Factors Associated With Concussion Rates in Youth Ice Hockey Players: Data From the Largest Longitudinal Cohort Study in Canadian Youth Ice Hockey.

OBJECTIVES: To examine factors associated with rates of game and practice-related concussion in youth ice hockey. DESIGN: Five-year prospective cohort (Safe2Play). SETTING: Community arenas (2013-2018). PARTICIPANTS: Four thousand eighteen male and 405 female ice hockey players (6584 player-seasons) participating in Under-13 (ages 11-12), Under-15 (ages 13-14), and Under-18 (ages 15-17) age groups. ASSESSMENT OF RISK FACTORS: Bodychecking policy, age group, year of play, level of play, previous injury in the previous year, lifetime concussion history, sex, player weight, and playing position. MAIN OUTCOME MEASUREMENTS: All game-related concussions were identified using validated injury surveillance methodology. Players with a suspected concussion were referred to a study sport medicine physician for diagnosis and management. Multilevel Poisson regression analysis including multiple imputation of missing covariates estimated incidence rate ratios (IRRs). MAIN RESULTS: A total of 554 game and 63 practice-related concussions were sustained over the 5 years. Female players (IRR Female/Male = 1.79; 95% CI: 1.26-2.53), playing in lower levels of play (IRR = 1.40; 95% CI: 1.10-1.77), and those with a previous injury (IRR = 1.46; 95% CI: 1.13, 1.88) or lifetime concussion history (IRR = 1.64; 95% CI: 1.34-2.00) had higher rates of game-related concussion. Policy disallowing bodychecking in games (IRR = 0.54; 95% CI: 0.40-0.72) and being a goaltender (IRR Goaltenders/Forwards = 0.57; 95% CI: 0.38-0.87) were protective against game-related concussion. Female sex was also associated with a higher practice-related concussion rate (IRR Female/Male = 2.63; 95% CI: 1.24-5.59). CONCLUSIONS: In the largest Canadian youth ice hockey longitudinal cohort to date, female players (despite policy disallowing bodychecking), players participating in lower levels of play, and those with an injury or concussion history had higher rates of concussion. Goalies and players in leagues that disallowed bodychecking had lower rates. Policy prohibiting bodychecking remains an effective concussion prevention strategy in youth ice hockey.

Psychosocial Factors Associated With Time to Recovery After Concussion in Adolescent Ice Hockey Players.

OBJECTIVE: To investigate the association between psychosocial factors and physician clearance to return to play (RTP) in youth ice hockey players after sport-related concussion. DESIGN: Prospective cohort study, Safe to Play (2013-2018). SETTING: Youth hockey leagues in Alberta and British Columbia, Canada. PARTICIPANTS: Three hundred fifty-three ice hockey players (aged 11-18 years) who sustained a total of 397 physician-diagnosed concussions. INDEPENDENT VARIABLES: Psychosocial variables. MAIN OUTCOME MEASURES: Players and parents completed psychosocial questionnaires preinjury. Players with a suspected concussion were referred for a study physician visit, during which they completed the Sport Concussion Assessment Tool (SCAT3/SCAT5) and single question ratings of distress and expectations of recovery. Time to recovery (TTR) was measured as days between concussion and physician clearance to RTP. Accelerated failure time models estimated the association of psychosocial factors with TTR, summarized with time ratios (TRs). Covariates included age, sex, body checking policy, days from concussion to the initial physician visit, and symptom severity at the initial physician visit. RESULTS: Self-report of increased peer-related problems on the Strengths and Difficulties Questionnaire (TR, 1.10 [95% CI, 1.02-1.19]), higher ratings of distress about concussion outcomes by participants (TR, 1.06 [95% CI, 1.01-1.11]) and parents (TR, 1.05 [95% CI, 1.01-1.09]), and higher parent ratings of distress about their child's well-being at the time of injury (TR, 1.06 [95% CI, 1.02-1.09]) were associated with longer recovery. CONCLUSIONS: Greater pre-existing peer-related problems and acute distress about concussion outcomes and youth well-being predicted longer TTR. Treatment targeting these psychosocial factors after concussion may promote recovery.

Self-reported concussions in Canada: A cross-sectional study.

Background: Traumatic brain injuries (TBIs) are a major public health concern impacting the lives of many Canadians. Among all TBIs, concussions are the most common. However, to date, the incidence of concussions among the Canadian population, has remained unknown. To address this data surveillance gap, this study presents national estimates on the percentage of Canadians aged 12 years or older (excluding those living in the territories) who sustained one or more concussions in 2019. Data and methods: This study used data collected from the Traumatic Brain Injury Rapid Response (TBIRR) module of the 2020 Canadian Community Health Survey, a cross-sectional health survey. Descriptive statistics and logistic regressions were conducted to summarize the information in the TBIRR module. Results: This study found that approximately 1.6% of Canadians aged 12 years or older reported sustaining one or more concussions in 2019. Age was significantly associated with concussion incidence after controlling for sex and annual household income, and the locations and activities surrounding respondents' most serious concussions varied by age group. Over one-third of respondents sustained multiple concussions. Interpretation: The results suggest that certain populations, particularly younger individuals, may be more affected by concussions. While circumstances surrounding concussions vary by age group, the most important contributing factors were sports or physical activities among youth and falls among the adult population. Monitoring concussions among the national population is an important activity in injury surveillance, as it can help evaluate the efficacy of injury prevention intervention and better understand knowledge gaps and the burden of this injury.

No association found between body checking experience and injury or concussion rates in adolescent ice hockey players.

OBJECTIVES: To compare rates of injury and concussion among U-15 (ages 13-14 years) ice hockey players playing in leagues allowing body checking, but who have a varying number of years of body checking experience. METHODS: This 5-year longitudinal cohort included U-15 ice hockey players playing in leagues where policy allowed body checking. Years of body checking experience were classified based on national/local body checking policy. All ice hockey game-related injuries were identified using a validated injury surveillance methodology. Players with a suspected concussion were referred to a study sport medicine physician. Multiple multilevel Poisson regression analysis was performed, adjusting for important covariates and a random effect at a team level (offset by game exposure hours), to estimate injury and concussion incidence rate ratios (IRRs). RESULTS: In total, 1647 players participated, contributing 1842 player-seasons (195 players participating in two seasons). Relative to no body checking experience, no significant differences were found in the adjusted IRRs for game-related injury for players with 1 year (IRR=1.06; 95% CI: 0.77 to 1.45) or 2+ years (IRR=1.16; 95% CI: 0.74 to 1.84) body checking experience. Similarly, no differences were found in the rates of concussion for players with 1 year (IRR=0.92; 95% CI: 0.59 to 1.42) or 2+ years (IRR=0.69; 95% CI: 0.38 to 1.25) body checking experience. CONCLUSIONS: Among ice hockey players aged 13-14 years participating in leagues permitting body checking, the adjusted rates of all injury and concussion were not significantly different between those that had body checking experience and those that did not. Based on these findings, no association was found between body checking experience and rates of injury or concussion specifically in adolescent ice hockey.

Body checking in non-elite adolescent ice hockey leagues: it is never too late for policy change aiming to protect the health of adolescents.

OBJECTIVES: The objective of this study is to evaluate the effect of policy change disallowing body checking in adolescent ice hockey leagues (ages 15-17) on reducing rates of injury and concussion. METHODS: This is a prospective cohort study. Players 15-17 years-old were recruited from teams in non-elite divisions of play (lower 40%-70% by division of play depending on year and city of play in leagues where policy permits or prohibit body checking in Alberta and British Columbia, Canada (2015-18). A validated injury surveillance methodology supported baseline, exposure-hours and injury data collection. Any player with a suspected concussion was referred to a study physician. Primary outcomes include game-related injuries, game-related injuries (>7 days time loss), game-related concussions and game-related concussions (>10 days time loss). RESULTS: 44 teams (453 player-seasons) from non-body checking and 52 teams (674 player-seasons) from body checking leagues participated. In body checking leagues there were 213 injuries (69 concussions) and in non-body checking leagues 40 injuries (18 concussions) during games. Based on multiple multilevel mixed-effects Poisson regression analyses, policy prohibiting body checking was associated with a lower rate of injury (incidence rate ratio (IRR): 0.38 (95% CI 0.24 to 0.6)) and concussion (IRR: 0.49; 95% CI 0.26 to 0.89). This translates to an absolute rate reduction of 7.82 injuries/1000 game-hours (95% CI 2.74 to 12.9) and the prevention of 7326 injuries (95% CI 2570 to 12083) in Canada annually. CONCLUSIONS: The rate of injury was 62% lower (concussion 51% lower) in leagues not permitting body checking in non-elite 15-17 years old leagues highlighting the potential public health impact of policy prohibiting body checking in older adolescent ice hockey players.

De-implementing Prolonged Rest Advice for Concussion in Primary Care Settings: A Pilot Stepped Wedge Cluster Randomized Trial.

OBJECTIVE: To evaluate the feasibility and preliminary efficacy of a de-implementation intervention to support return-to-activity guideline use after concussion. SETTING: Community. PARTICIPANTS: Family physicians in community practice (n = 21 at 5 clinics). DESIGN: Pilot stepped wedge cluster randomized trial with qualitative interviews. Training on new guidelines for return to activity after concussion was provided in education outreach visits. MAIN MEASURES: The primary feasibility outcomes were recruitment, retention, and postencounter form completion (physicians prospectively recorded what they did for each new patient with concussion). Efficacy indicators included a knowledge test and guideline compliance based on postencounter form data. Qualitative interviews covered Theoretical Domains Framework elements. RESULTS: Recruitment, retention, and postencounter form completion rates all fell below feasibility benchmarks. Family physicians demonstrated increased knowledge about the return-to-activity guideline (M = 8.8 true-false items correct out of 10 after vs 6.3 before) and improved guideline adherence (86% after vs 25% before) after the training. Qualitative interviews revealed important barriers (eg, beliefs about contraindications) and facilitators (eg, patient handouts) to behavior change. CONCLUSIONS: Education outreach visits might facilitate de-implementation of prolonged rest advice after concussion, but methodological changes will be necessary to improve the feasibility of a larger trial. The qualitative findings highlight opportunities for refining the intervention.

Evidence of altered interhemispheric communication after pediatric concussion.

OBJECTIVES: To investigate neurophysiological alterations within the typical symptomatic period after concussion (1-month) and throughout recovery (6-months) in adolescents; and (2) to examine relationships between neurophysiological and upper limb kinematic outcomes.METHODS: 18 adolescents with concussion were compared to 17 healthy controls. Transcranial magnetic stimulation (TMS) was used to assess neurophysiological differences between groups including: short- and long-interval intracortical inhibition, intracortical facilitation, short- and long-latency afferent inhibition, afferent facilitation, and transcallosal inhibition (TCI). Behavioral measures of upper limb kinematics were assessed with a robotic device.RESULTS: Mixed model analysis of neurophysiological data identified two key findings. First, participants with concussion demonstrated delayed onset of interhemispheric inhibition, as indexed by TCI, compared to healthy controls. Second, our exploratory analysis indicated that the magnitude of TCI onset delay in adolescents with concussion was related to upper limb kinematics.CONCLUSIONS: Our findings indicate that concussion in adolescence alters interhemispheric communication. We note relationships between neurophysiological and kinematic data, suggesting an affinity for individuals with less concussion-related physiological change to improve their motor behavior over time. These data serve as an important step in future development of assessments (neurobiological and clinical) and interventions for concussion.

Does disallowing body checking in non-elite 13- to 14-year-old ice hockey leagues reduce rates of injury and concussion? A cohort study in two Canadian provinces.

OBJECTIVE: To compare rates of injury and concussion among non-elite (lowest 60% by division of play) Bantam (ages 13-14 years) ice hockey leagues that disallow body checking to non-elite Bantam leagues that allow body checking. METHODS: In this 2-year cohort study, Bantam non-elite ice hockey players were recruited from leagues where policy allowed body checking in games (Calgary/Edmonton 2014-2015, Edmonton 2015-2016) and where policy disallowed body checking (Kelowna/Vancouver 2014-2015, Calgary 2015-2016). All ice hockey game-related injuries resulting in medical attention, inability to complete a session and/or time loss from hockey were identified using valid injury surveillance methodology. Any player suspected of having concussion was referred to a study physician for diagnosis and management. RESULTS: 49 body checking (608 players) and 33 non-body checking teams (396 players) participated. There were 129 injuries (incidence rate (IR)=7.98/1000 hours) and 54 concussions (IR=3.34/1000 hours) in the body checking teams in games. After policy change, there were 31 injuries (IR=3.66/1000 hours) and 17 concussions (IR=2.01/1000 hours) in games. Policy disallowing body checking was associated with a lower rate of all injury (adjusted incidence rate ratio (IRR)=0.44; 95% CI: 0.27 to 0.74). The point estimate showed a lower rate of concussion (adjusted IRR=0.6; 95% CI: 0.31 to 1.18), but this was not statistically significant. CONCLUSION: Policy change disallowing body checking in non-elite Bantam ice hockey resulted in a 56% lower rate of injury. There is growing evidence that disallowing body checking in youth ice hockey is associated with fewer injuries.

'Active & Safe Central': development of an online resource for the prevention of injury in sport and recreational activity.

BACKGROUND: Sport and recreation related injuries exert a significant cost on the healthcare system. As prevention researchers and practitioners, we have a responsibility to provide guidance towards prevention to those who participate in sport and recreation, and those that coach, treat and parent children that participate. The objective of this project was to use an integrated knowledge translation approach to develop an end user-driven digital platform that provides injury prevention information and resources across 51 sport and recreational activities. DESIGN: We used an integrated knowledge translation approach to scope and develop an online sport and recreational injury prevention resource. A project team was formed that included end users-coaches, parents and athletes, injury researchers and practitioners, as well as members of a digital design team. All members of the project team informed the development process, including a review of literature and existing resources, the translation of evidence and development of the platform. At all stages of development, members of the project team cocreated knowledge for the tool, including forming the research questions, the approach, feasibility and development of outcomes. CONCLUSION: The 'Active & Safe Central' (https://activesafe.ca/) platform provides web-based sport injury and prevention information. This user-friendly, web and mobile accessible platform can increase the reach, awareness and implementation of prevention programming in sport and recreational activity.

Return to learn after concussion in children.

Question Despite recent interest in the pathophysiology and management of concussion in children, as well as the ongoing concern about return to activity, advice regarding the type and length of cognitive rest has been inconsistent. What should I recommend to the children and adolescents in my clinic regarding cognitive rest following mild concussion? Answer Strict cognitive rest is not needed in those with mild concussion. Evidence suggests a decrease in usual activity to a level that allows children to remain asymptomatic, followed by a gradual return to learning, is appropriate. It is clear that either too little or too much activity is disadvantageous to recovery and can worsen outcomes.

A qualitative review of sports concussion education: prime time for evidence-based knowledge translation.

BACKGROUND: Educating athletes, coaches, parents and healthcare providers about concussion management is a public health priority. There is an abundance of information on sports concussions supported by position statements from governing sport and medical organisations. Yet surveys of athletes, parents, coaches and healthcare providers continue to identify multiple barriers to the successful management of sports concussion. To date, efforts to provide education using empirically sound methodologies are lacking. PURPOSE: To provide a comprehensive review of scientific research on concussion education efforts and make recommendations for enhancing these efforts. STUDY DESIGN: Qualitative literature review of sports concussion education. METHODS: Databases including PubMed, Sport Discus and MEDLINE were searched using standardised terms, alone and in combination, including 'concussion', 'sport', 'knowledge', 'education' and 'outcome'. RESULTS: Studies measuring the success of education interventions suggest that simply presenting available information may help to increase knowledge about concussions, but it does not produce long-term changes in behaviour among athletes. Currently, no empirical reviews have evaluated the success of commercially available sports concussion applications. The most successful education efforts have taken steps to ensure materials are user-friendly, interactive, utilise more than one modality to present information and are embedded in mandated training programmes or support legislation. Psychosocial theory-driven methods used to understand and improve 'buy in' from intended audiences have shown promise in changing behaviour. CONCLUSIONS: More deliberate and methodologically sound steps must be taken to optimise education and knowledge translation efforts in sports concussion.

Bicycling crash circumstances vary by route type: a cross-sectional analysis.

BACKGROUND: Widely varying crash circumstances have been reported for bicycling injuries, likely because of differing bicycling populations and environments. We used data from the Bicyclists' Injuries and the Cycling Environment Study in Vancouver and Toronto, Canada, to describe the crash circumstances of people injured while cycling for utilitarian and leisure purposes. We examined the association of crash circumstances with route type. METHODS: Adult cyclists injured and treated in a hospital emergency department described their crash circumstances. These were classified into major categories (collision vs. fall, motor vehicle involved vs. not) and subcategories. The distribution of circumstances was tallied for each of 14 route types defined in an earlier analysis. Ratios of observed vs. expected were tallied for each circumstance and route type combination. RESULTS: Of 690 crashes, 683 could be characterized for this analysis. Most (74%) were collisions. Collisions included those with motor vehicles (34%), streetcar (tram) or train tracks (14%), other surface features (10%), infrastructure (10%), and pedestrians, cyclists, or animals (6%). The remainder of the crashes were falls (26%), many as a result of collision avoidance manoeuvres. Motor vehicles were involved directly or indirectly with 48% of crashes. Crash circumstances were distributed differently by route type, for example, collisions with motor vehicles, including "doorings", were overrepresented on major streets with parked cars. Collisions involving streetcar tracks were overrepresented on major streets. Collisions involving infrastructure (curbs, posts, bollards, street furniture) were overrepresented on multiuse paths and bike paths. CONCLUSIONS: These data supplement our previous analyses of relative risks by route type by indicating the types of crashes that occur on each route type. This information can guide municipal engineers and planners towards improvements that would make cycling safer.

Correction: Currie et al. Reality Check 2: The Cost-Effectiveness of Policy Disallowing Body Checking in Non-Elite 13- to 14-Year-Old Ice Hockey Players. Int. J. Environ. Res. Public Health 2021, 18, 6322.

There was an error in our original publication [...].

Comparing the effects of infrastructure on bicycling injury at intersections and non-intersections using a case-crossover design.

BACKGROUND: This study examined the impact of transportation infrastructure at intersection and non-intersection locations on bicycling injury risk. METHODS: In Vancouver and Toronto, we studied adult cyclists who were injured and treated at a hospital emergency department. A case-crossover design compared the infrastructure of injury and control sites within each injured bicyclist's route. Intersection injury sites (N=210) were compared to randomly selected intersection control sites (N=272). Non-intersection injury sites (N=478) were compared to randomly selected non-intersection control sites (N=801). RESULTS: At intersections, the types of routes meeting and the intersection design influenced safety. Intersections of two local streets (no demarcated traffic lanes) had approximately one-fifth the risk (adjusted OR 0.19, 95% CI 0.05 to 0.66) of intersections of two major streets (more than two traffic lanes). Motor vehicle speeds less than 30 km/h also reduced risk (adjusted OR 0.52, 95% CI 0.29 to 0.92). Traffic circles (small roundabouts) on local streets increased the risk of these otherwise safe intersections (adjusted OR 7.98, 95% CI 1.79 to 35.6). At non-intersection locations, very low risks were found for cycle tracks (bike lanes physically separated from motor vehicle traffic; adjusted OR 0.05, 95% CI 0.01 to 0.59) and local streets with diverters that reduce motor vehicle traffic (adjusted OR 0.04, 95% CI 0.003 to 0.60). Downhill grades increased risks at both intersections and non-intersections. CONCLUSIONS: These results provide guidance for transportation planners and engineers: at local street intersections, traditional stops are safer than traffic circles, and at non-intersections, cycle tracks alongside major streets and traffic diversion from local streets are safer than no bicycle infrastructure.

Barriers and facilitators to the uptake of the Concussion Awareness Training Tool as continuing medical education in primary care.

Aim: Continuing medical education (CME) informs physicians on current research. The Concussion Awareness Training Tool (CATT) provides education on concussion diagnosis and treatment. The aims of this study were to explore physician CME practices and preferences, understand barriers and facilitators to implementing the CATT as CME, and provide recommendations. Materials & methods: Physicians in British Columbia, Canada participated in an online survey and telephone interview. Descriptive analysis of quantitative data, and text-based data analysis were undertaken to identify themes. Results: Barriers included lack of time and awareness of the resource. Facilitators were its ease of use, accessibility, conciseness and comprehensiveness. Conclusion: The perceptions of barriers and facilitators reported by physicians are important to understand and better promote the use of the CATT.

Doctors take continuing medical education (CME) to stay on top of new information and practices. The Concussion Awareness Training Tool (CATT) is available for doctors to learn more about concussion care. This study looked at how doctors in British Columbia, Canada are taking CME training, and what factors are encouraging or preventing them from using the CATT. Doctors reported a lack of time for taking CME, and not knowing about this resource. Those who had taken the CATT training reported that it is easy to use, accessible, concise, and comprehensive. This information will be used to improve promotion of this resource.

Follow-up visits after a concussion in the pediatric population: An integrative review.

BACKGROUND: Concussions are a significant health issue for children and youth. After a concussion diagnosis, follow-up visits with a health care provider are important for reassessment, continued management, and further education. OBJECTIVE: This review aimed to synthesize and analyse the current state of the literature on follow-up visits of children with a concussive injury and examine the factors associated with follow-up visits. METHODS: An integrative review was conducted based on Whittemore and Knafl's framework. Databases searched included PubMed, MEDLINE, CINAHL, PsycINFO, and Google Scholar. RESULTS: Twenty-four articles were reviewed. We identified follow-up visit rates, timing to a first follow-up visit, and factors associated with follow-up visits as common themes. Follow-up visit rates ranged widely, from 13.2 to 99.5%, but time to the first follow-up visit was only reported in eight studies. Three types of factors were associated with attending a follow-up visit: injury-related factors, individual factors, and health service factors. CONCLUSION: Concussed children and youth have varying rates of follow-up care after an initial concussion diagnosis, with little known about the timing of this visit. Diverse factors are associated with the first follow-up visit. Further research on follow-up visits after a concussion in this population is warranted.

Activity and Recovery Among Youth With Concussion: A Meta-analysis.

CONTEXT: Concussions in youth are highly prevalent. Previously, rest was prescribed to prevent adverse outcomes; however, early return to activity is emerging to improve the recovery trajectory. OBJECTIVES: To evaluate the effectiveness of early return to physical and social activity interventions on recovery outcomes in youth with concussion. DATA SOURCES: A systematic review was conducted up to October 2022. STUDY SELECTION: We included randomized controlled trials (RCTs) and non-RCTs that reported effects of activity-based interventions on symptoms, quality-of-life (QoL), and return to preinjury activity levels in children and youth after a concussion. DATA EXTRACTION: Three authors independently extracted data on publication year and country, study setting and design, sample size, participant demographics, intervention, outcome(s), and author conclusion. Meta-analysis was conducted on appropriate RCTs. RESULTS: Twenty-four studies were included in the final review, of which 10 were RCTs. There was a significant effect of activity interventions on symptom reporting (standardized mean difference, 0.39 [95% confidence interval, 0.15 to 0.63]; I2, 0%; P = .002). There was not a significant effect of activity-based interventions on QoL (mean difference, -0.91 [95% confidence interval, -7.76 to 5.94]; I2, 0%; P = .79). No meta-analysis was performed on return to preinjury activity levels because of insufficient number of RCTs conducted. LIMITATIONS: One outcome was excluded from the meta-analysis. Interventions emphasizing social activity were lacking. CONCLUSIONS: Findings indicate that activity-based interventions may significantly improve concussion symptoms. There is insufficient data to understand the effect of activity-based intervention on QoL and return to preinjury activity levels.

The Concussion Awareness Training Tool for Women's Support Workers Improves Knowledge of Intimate Partner Violence-Caused Brain Injury.

Women who experience physical intimate partner violence (IPV) are at high risk of suffering a brain injury (BI) due to head impacts and/or strangulation. Currently, most staff at women's shelters tend not to be aware of IPV-caused BIs. The objective of this study was to address this by developing a new online module within the Concussion Awareness Training Tool (cattonline.com) specifically focused on IPV-caused BI, and measuring its effectiveness in increasing BI awareness and knowledge among staff members at women's shelters. A mixed-methods approach was used which included (i) a survey to measure participant knowledge before and after completing the module; (ii) a 1-on-1 interview 6 months post-training to better understand participants' perceptions of what effect the training had on how they worked with women in their job; and (iii) an evaluation of the content of the module using behavior change techniques. About 81 participants recruited from staff at women's shelters completed the pre/post survey. The average BI knowledge score increased significantly from the pre-survey (M = 8.12/12, SD = 1.05) to the post-survey (M = 9.72/12, SD = 1.62), t(80) = 9.12, P < .001, d = 1.01). Analysis of the interviews with 9 participants highlighted 3 main themes arising from the module: knowledge, mindfulness, and advocacy. All participants felt their knowledge of IPV-caused BIs had increased and said they would recommend the training to their co-workers. Analysis of the module content revealed the most frequent behavior change techniques were related to instructions on how to perform screening and accommodation for IPV-caused BI. The results showed the module was effective in increasing knowledge of IPV-caused BIs amongst women's shelter staff as well as improving how they advocate for, and are mindful of, their clients with BIs. This online training may help improve the care women with IPV-caused BIs receive, and ultimately improve their quality of life.

Development of a tailored concussion education program for athletes: a pragmatic multimethods design and integrated knowledge translation approach from needs assessment to design.

OBJECTIVES: To understand Canadian university athletic programme concussion management needs, and to describe development and content of a tailored online concussion education tool for Canadian university/college athletes. DESIGN: An integrated knowledge translation multiphased, multimethods approach was used. Phases included a needs assessment survey with university representatives and athletes, content selection, mapping behavioural goals to evidenced-based behaviour change techniques, script/storyboard development, engagement interviews with university athletes and tool development using user-centred design techniques. SETTING: Canadian U SPORTS universities (n=56). PARTICIPANTS: Overall, 64 university representatives (eg, administrators, clinicians) and 27 varsity athletes (52% male, 48% female) completed the needs assessment survey. Five athletes participated in engagement interviews. OUTCOME MEASURES: Surveys assessed previous athlete concussion education, recommendations for concussion topics and tool design, concussion management challenges and interest in implementing a new course. RESULTS: Institutions used a median (Med) of two (range 1-5) approaches when educating athletes about concussion. Common approaches were classroom-style education (50%), online training (41%) and informational handouts (39%). University representatives rated most important topics as: (1) what is a concussion, (2) how to recognise a concussion and (3) how to report a concussion (Medall=4.8/5). Athletes felt symptom recognition (96%) and effects on the brain (85%) were most important. The majority of athletes preferred learning via computer (81%) and preferred to learn alone (48%) versus group learning (7%). The final resource was designed to influence four behaviours: (1) report symptoms, (2) seek care, (3) encourage teammates to report symptoms and (4) support teammates through concussion recovery. Examples of behaviour change techniques included: knowledge/skills, problem-solving scenarios, verbal persuasion and social comparison. Athletes are guided through different interactions (eg, videos, flip cards, scenarios, testimonials) to maximise engagement (material review takes ~30 min). CONCLUSIONS: The Concussion Awareness Training Tool for athletes is the first Canadian education tool designed to address the needs of Canadian university/college athletes.