Page 95 - JSOM Fall 2020

These statements recognize the importance of organizational emphasized their application for college athletes and military
(e.g., athletic department, military unit, military service) pro- service academy cadets, they can also be considered within the
cesses in implementing effective approaches to concussion ed- context of youth sports.
ucation. Organizations should consider how their stated and
unstated values might support or undermine disclosure-related These recommendations underscore the critical and active
initiatives. Organizational stakeholders, including adminis- role of organizations in successful dissemination and imple-
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trators and military leaders, should discuss ways that unstated mentation of concussion disclosure initiatives. Statements
institutional values (such as playing through pain, etc.,) that are addressed local adaptation, within-setting communication, or-
counter to concussion safety might be internalized by athletes/ ganizational values, stakeholder engaged planning, and eval-
Servicemembers. In the military this has been a recent topic of uation—all components of dominant implementation science
discussion for other mental health issues, with organizational frameworks such as the Consolidated Framework for Imple-
and leadership support identified as important facilitators of a mentation Research. The provided recommendations also
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culture that reduces stigma related to care seeking With re- align with processes advocated in evidence-based delivery sys-
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spect to concussion, the present results suggest that deliberate tems in prevention science for changing ‘cultures’ that support
messaging about safety-supportive organizational values, and unhealthy behaviors and for selecting, adapting and delivering
alignment of these values with other core organizational values tested and effective programs. Implementation and organi-
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(e.g., athletic performance, military readiness) is recommended. zational culture are infrequently addressed in sports medicine
This can help create a culture where messaging about concus- research, limiting the potential impact and sustainability of
sion safety is viewed as credible by key stakeholders. Perceptions efforts in a variety of injury-related domains. The process we
of the coaching staff’s commitment to concussion safety climate described here provides a model for making implementation
is associated with greater player self-efficacy and strong social and organizational culture a focus of future consensus efforts
norms for concussion-symptom disclosure. Central to all or- in the sports medicine domain. Specifically, the consensus pro-
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ganization-level recommendations is collaboration, stakeholder cess (1) engaged in diverse group of stakeholders from insti-
engagement and local tailoring. Working with student-athletes/ tutions with varying resource levels, organizational structures
Servicemembers can help institutions select approaches to inter- and needs, and (2) considered both feasibility and utility as
vention that address setting-specific needs and resources. Thus, key criterions for recommendation inclusion. Importantly, be-
it is recommended that institutions have an ongoing process cause feasibility was a key determinant for recommendation
for gauging the effectiveness of their selected approach(es) to inclusion, statements that participants agreed would be useful
concussion education in changing disclosure behavior. Ideally, but not feasible were not retained. As disclosure-supportive in-
this would be in the form of valid and reliable common data terventions and resources are developed the present consensus
elements related to concussion disclosure that would serve the process should be revisited and guidance updated.
military, athletics, and the general public. Such data collection
could also have the benefit of informing guidance at a national To optimize the use of the present recommendations, orga-
level by helping build a sufficient evidence base for systematic nizations should establish a multidisciplinary implementation
quantitative comparisons of the effectiveness of different educa- team. This team should review the list of recommendations and
tional approaches and elements. At present, such disclosure-re- conduct an inventory of current practices and gaps. Because of
lated common data elements do not exist; their development the importance of tailoring educational approaches to local
and validation is an important area for future research. needs, this multidisciplinary team should work with athletes/
Servicemembers and other stakeholders to identify their spe-
cific needs (Recommendation 15), to evaluate the effectiveness
Conclusion
of approaches chosen (Recommendation 16), and to adapt
Results of the consensus process suggest the importance of ap- approaches accordingly. Further work is needed to provide
plying a social-ecological approach to address the problem of structured support for local implementation teams in this pro-
how to increase concussion disclosure. 14–16 This means consid- cess of assessment and planning. Such implementation support
ering determinants of behavior at multiple levels. Recommen- could also include access to educational interventions that are
dations were inclusive of the beliefs of the individual at-risk consistent with the present guidelines as such resources are
of concussion (athlete or Servicemember), key interpersonal developed. Policy-level changes by governing bodies to align
relationships supportive of individual behavior, and processes with the present guidelines may also be a useful strategy for
at the team, unit and institution level. Adopting this multi- encouraging organization-level implementation, perhaps most
level, multi-stakeholder approach to increasing concussion efficiently increasing organizational motivation to change by
disclosure is a departure from viewing concussion education increasing the salience or consequences of non-compliance.
as something that is delivered only to athletes or military ser- Ensuring that such policies are communicated clearly to or-
vice academy cadets at a single time point. While there is a ganizational members and are also readily available to others
need for ongoing concussion education program development who may be influenced by them (e.g., parents) is critical for
and evaluation work (e.g., including content specified and their influence on organizational culture and behavior.
implementation strategies), the recommendations make clear
that it is unlikely that a single educational approach delivered As the field of research related to concussion disclosure and
at a single point in time is going to be effective for all individ- implementation of disclosure supportive interventions ma-
uals in all settings. Thus, institutions are encouraged to view tures, there is a need for systematic reviews and meta-analy-
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concussion disclosure as a local cultural issue, and the pres- ses to identify key individual, interpersonal and institutional
ent recommendations as a guide for establishing and main- intervention targets. Such efforts would be facilitated by im-
taining ongoing processes of concussion education that can proved methods of eliciting data about disclosure that are
create and sustain local cultures supportive of concussion dis- more efficient and comparable than current one-off surveys
closure. Although presentation of these recommendations has developed by independent research teams. The results of the

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