"Letter to my future self" as a device for assessing health education effectiveness.

OBJECTIVE: To examine whether a "letter to my future self" analyzed using structural topic modeling (STM) represents a useful technique in revealing how participants integrate educational content into planned future behaviors. METHODS: 453 club-sports athletes in a concussion-education randomized control study wrote two-paragraph letters describing what they hoped to remember after viewing one of three randomly assigned educational interventions. RESULTS: A six-topic solution revealed three topics related to the content of the education and three topics related to the participant behavioral takeaways. The content-related topics reflected the educational content viewed. The behavioral takeaway topics indicated that the Consequence-based education was more likely to generate the Concussion Seriousness[CS:23%] topic while Traditional(24%) and Consequence-based(20%) interventions were more likely to generate the Responsibility for Brain Health[BH] topic. Traditional(21%) and Revised-symptom(17%) interventions were more likely to generate the Awareness and Action topics. CONCLUSION: Unstructured user-generated data in the form of a "letter to my future self" analyzed using structural topic modeling provides a novel evaluation of the present and likely future impact of educational interventions. PRACTICE IMPLICATIONS: Patient educators can enhance the effectiveness of education through the application of these methods to the evaluation of and innovation in programs.

The Role of Athlete Competitiveness in High School Sport Specialization in the United States.

Background: Sport specialization has been associated with increased injury and negative psychosocial effects on young athletes. With the continuing trend toward specialization, studies have begun to examine what motivates this decision (eg, building a skill, getting a scholarship). No study has directly assessed the personal characteristics underlying these stated reasons. Purpose/Hypothesis: This study examined the role of athlete competitiveness (enjoyment of competition and competitive contentiousness) as a characteristic associated with propensity to specialize in the United States. We hypothesized that, at the high school level, athletes would be more likely to engage in sport specialization owing to enjoyment of competition versus competitive contentiousness. Study Design: Cross-sectional study; Level of evidence, 3. Methods: We conducted an online survey of 975 high school athletes in the United States who were recruited via the Dynata research panel. Measures included a previously published sport specialization categorization (low, medium, high) and the 2 dimensions of the Revised Competitiveness Index (enjoyment of competition and competitive contentiousness). Also collected were athlete characteristics, sports played by the athletes, level of competition, and whether they planned to play sports in college. Analytical methods employed included cross-tabulations, multinomial logit, and ordinary least squares regression. Results: Overall, 22.4% of the athletes reported a high, 34.8% reported a medium, and 42.9% reported a small level of specialization. No differences in the distribution of sport specialization by sex or age were observed; however, athletes who definitely planned to play in college were significantly more likely to have a high level of specialization (P < .001). Enjoyment of competition was associated with greater specialization (beta = .196; P < .001), whereas competitive contentiousness was associated with lower levels of specialization (beta = -.299; P < .001). These findings were robust to all 3 different analytical methods we employed. Conclusion: Study findings indicated that, while athlete competitiveness is associated with sport specialization, the nature of that competitiveness determined the association. Being an argumentative contrarian may predispose athletes to lower levels of sport specialization, whereas enjoying competition may encourage higher levels of specialization.

Parents and coaches as transformational leaders: Motivating high school athletes' intentions to report concussion symptoms across socioeconomic statuses.

PURPOSE: Studies demonstrate that parents and coaches play a role in an athlete's concussion reporting decision primarily through their influence on the decision environment. Little work, however, has explored how a given parenting/coaching style operates to promote intentions and much less work has examined whether the impact of parenting/coaching on concussion reporting differs by socioeconomic status. Transformational parenting/coaching (i.e., a focus on building autonomy and self-efficacy in athletes) represents one promising approach given its effects on other outcomes (e.g., health, burnout, aggression). We hypothesize that athlete perceptions of transformational parenting/coaching will be associated with their reporting intentions directly and through the athlete's motivation for playing their sport regardless of household income. METHODS: A national survey of 1023 high-school athletes measured athlete perceptions of transformational parenting/coaching, sport motivation, and reporting intentions. Structural Equation Modeling was used to examine hypotheses. RESULTS: Transformational parenting was directly associated with reporting intentions (ß: Reporting Intentions = .265; Scenario 1 = 0.206; Scenario 2 = 0.260) and indirectly through increased autonomous/decreased controlled motivation. Transformational coaching was not directly associated with Reporting Intentions (ß = 0.008, p = .816) or Scenario 2 (ß = 0.046, p = .198) but was for Scenario 1 (ß = 0.077, p = .003). Transformational coaching was also associated with reporting intention indirectly through increased autonomous, but not controlled motivation. Athletes with household income of $50,000+ were more likely to report transformational parenting/coaching; however, the effects of transformational parenting/coaching did not differ for athletes from higher versus lower-income households. CONCLUSIONS: Transformational parenting/coaching may encourage greater concussion reporting intentions primarily through increased autonomous (i.e., self-directed) sport motivation regardless of socioeconomic status. Cultivating transformational leadership in parents/coaches can have a positive impact on the athlete's intention to report concussion-like symptoms.

Sport Motivation as a Possible Indicator of Concussion Reporting Intentions Among Young Athletes.

OBJECTIVE: To assess the relationship between sport motivation and intentions to report concussion symptoms among young adult athletes. DESIGN: Cross-sectional study (level of evidence: 3). SUBJECTS: One thousand three hundred five young adult athletes of various sports and levels of competitiveness from the Survey Sampling International panel. METHODS: Data were collected through an online survey. Ordinary least squares regression was used to examine the relationship between motivation and reporting intentions controlling for competitiveness and perceived risk of injury. RESULTS: Athletes who play their sport for self-regulated (autonomous) reasons have higher intentions to seek care for concussion-like symptoms, whereas those who play to achieve gains external to the sport or avoid punishment (controlled motivation) have lower intentions. A one-point increase in autonomous motivation was associated with an 11.5-point increase in reporting intention (t = 6.629, P < 0.001), whereas a one-point increase in controlled motivation was associated with an 8.1-point decrease in reporting intention (t = -4.562, P < 0.001). Betas from the model suggested that autonomous motivation had a stronger effect than controlled motivation (0.226 vs -0.163). CONCLUSIONS: Innovation in care, concussion education, and cultivation of team culture supportive of autonomous motivation could increase concussion reporting. Measuring sport motivation may reveal which athletes require more proactive attention to ensure symptoms are not concealed. Furthermore, messages to reinforce autonomous motivation may increase willingness to report.

A Social-Marketing Intervention and Concussion-Reporting Beliefs.

CONTEXT: Concussion-symptom education remains the primary approach used by athletic trainers to address underreporting of possible sport-related concussions. Social marketing represents an untapped approach to promote concussion reporting by communicating the benefits or consequences of reporting or not reporting, respectively. OBJECTIVE: To apply expectancy value theory and identify how marketing the possible consequences of concealing concussion symptoms influenced young adults' concussion-reporting beliefs to increase the likelihood of reporting. DESIGN: Randomized controlled clinical trial. SETTING: Laboratory. PATIENTS OR OTHER PARTICIPANTS: A total of 468 competitive collegiate club sport athletes at a large US university who engaged in 1 of 46 sports with various levels of concussion risk. INTERVENTION(S): Participants were randomly assigned by team to 1 of 3 conditions. The treatment condition was a social-marketing program focused on the possible consequences of the reporting decision. The control condition was traditional concussion-symptom education based on the National Collegiate Athletic Association's publication, "Concussion: A Fact Sheet for Student-Athletes." An additional condition mirrored the traditional symptom education but included a less clinical delivery. MAIN OUTCOME MEASURE(S): Positive and negative beliefs regarding concussion reporting were assessed. We applied expectancy value theory, which posits that changing beliefs in the short term will produce greater reporting intentions in the long term. RESULTS: Club sport athletes exposed to consequence-based social marketing showed higher levels of positive reporting beliefs and lower levels of negative reporting beliefs than athletes exposed to traditional or revised symptom education. We observed no differences between the traditional and revised symptom-education programs. Exposure to consequence-based marketing decreased negative beliefs about reporting (B = -0.165, P = .01) and increased positive beliefs about reporting (B = 0.165, P = .01). CONCLUSIONS: Social marketing offers athletic trainers another strategic tool for motivating athletes to report concussion symptoms by translating scientific findings into marketable statements and then communicating the benefits of reporting or the negative consequences of concealing concussion symptoms.

Reporting Skill: The Missing Ingredient in Concussion Reporting Intention Assessment.

BACKGROUND: Extant literature suggests that a substantial portion of athletes may not report a possible concussion and that concussion knowledge is insufficient to predict concussion reporting behavior. One area that has not been explored is reporting skill; that is, mastery of the actions required to report a concussion. This study evaluated the relationship between reporting skill and reporting intention, introducing a measure of the reporting skill construct. HYPOTHESES: Reporting intentions will be more closely associated with reporting skill than with concussion/symptom knowledge. The relationship between concussion (or symptom) knowledge and reporting intentions will differ by level of reporting skill. STUDY DESIGN: Repeated cross-sectional study. LEVEL OF EVIDENCE: Level 2. METHODS: A set of items was administered to young adults aged 18 to 24 years from the Survey Sampling International panel. Exploratory/confirmatory factor analyses were conducted on 2 waves of data to develop the scale (n = 899). Hypotheses were tested using structural equation modeling on the responses from the third wave of participants (n = 406). RESULTS: Knowing the actions to take in reporting was more important than having knowledge of concussions or concussion symptoms. Reporting skill, not concussion or concussion symptom knowledge, was associated with higher intentions to report symptoms. Among those with higher levels of reporting skill, concussion symptom knowledge (but not general concussion knowledge) was associated with higher intentions to report symptoms. CONCLUSION: Reporting skill is an important and, until now, missing ingredient in the concussion literature and practice. CLINICAL RELEVANCE: Incorporating reporting skill development in concussion education and team activities to teach athletes how to report is likely to improve actual reporting intentions. While further study is needed with particular sports and additional age groups, reporting skill holds promise as a new avenue for increased concussion reporting.

School and Community Socioeconomic Status and Access to Athletic Trainer Services in Wisconsin Secondary Schools.

CONTEXT: Secondary schools have made significant progress in providing athletic trainer (AT) coverage to their student-athletes, but the levels of access at schools with ATs may vary widely. Socioeconomic disparities in medical coverage and access have been noted in other health care fields, but such disparities in the level of access to AT services have not been thoroughly examined. OBJECTIVE: To determine if (1) access to AT services or (2) the level of access (AT hours per week and athletes per AT hour) differed based on the socioeconomic characteristics of secondary schools. DESIGN: Cross-sectional study. SETTING: Mailed and e-mailed surveys. PATIENTS OR OTHER PARTICIPANTS: High school athletic directors and ATs from 402 Wisconsin high schools. MAIN OUTCOME MEASURE(S): Respondents provided information as to whether their school used the services of an AT and the number of hours per week that their school had an AT on-site. The number of athletes per AT hour was calculated by dividing the total number of athletes at the school by the number of hours of AT coverage per week. The socioeconomic status of each school was determined using the percentage of students with free or reduced-cost lunch and the county median household income (MHI). RESULTS: Schools without an AT on-site were in lower MHI counties ( P < .001) and had more students eligible for a free or reduced-cost lunch ( P < .001). Lower levels of AT access (fewer hours of AT access per week and more athletes per AT hour) were observed at schools in the lowest third of the county MHI and with the highest third of students eligible for a free or reduced-cost lunch ( P < .001). CONCLUSIONS: Socioeconomic disparities were present in access to AT services. New models are needed to focus on providing a high level of AT access for all student-athletes, regardless of socioeconomic status.

Changes in Health-Related Quality of Life and Knee Function After Knee Injury in Young Female Athletes.

BACKGROUND: Recent literature has called for greater attention to evidence-based practice in sports medicine with the documentation of overall status and impairments following injury. The prospective documentation of impairments associated with knee injuries in female athletes regarding their health-related quality of life (HRQoL) and knee function (KF) of high school and collegiate athletes is limited. Assessing the effect knee injuries have on young female athletes may allow clinicians to better understand the perspectives of the athletes who sustain these injuries. PURPOSE: To document the changes over 12 months in self-reported HRQoL and KF in young females who have sustained a knee injury. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A convenience sample of 242 females (mean age, 17.4 ± 2.4 years) who injured their knee participating in sport or recreational activities was utilized. Injuries were categorized as anterior cruciate ligament tears (ACL), anterior knee pain (AKP), patellar instability (PAT), meniscus tear (MNT), iliotibial band syndrome (ITB), collateral ligament sprain (COL), and other (OTH). HRQoL was assessed with the Short Form-12 v 2.0 survey (SF-12) physical component summary (PCS) and mental component summary (MCS). KF was assessed with the 2000 International Knee Documentation Committee survey (IKDC). Dependent variables included the paired differences in the 2000 IKDC as well as SF-12 composite scores from preinjury through 12 months postdiagnosis. Paired differences were assessed with repeated-measures analyses of variance (P ≤ .05). RESULTS: IKDC scores were lower through 12 months for ACL, AKP, and PAT; through 6 months for MNT; and through 3 months for COL and OTH. HRQoL PCS and MCS scores were lower through 3 to 12 months depending on the type of injury classification. CONCLUSION: Knee injuries can negatively affect KF and HRQoL for up to 12 months in young females. Sports medicine providers need to be aware of these impacts as they work to effectively treat individuals with these injuries.

Comparison of IKDC and SANE Outcome Measures Following Knee Injury in Active Female Patients.

BACKGROUND: Knee injury among young, active female patients remains a public health issue. Clinicians are called upon to pay greater attention to patient-oriented outcomes to evaluate the impact of these injuries. Little agreement exists on which outcome measures are best, and clinicians cite several barriers to their use. Single Assessment Numerical Evaluation (SANE) may provide meaningful outcome information while lessening the time burden associated with other patient-oriented measures. HYPOTHESIS: The SANE and International Knee Documentation Committee (IKDC) scores would be strongly correlated in a cohort of young active female patients with knee injuries from preinjury through 1-year follow-up and that a minimal clinically important difference (MCID) could be calculated for the SANE score. STUDY DESIGN: Observational prospective cohort. METHODS: Two hundred sixty-three subjects completed SANE and IKDC at preinjury by recall, time of injury, and 3, 6, and 12 months postinjury. Pearson correlation coefficients were used to assess the association between SANE and IKDC. Repeated-measures analysis of variance was used to determine differences in SANE and IKDC over time. MCID was calculated for SANE using IKDC MCID as an anchor. RESULTS: Moderate to strong correlations were seen between SANE and IKDC (0.65-0.83). SANE, on average, was 2.7 (95% confidence interval, 1.5-3.9; P < 0.00) units greater than IKDC over all time points. MCID for the SANE was calculated as 7 for a 6-month follow-up and 19 for a 12-month follow-up. CONCLUSION: SANE scores were moderately to strongly correlated to IKDC scores across all time points. Reported MCID values for the SANE should be utilized to measure meaningful changes over time for young, active female patients with knee injuries. CLINICAL RELEVANCE: Providing clinicians with patient-oriented outcome measures that can be obtained with little clinician and patient burden may allow for greater acceptance and use of outcome measures in clinical settings.