationships may be confounded by demographic variables or other variables that were not captured in this study. The next steps for this research should include the delivery of this survey to a larger, more diverse youth sample where relationships between constructs can be further explored. Additionally, further reliability and validating testing should be conducted.

Conclusions

This work highlights numerous implications for pediatric concussion research and practice as receiving social support after a concussion has the potential to promote positive health outcomes among youth by mitigating emotional and behavioral concussion symptoms. This study identified gaps in concussion knowledge and that not all youth have positive intentions to provide social support to a peer with a concussion, emphasizing the need for tailored educational concussion interventions to increase concussion knowledge and enhance intentions to provide social support among youth. These educational concussion interventions have the potential to promote positive behavior change toward providing social support, ultimately creating a more supportive environment for youth. The findings from this study contribute to an initial exploration of youths’ intentions to provide social support to a peer with a concussion which can be built upon in future studies.

Acknowledgments

The authors would like to thank all of the youth for their involvement in this research. We would like to acknowledge the efforts of the members of the ‘Youth Concussion Awareness Network’ (You-CAN) team, the OAK Concussion Lab and the Bloorview Research Institute, specifically Rosephine Del Fernandes and Helena Kita. The authors would also like to thank Lisa Avery for contributing her expertise in statistical analysis.

Disclosure statement

MGH presently receives research funding from the Canadian Institutes of Health Research (CIHR), Canadian Institute for Military and Veteran Health Research (CIMVHR) and Ontario Brain Institute (OBI). MGH is also an employed consultant with the National Hockey League Players’ Association (NHLPA) and founder/shareholder of Rhea Health Inc, a digital active rehabilitation platform for concussion and mental health conditions.

RZ has current or past competitively funded research grants from Canadian Institutes of Health Research (CIHR), National Institutes of Health (NIH), Health Canada, Ontario Neurotrauma Foundation (ONF), Ontario Ministry of Health, Physician Services Incorporated (PSI) Foundation, CHEO Foundation, University of Ottawa Brain and Mind Research Institute, Ontario Brain Institute (OBI), and Ontario SPOR Support Unit (OSSU), and the National Football League (NFL) Scientific Advisory Board. RZ holds a Clinical Research Chair in Pediatric Concussion from the University of Ottawa and is on the advisory board for Parachute Canada (a nonprofit injury prevention charity) and the board of directors for the North American Brain Injury Society (volunteer unpaid). RZ is the co-founder, Scientific Director and a minority shareholder in 360 Concussion Care, an interdisciplinary concussion clinic.

NR is a holder of a Canada Research Chair (Tier 2) in Pediatric Concussion and reports receiving grants and research funding from the Canadian Institutes of Health Research (CIHR), Ontario Neurotrauma Foundation (ONF), Public Health Agency of Canada (PHAC), Parachute Canada, Special Olympics Canada, Greater Toronto Hockey League, Dr Tom Pashby Sport Safety Fund, Holland Bloorview Kids Rehabilitation Hospital and Scotiabank. NR is an investigator in a multicentre study funded by the National Football League (NFL) Scientific Advisory Board; he does not receive any research funding or financial benefit. NR is a minority shareholder in 360 Concussion Care, an interdisciplinary concussion clinic.

Additional information

Funding

This work was supported by the Canadian Institutes of Health Research (#153025) and the Ward Family (The Ward Family Summer Student Research Program, Holland Bloorview Kids Rehabilitation Hospital). KM’s doctoral work was supported through the Kimel Family Graduate Student Scholarship in Pediatric Rehabilitation, the Queen Elizabeth II/Patty Rigby & John Wedge Graduate Scholarship in Science and Technology, and the Ontario Graduate Scholarship.

Appendices

Appendix A. Social Support Concussion Survey

Section 1: Anonymous Identification Code

Please read each question below and select the answer.

1. The third letter of your full first name.

Table

A	B	C	D	E	F	G	H	I	J
K	L	M	N	O	P	Q	R	S	T
U	V	W	X	Y	Z

2. The first letter of your current high school’s full name.

Table

A	B	C	D	E	F	G	H	I	J
K	L	M	N	O	P	Q	R	S	T
U	V	W	X	Y	Z

3. The first letter of the month in which you were born.

Table

J

F

M

A

S

O

N

D

4. The last letter of your last name.

Table

A	B	C	D	E	F	G	H	I	J
K	L	M	N	O	P	Q	R	S	T
U	V	W	X	Y	Z

5. The last number of your cell phone number (if you do not have a cell phone, select #).

Table

0

1

2

3

4

5

6

7

8

9

#

6. The first letter of your street name.

Table

A	B	C	D	E	F	G	H	I	J
K	L	M	N	O	P	Q	R	S	T
U	V	W	X	Y	Z

7. The date you were born.

Table

1	2	3	4	5	6	7	8	9	10	11
12	13	14	15	16	17	18	19	20	21	22
23	24	25	26	27	28	29	30	31

8. The last letter of the city/town you were born in.

Table

A	B	C	D	E	F	G	H	I	J
K	L	M	N	O	P	Q	R	S	T
U	V	W	X	Y	Z

Section 2: Participant Demographics

Please read each question below and select the answer.

1. Grade at the start of this school year:

• □ 9

• □ 10

• □ 11

• □ 12

• □ Other: __________

2. Gender:

• □ Male

• □ Female

• □ Prefer not to specify

• □ Other: __________

3. Age:

• □ 12

• □ 13

• □ 14

• □ 15

• □ 16

• □ 17

• □ 18

• □ 19

• □ Other: __________

4. In the last 12 months, what organized sports (ie. on a school team, or in a league or club) have you participated in (individually or on a team)? (check all that apply)

Table

□ Ball Hockey □ Baseball □ Basketball □ Badminton □ Boxing □ Cheerleading □ Cross Country Running □ Cycling (Road) □ Curling □ Dance □ Diving □ Downhill Skiing □ Equestrian □ Field Hockey □ Figure Skating □ Football □ Golf □ Gymnastics □ Hockey □ Kickball □ Lacrosse □ Martial Arts (e.g. Karate, Tae Kwon Do, Judo, etc.) □ Mountain Biking

□ Nordic (Cross-Country) Skiing □ Ringette □ Roller Derby □ Rowing □ Rugby □ Running □ Snowboarding □ Soccer □ Softball □ Speed Skating □ Spikeball □ Swimming □ Synchronized Swimming □ Tennis □ Track and Field □ Ultimate Frisbee □ Volleyball □ Waterpolo □ Weightlifting □ Wrestling □ I do not play organized sports □ I play sports recreationally □ Other please specify: __________

5. Have you ever been diagnosed with a concussion?

• □ Yes

• □ No

• □ Not sure

• □ Prefer not to answer

If yes, how many?

• □ 1

• □ 2

• □ 3

• □ 4

• □ 5 or more

If yes, when was the last one? __________ (MM-YYYY).

6. Has somebody close to you, like a friend, teammate or family member ever been diagnosed with a concussion

• □ Yes

• □ No

• □ Not sure

7. Do you think you know a lot about concussions?

• □ Yes

• □ No

If yes, how did you learn about concussions (select all that apply):

• □ Information from an adult (teacher, parent, coach, health-care professional, etc.)

• □ Information from a course

• □ Looked up information on your own

• □ Information from a friend or sibling

• □ Other: __________

8. During the past year, did you learnabout concussions at school?

• □ Yes

• □ No

Section 3: Concussion Knowledge

A. These questions contain statements about concussions that may or may not be true. To the best of your knowledge, please select true or false for each statement.

Table

(1) In order to be diagnosed with a concussion, you have to be knocked out.	True	False
(2) A concussion can only occur if there is a direct hit to the head.	True	False
(3) You cannot get an injury while playing sports.	True	False
(4) Immediately returning to play after experiencing a suspected concussion can delay getting better.	True	False
(5) Symptoms of a concussion can sometimes last for several weeks.	True	False
(6) Concussions can sometimes lead to sadness and difficulty sleeping.	True	False
(7) Students in grade 3 and grade 12 are always the same age.	True	False
(8) You can tell if someone has a concussion by looking at them.	True	False
(9) A person may feel lonely when recovering from a concussion.	True	False
(10) Sometimes students need to be away from school for a couple days after being diagnosed with a concussion.	True	False
(11) A concussion can only occur during sports.	True	False
(12) All youth experience sensitivity to light and nausea after being diagnosed with a concussion.	True	False

B. Think about someone who has had a concussion. Check off the following signs and symptoms that you believe are common to experience AFTER a concussion.

Table

□ Hives	□ Feeling in a “Fog”
□ Headache	□ Sadness
□ Skin Rash	□ Feeling Slowed Down
□ Drowsiness	□ Reduced Breathing Rate
□ Sensitivity to Light	□ Excessive Studying
□ Difficulty Remembering	□ Difficulty Concentrating
□ Black Eye	□ Dizziness
□ Fever	□ Joint Stiffness
□ Balance Problems	□ Irritability
□ Nausea	□ Hair Loss

Section 4: Attitudes

Please rate how strongly you agree with each statement. If my friend has a concussion …

Table

(13) I would let them know where they can get more information about concussions.	Strongly Disagree	Disagree	Agree	Strongly Agree
(14) I would tell them why it is important to be seen by a doctor.	Strongly Disagree	Disagree	Agree	Strongly Agree
(15) I would tell them to sit in a dark room and rest.	Strongly Disagree	Disagree	Agree	Strongly Agree
(16) I would not ask them about their experience.	Strongly Disagree	Disagree	Agree	Strongly Agree
(17) I would check to see how they are feeling.	Strongly Disagree	Disagree	Agree	Strongly Agree
(18) I would make sure they know that I am thinking about them.	Strongly Disagree	Disagree	Agree	Strongly Agree
(19) I would make sure to leave them alone while they are recovering.	Strongly Disagree	Disagree	Agree	Strongly Agree
(20) I would text them to make sure they still feel part of the team while they are recovering.	Strongly Disagree	Disagree	Agree	Strongly Agree
(24) I would make fun of them for talking about their concussion symptoms.	Strongly Disagree	Disagree	Agree	Strongly Agree
(22) I would help them study for an upcoming test after they missed days of school.	Strongly Disagree	Disagree	Agree	Strongly Agree
(23) I would ask them how I can help them make up for missed school work.	Strongly Disagree	Disagree	Agree	Strongly Agree
(24) I would offer to take notes for them.	Strongly Disagree	Disagree	Agree	Strongly Agree

Section 5: Social Support Subjective Norms

Please read each of the following scenarios and rate how strongly you agree or disagree with the statements that follow.

Scenario A: A student runs into another student during a sport competition and complains of a headache, dizziness and difficulty concentrating. The student is diagnosed with a concussion and misses the next day of school.

Table

(25) My close friends would provide the student with notes and handouts from classes they missed.	Strongly Disagree	Disagree	Agree	Strongly Agree
(26) Most students at my school would provide the student with notes and handouts from the classes they missed.	Strongly Disagree	Disagree	Agree	Strongly Agree

Scenario B: A student slips in the stairwell at school, hitting their head against the wall. The student does not black out, but cannot remember exactly what happened. They do not have dizziness or nausea but complain of difficulty concentrating in class.

Table

(27) My close friends would explain why it is important that the student sees a doctor as they have signs of a concussion.	Strongly Disagree	Disagree	Agree	Strongly Agree
(28) Most students at my school would explain why it is important that the student sees a doctor as they have signs of a concussion.	Strongly Disagree	Disagree	Agree	Strongly Agree

Section 6: Social Support Self-Efficacy

Please rate how strongly you agree with each statement

A. If my friend has a concussion, I am confident in my ability to …

Table

(29) Direct them where to go to school for concussion support, even if I have never had a concussion.	Strongly Disagree	Disagree	Agree	Strongly Agree
(30) Explain why they may need to switch seats in the classroom, even if it was in front of our classmates.	Strongly Disagree	Disagree	Agree	Strongly Agree
(31) Explain common concussion symptoms to them, even if I have never had a concussion.	Strongly Disagree	Disagree	Agree	Strongly Agree
(32) Treat them the same as before their concussion, even if they cannot participate in practice.	Strongly Disagree	Disagree	Agree	Strongly Agree
(33) Reassure them of not playing in our final game, even if our teammates feel that they are letting the team down.	Strongly Disagree	Disagree	Agree	Strongly Agree
(34) Make sure they still feel part of the group, even if they missed a couple of days of school.	Strongly Disagree	Disagree	Agree	Strongly Agree
(35) Bring them homework from school, even though I will have to walk or be driven to their house.	Strongly Disagree	Disagree	Agree	Strongly Agree
(36) Walk with them to class, even though it might take away from time with other friends.	Strongly Disagree	Disagree	Agree	Strongly Agree
(37) Eat lunch with them in a quiet place, even if all my other friends are eating somewhere loud.	Strongly Disagree	Disagree	Agree	Strongly Agree
(38) Help them study for a test, even if I had my own studying to do.	Strongly Disagree	Disagree	Agree	Strongly Agree

Section 7: Intentions to Provide Social Support

Please rate how strongly you agree with each statement.

A. If my friend has a concussion I would …

Table

(39) Tell them to talk to their parent/guardian if they were feeling in a fog after falling off a bike.	Strongly Disagree	Disagree	Agree	Strongly Agree
(40) Encourage them to play in a sports competition if they were still experiencing symptoms.	Strongly Disagree	Disagree	Agree	Strongly Agree
(41) Encourage them to talk to their teacher if they were having trouble concentrating at school.	Strongly Disagree	Disagree	Agree	Strongly Agree
(42) Listen to them describe how they are feeling.	Strongly Disagree	Disagree	Agree	Strongly Agree
(42) Text them to check on them if they were not at school.	Strongly Disagree	Disagree	Agree	Strongly Agree
(42) Tell them that I thought they were faking their symptoms to get out of school.	Strongly Disagree	Disagree	Agree	Strongly Agree
(45) Take their shift at work if they needed time off.	Strongly Disagree	Disagree	Agree	Strongly Agree
(46) Be unlikely to give them notes from the classes they missed.	Strongly Disagree	Disagree	Agree	Strongly Agree
(47) Bring them updates from the school club they are involved with.	Strongly Disagree	Disagree	Agree	Strongly Agree
(48) Take their role in a group presentation if they were unable to come to class.	Strongly Disagree	Disagree	Agree	Strongly Agree