Evaluating Concussion Nondisclosure in College Athletes using a Health Disparities Framework and Appreciation for Social Determinants of Health

Jessica Wallace
Erica Beidler, Duquesne University, Department of Athletic Training, Assistant Professor, 600 Forbes Avenue, 118 Health Sciences Building Pittsburgh, PA 15280.
Johna K. Register-Mihalik, The University of North Carolina at Chapel Hill, Department of Exercise and Sport Science, Co-Director, STAR Heel Performance Laboratory, Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center Injury Prevention Research Center, Associate Professor Chapel Hill, NC 27599-8700.
Tamaria Hibbler, Michigan State University, Department of Athletics, Assistant Athletic Trainer, 771 Chestnut Road, East Lansing, MI 48824.
Abigail Bretzin, Postdoctoral Research Fellow, University of Pennsylvania, Department of Epidemiology, Philadelphia, PA.
Spencer DeMedal, Undergraduate Research Assistant, Duquesne University, Department of Biological Sciences, 118 Health Sciences Building Pittsburgh, PA 15280.
Zachary Y. Kerr, The University of North Carolina at Chapel Hill, Department of Exercise and Sport Science, Assistant Professor, 313 Woollen Gym, CB#8700, Chapel Hill, NC 27599-8700.


CONTEXT: There is limited research concerning the relationship between social determinants of health, including race, healthcare access, socioeconomic status (SES), and physical environment; and, concussion nondisclosure in college-athletes. However, in high school athletes, disparities have been noted, with Black athletes attending under-resourced schools and lacking access to an athletic trainer (AT) disclosing fewer concussions. OBJECTIVE: To investigate whether concussion nondisclosure disparities exist by 1) race, 2) SES, and 3) AT healthcare access prior to college; and to understand the differential reasons for concussion nondisclosure between Black and White college-athletes. DESIGN: Cross-sectional Setting: College athletics Participants: 735 college-athletes (84.6% White, 15.4% Black) Main Outcome Measures: Participants completed a questionnaire that directly assessed concussion nondisclosure, including reasons for not reporting a suspected concussion. With the premise of investigating social determinants of health, race was the primary exposure of interest. The outcome of interest, nondisclosure, was assessed with a binary (yes/no) question, "Have you ever sustained a concussion that you did not report to your coach, athletic trainer, parent, teammate, or anyone else?" RESULTS: Overall, among White and Black athletes 15.6% and 17.7% respectively reported a history of concussion nondisclosure. No significant differences were found by race for distributions of history of concussion nondisclosure (p=0.57). Race was not associated with concussion nondisclosure when evaluated as an effect modification measure or confounder; and, no significant associations were noted by SES or high school AT access. Differences by race for reported reasons for nondisclosure were found for: "At the time I did not think it was a concussion" (p=0.045) and "I thought my teammates would think I am weak" (p=0.03) with Black athletes reporting these more frequently than White athletes. CONCLUSIONS: These data help to contextualize race and its intersection with other social determinants of health that could influence concussion nondisclosure outcomes in college-athletes.