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Abstract
Background/aim Concussion guidelines exist for multiple community sports. Parents are key stakeholders in guideline implementation and in appropriate responses following concussive injury. The purpose of this qualitative investigation was to understand how parents of community-level Australian Football (AF) players experience and perceive concussion guidelines in order to inform the design and implementation of concussion guidelines in community sport.
Methods A cross-sectional qualitative approach was adopted to allow for an open and detailed exploration of the views of parents of junior community AF players (ie, those aged <16 years) regarding concussion guidelines of the AF League (AFL)—the national governing body for AF. Participants were 15 parents of junior community AF players from two clubs affiliated with a large regional community AF League.
Results The key experiences and perceptions of the parents included appreciation that the guidelines outlined the postconcussion process that should be followed, desires for better understanding of the guidelines by general practitioners (ie, medical doctors) who care for children with concussion, having more readily available information for parents and receiving more formal policy guiding timing of return-to-participation following concussion. Difficulties with the guidelines not addressing delayed presentations of concussion were also frequently mentioned.
Conclusions Parents are key stakeholders in concussion prevention and care in community sport. As such, their input should be considered when developing guidelines and resources for community sport. Furthermore, concussion information should be made available to parents in an easily accessible and community-friendly form.
- Concussion
- Qualitative
- Australian football
- Implementation
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What are the findings?
Parents are concerned about medical doctors’ knowledge and management of concussion.
Systematically available concussion educational material and guideline information is important to parents.
Parents desire clearer information on timing of return–to–participation.
Introduction
Targeted guidelines exist in various sports to encourage an appropriate response following concussion among participants.1–4 These guidelines include appropriate steps to follow should someone sustain a suspected concussion and have been adapted for many types of community sports, including Australian Football (AF).3 4 Stakeholder understanding and implementation of these guidelines are key to achieving the intended outcomes of appropriate injury recognition and management, and ultimately improved safety following concussion. Parents are a primary stakeholder to consider in concussion guideline development and implementation in the community sport setting. Furthermore, a recent study among parents of AF players suggested that those with concussion-related training had better knowledge than those with no training or background.5 Parental involvement in this setting is high and parents are the primary care-seekers for their children following concussion.6
Despite the role of parents in the implementation and sustainability of concussion guidelines, no studies have evaluated parents’ perceptions of these guidelines and their perceived advantages and disadvantages. The purpose of this qualitative investigation was to understand how parents of community-level AF players experience and perceive concussion guidelines in order to inform the design and implementation of concussion guidelines in community sport.
Methods
A qualitative approach was adopted to allow for an open and detailed exploration of parents of junior community AF players’ (ie, those aged <16 years) views on the AF League’s (AFL—the national governing body for AF) concussion guidelines. A convenience sample of 15 parents of junior male community AF players from two clubs affiliated with a large regional community AF league was recruited. Being a parent of a child who was playing AF in the current season was the only inclusion criterion. The groups included both male and female parents from two clubs affiliated with a large regional community AF league. These clubs (and parents) were the only ones who responded to an invitation to parents to participate in the study, circulated through the AF league’s networks. At the time of the study, the AF league was a male league, so all focus participants were parents of boys. Two focus groups (group 1 n=9, group 2 n=6) were conducted. The focus groups were conducted at the respective club’s clubrooms, and the parents participated in a focus group with other parents from their child’s club only.
The parents were encouraged to access the 2011 AFL concussion guidelines one week before the focus groups. They were also provided with a hard copy of these guidelines at the time of the group. Focus group discussions were conducted before the end of the 2012 playing season. They were led by author AD, an experienced focus group facilitator, with assistance from the lead author. Each discussion lasted approximately 1 hour and took place at the AF club's clubrooms on a midweek evening.
At the beginning of each focus group, parents were provided with a written scenario and some follow-up questions. They were asked to write dot point responses to the questions to stimulate their thinking around some of the issues that would then be discussed. The remainder of each focus group followed a semistructured script. Group discussions were audio-recorded and transcribed verbatim. Transcripts were checked for accuracy against the audio-recordings and corrected for anomalies. The transcripts were read and re-read, and hand-coded by two authors (PW and JR-M) using thematic analysis as a framework. Transcripts were coded independently and discrepancies were resolved through discussion. The coding scheme was designed to extract major and subthemes relating to the focus group discussion themes of advantages and disadvantages to implementing the guidelines, facilitators and barriers to using the guidelines, as well as ways to improve the guidelines and deliver them more effectively.
The study was approved by the Monash University Human Research Ethics Committee. Participants were given a plain language statement about the research project and provided written, informed consent prior to study participation.
Results
Approximately one-third of the parents were also sports trainers who provided field-side first aid support. These sports trainers, who are usually volunteers with a sports team, undergo several hours of accredited sports first aid training. Thus, it is likely that parents who are also sports trainers would be more knowledgeable about, and more interested and experienced in dealing with, concussion than others. While the perceptions and experiences of people who are both parents and sports trainers may be different to those of people who are a parent only, including parents who are sports trainers in the current sample reflects the dual roles of many parents in community AF.
Table 1 outlines the subthemes identified for the advantages and disadvantages. Table 2 outlines the subthemes identified for facilitators and barriers. Table 3 outlines the subthemes identified to improve and deliver the guidelines.
Parent-stated advantages and disadvantages to implementing the concussion guidelines in community Australian Football
Parent-stated facilitators and barriers to appropriate use of the concussion guidelines in community Australian Football
Ways to improve and delivery the guidelines more effectively
Discussion
This study highlights the experiences and perceptions of parents of junior community AF players in the implementation and use of the AF concussion guidelines. The key experiences and perceptions most commonly discussed by the parents in the focus group sessions were:
appreciation that the guidelines outlined the postconcussion process that should be followed
desires for a better understanding of the guidelines by general practitioners (GP) (ie, doctors) who care for children with concussion including that they follow and provide advice on the guidelines
desires to have more information available to parents in a systematic fashion and a more formal policy around timing of return-to-participation following concussion (eg, 2-week mandatory no play period)
difficulties with the guidelines not addressing delayed presentations of concussion.
These perceptions, particularly those around the level of knowledge and understanding about concussion held by GPs/medical doctors and the associated lack of confidence in the care they provide, reiterate the previously stated need for improved community-based education and understanding of the best practices around concussion recognition and management among all stakeholders, including the players themselves.7 In Australia, GPs typically complete 4 years of undergraduate medical training, followed by an hospital internship and 3–4 years of training to obtain specialist (GP) registration. Their training is general in nature and includes very little sports medicine or concussion-related education.
Club-level implementation
While this study examined perceptions around the 2011 guidelines, the AFL has updated their guidelines8 to address some of the barriers and drivers observed in this study. The new guidelines include parent, player and practitioner information but many parents of community-level players may not be aware of these resources. Being directed towards this information, and perhaps even including some of this information in the process of registering to participate in the sport, may improve dissemination. In addition, community clubs and leagues should encourage their local GPs to become familiar with these resources and guidelines. Clubs could also develop partnerships with GPs who do have this knowledge, so that they can recommend or direct parents to visit these specific GPs. While these findings are specific to community AF, other governing bodies across the world have recommended and produced similar guidelines.9 10 Therefore, these findings could also improve the development and implementation of concussion guidelines across various sports.
Limitations
This study is limited by the fact that only two focus groups were conducted. However, saturation of topics raised by the participants was reached and it is not expected that the major findings from this study would have changed if more focus groups had been conducted. Unfortunately, we did not record the profiles of the participants in terms of their gender, age or roles with teams of players, and so on, so it is not possible to describe the specific participants in detail. As noted above, some participants were trained in sports first aid, including concussion recognition and management, and their views may have skewed the results towards them being more aware of concussion-related issues than other parents. The study was conducted in a male-only AF league, so the views expressed were from parents of boys. Parents of girls may hold different views about concussion guidelines and this should be explored in future research, especially given the increasing popularity of female AF.
Conclusions
Parents are key stakeholders in concussion recognition and management in community sport. Important factors to consider when developing and implementing improved concussion guidelines in community sport include increasing their accessibility and visibility for parents and players, addressing delayed presentation of concussion symptoms, explaining how and why to use the guidelines, and developing and enforcing club and league policies that support the use of best practice guidelines when caring for young athletes suffering a concussion.
Footnotes
Acknowledgements The Australian Collaboration for Research into Injury in Sport and its Prevention is one of the International Research Centres for the Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee. Aspects of this work were undertaken when authors PEW, AD and CFF were previously employed at Monash University.
Contributors PEW and JS designed the focus group schedule. PEW and AD conducted the focus groups. PEW and JRM, with advice from JS, undertook the qualitative coding and analysis of the focus group data. CFF contributed to the design of the larger study that this project was associated with. All authors assisted with the interpretation of the findings. PEW led the writing of the paper and all other authors contributed to its editing and gave their approval of the manuscript for submission.
Competing interests None declared.
Ethics approval Monash University Human Research Ethics Committee (HREC CF12/1178 2012000575).
Provenance and peer review Not commissioned; externally peer reviewed.