Objective To understand the factors affecting the decision to self-report a concussion – particularly among sub-groups like athletes and future pilots.

Design Survey.

Setting A United States military academy.

Participants Voluntarily participatingcadets (n=2,503, 23.9%=female).

Assessment of risk factors NCAA Division I athlete status, future pilot status, gender, school year were examined as factors affecting self-report.

Outcome measure Anticipated Self-Report (ASR) of concussion on a scale from 1–9 (most to least likely to self-report). Cadets completed a 2-page survey matching ASR to demographic risk factors (above), and to self-report questions assessing Costs, Rewards, Attitude, Subjective Norms, Self-Efficacy, and Social Support.

Main results Cadets demonstrated an overall willingness to self-report a concussion – indicated by a mean ASR score of 6.07 (95% CI=5.97–6.17, SD=2.47, median=7.00, n=2.332) above the scale midpoint. Costs (r=−0.61, p<0.001), Rewards (r=0.67, p<0.001) and Attitude (r=0.70, p<0.001) were highly, significantly predictive of ASR. Cadet sub-populations revealed the importance of specific costs. Aspiring pilots – concerned about concussions affecting their pilot qualification status –steadily decreased ASR by year, while non-pilot cadets retained consistent ASR, shown by Future Pilot x Class Year ANOVA (F(3,2196)=11.78, p<0.001). NCAA Athletes, conversely, showed no ASR differences from non-athletes, t(2251)=0.16, p=0.87, CI =±0.23.

Conclusions Symptom self-report is a crucial factor in all stages of concussion care. Costs and rewards affecting self-report may have unique contexts that drive unexpected self-report patterns. Here, aspiring pilots showed lower self-report behaviour while athletes showed average self-report behaviour – based on perceived costs to career aspirations. These data will be used to design interventions to increase to concussion self-report.

Competing interests All authors received funding from the National Collegiate Athletic Association and Department of Defense (NCAA Mind Matters Challenge).