Concussions and other traumatic brain injuries (TBIs) that occur during sports- or recreation-related (SRR) activities disproportionately affect children under the age of 18 (Coronado et al., 2015). The Centers for Disease Control and Prevention (CDC) estimated that in 2016 more than 273,000 children aged 17 years and under sought care in U.S. emergency departments for an SRR-TBI, including concussions (Sarmiento et al., 2019). TBIs sustained in contact sports accounted for approximately 45% of all SRR-TBI emergency department visits among children between 2010 and 2016 (Sarmiento et al., 2019).

In order to help improve awareness about concussions and other TBIs, CDC has distributed educational materials and messages through its HEADS UP campaign for more than 15 years (Centers for Disease Control and Prevention, 2016; Sarmiento, Hoffman, Dmitrovsky, & Lee, 2014). The goal of the campaign is to “Protect kids and teens by raising awareness and informing action to improve prevention, recognition, and response to concussion and other serious brain injuries” (Centers for Disease Control and Prevention, 2016). The most accessed educational tool in the CDC HEADS UP campaign is an online training for youth sports coaches. Approximately 10,000 to 30,000 individuals complete the training each month (Sarmiento et al., 2014). First released in 2010, the CDC HEADS UP online training course for youth sports coaches includes learning objectives aimed at improving: (1) understanding of concussion and its potential consequences; (2) recognition of concussion signs and symptoms and how to respond; (3) coaches’ ability to implement return to activity (sports and school) steps after a concussion; and (4) focus on concussion prevention and preparedness (Centers for Disease Control and Prevention, 2017).

In 2017, CDC updated the training and added pre-test and post-test modules (Centers for Disease Control and Prevention, 2017). The pre- and post-test modules were designed to help evaluate the effectiveness of the training on concussion knowledge, attitudes, and intentional behavioral intentions (e.g., likelihood of taking actions if a concussion is suspected) prior to and immediately following completion of the training. Although designed for youth sports coaches, the training is publicly available and commonly used by sports officials and athletic trainers. In fact, among the sample of over 200,000 respondents who took the training between November 2016 and November 2017, 2% were athletic trainers and 5% were sports officials. Additionally, the preponderance of concussion education and training available is for coaches. Therefore, if athletic trainers and sports officials are interested in educating themselves about concussion prevention and response best practices, they often need to take advantage of resources aimed at coaches.

Both sports officials and athletic trainers are integral to supporting athlete safety and injury prevention. However, their individual roles in addressing these issues are unique. Sports officials (also referred to as referees and umpires) are present at sports competitions and games to help maintain standards of play (Bureau of Labor Statistics, 2019). To support athlete safety, sports officials enforce the rules of the sport, assess penalties when necessary, and inspect sports equipment and facilities (Bureau of Labor Statistics, 2019). Sports officials are often in close proximity to athletes, allowing them to observe potential head impacts and associated signs of a concussion. If a concussion or other injury is suspected, sports officials can stop the game or competition and request medical attention for an athlete. A study of college football sports officials found that knowledge about concussion symptoms is associated with greater self-efficacy for calling an injury timeout for a possible concussion (Kroshus, Parsons, & Hainline, 2017). In 2014, CDC developed an educational handout for sports officials on concussion. However, to our knowledge there is no published literature on sports officials’ concussion knowledge, attitudes, and behaviors at the youth sports level. In addition, there is no available research on the effectiveness of concussion educational materials or interventions developed specifically for sports officials at the youth sports level.

The role of athletic trainers and their positive contributions to concussion identification and response at the high school and college levels is well-documented (Broglio et al., 2014; Kroshus, Rivara, Whitlock, Herring, & Chrisman, 2017; McGuine et al., 2018). Athletic trainers conduct concussion evaluations, initiate plans for concussion management, and assist with concussion education and prevention (Broglio et al., 2014). The National Athletic Trainers’ Association (NATA) recommends that sports programs have athletic trainers at both practices and games (Broglio et al., 2014). At the high school level, approximately 70% of schools have access to a full-time, part-time, or per diem athletic trainer (Pryor et al., 2015). Current estimates of youth sports program’s access to athletic trainers at practices and competitions falls well short of this and the NATA recommendation, with only 53% of youth sports coaches in one study reporting having access to an athletic trainer at some or all games and practices (Sarmiento, Daugherty, & DePadilla, 2019). There are a limited number studies on educational tools and knowledge related to concussion among athletic trainers at the high school level (McGrath, McGrath, & Bastola, 2017; Naftel, Yust, Nichols, King, & Davis, 2014). However, as with sports officials, research on concussion knowledge, attitudes, and behaviors, or the effectiveness of interventions developed specifically for athletic trainers at the youth sports level, is not currently available.

The purpose of this paper is to present findings from an analysis of the CDC HEADS UP online training pre-test and post-test modules completed by participants who self-reported as an athletic trainer or sports official. Changes in knowledge, attitudes, and behavioral intentions related to concussion among these groups prior to and immediately after completing the training are examined. Findings from this manuscript can help CDC update the HEADS UP campaign content, including updates to future iterations of the training and other materials.

In response to the educational requirements included within many of the state-level concussion in sports laws (Harvey, 2013), coaches and others involved in youth athletics are often directed by their sports programs or schools to complete the CDC HEADS UP online training prior to the start of the sports season. The CDC HEADS UP training is offered at no cost and accessible to any individual through CDC’s website (Centers for Disease Control and Prevention, 2017). Responses to the training’s pre- and post-tests are recorded in a secure database using a unique code to protect the privacy of the participants. Data for this paper were collected between November 2016 and November 2017. The course took approximately 30–40 min to complete (the tests took approximately 10 min) and the participants received a certificate of completion upon passing the post-test. CDC determined that data collection was not subject to Institutional Review as the data were collected as part of the regular function of the training and designed for training improvement and evaluation.

The sports officials and athletic trainers who took the CDC HEADS UP training were involved with a variety of sports (Table 1). The most common sport for sports officials was soccer (50.2%), followed by baseball (31.9%), and basketball (23.0%). Soccer was also the most common sport among athletic trainers (35.9%), followed by football (27.7%), and basketball (25.7%). Most sports officials and athletic trainers worked with multiple age groups of children, but the most common age group that sports officials worked with was children aged 11–13 years (72.7%). The most common age group athletic trainers worked with were those aged 14–18 years (63.2%). About three-fourths of both sports officials (77.6%) and athletic trainers (73.4%) reported working with both boys and girls.

Table 2 displays the results of the changes in percentage of respondents who answered each pre- and post-test knowledge question correctly. Of the 13 questions, eight pre-test questions were answered correctly by 90% or more sports officials and seven questions were answered correctly by more than 90% of athletic trainers. All questions demonstrated statistically significant improvement from pre- to post-test, and most also had a medium or high level of practical significance as judged by Cohen’s g. However, because of the large number of questions, only results related to the questions in which fewer than 90% of respondents knew the correct answer on the pre-test are presented here in the text (full results are available in Table 2).

About 88.6% of sports officials and 86.5% of athletics trainers knew that it was true that, “Athletes who have ever had a concussion are at increased risk for another concussion,” in the pre-test. Those percentages improved to 94.6% and 93.5%, respectively, and both Cohen’s g’s for the differences indicate a large level of practical significance (g = 0.31 and 0.30, respectively). About 34.3% of sports officials and 34.5% of athletic trainers knew that it was true that, “Athletes who are removed from play because of a possible concussion should return to play only after they are back to their regular school activities,” in the pre-test. In the post-test these percentages improved to 57.0% and 55.2%, respectively. The improvements were statistically significant (p < 0.0001) and the effect size indicated a large level of practical significance (Cohen’s g = 0.31 and 0.28, respectively). About 6 in 10 sports officials (62.4%) and athletic trainers (59.1%) knew the correct response to the scenario asking what to do with an athlete who sustains a concussion during a game but wants to keep playing. In the post-test these percentages increased to 89.1% an 86.5%, respectively. The changes were statistically significant (both p < 0.0001) and had a large practical significance (both Cohen’s g = 0.44). In the pre-test, 68.4% of sports officials and 66.4% of athletic trainers knew the correct response to “Most athletes with a concussion feel better [in what time frame]?” In the post-test, 81.4% of sports officials and 77.6% of athletic trainers answered it correctly. These differences were statistically significant (both p < 0.0001) and demonstrated a large level of practical significance (Cohen’s g = 0.26) for sports officials and a medium level of practical significance (Cohen’s g = 0.22) for athletic trainers. Finally, 45.0% of sports officials and 42.9% of athletic trainers knew the correct answer to the question, “What percentage of athletes do researchers think try to hide their concussion symptoms from their coach?” in the pre-test. These percentages improved to 63.9% and 58.7% in the post-test. Both of these improvements were statistically significant (both p < 0.0001) and had a medium level of practical significance (Cohen’s g = 0.24 and 0.21, respectively).

The distribution and median score for the respondents’ pre- and post-test attitudes are displayed in Table 3. Because all the changes between the pre- and post-test for the attitude items were statistically significant at p < 0.05, we instead focus on those changes that had a medium or high level of practical significance. For the item, “I am confident in my ability to recognize concussion symptoms in youth athletes,” the median score for sports officials and athletic trainers both improved from a 4 to a 5. The difference for both also demonstrated a high level of practical significance (r = −0.62 and −0.55, respectively). While the median score for the item, “There are things I can do to help prevent concussion among my athletes,” did not change between the pre- and post-test for either sports officials or athletic trainers, the difference had a medium level of practical significance for both sports officials (r = −0.39) and athletic trainers (−0.35), and the percentage who agreed or strongly agreed increased from the pre-test (90.6% and 92.3%, respectively) to the post-test (96.9% and 97.7%, respectively). The median score for the item, “I am confident in my ability to help an athlete with the return to play process,” improved from 4 to 5 for both sports officials and athletic trainers. Both changes demonstrated a high level of practical significance (r = −0.59 and −0.50, respectively). For the item, “I talk with my athletes about concussion and encourage them to report concussion symptoms,” the median score improved from a 4 to a 5 for sports officials but remained at a 5 for athletic trainers (however, the percentage who agreed or strongly agreed increased from 81.8% to 95.8%). The difference for sports officials had a high level of practical significance (r = −0.51) and a medium level of practical significance (r = −0.48) for athletic trainers.

Lastly, the median score for the item, “I plan to teach my athletes ways to prevent concussion,” improved from a 4 to a 5 for sports officials but again remained at a 5 for athletic trainers (the percentage who agreed or strongly agreed increased from 93.9% to 98.4%). The difference between pre- and post-test demonstrated a medium effect size for both groups (r = −0.46 and −0.38, respectively).

This study found that sports officials’ and athletic trainers’ concussion knowledge, attitudes, and behavioral intentions improved immediately following completion of the CDC HEADS UP online training. Reducing knowledge gaps among sports officials and athletic trainers is critical as both groups play an integral part in recognizing and responding to possible sports-related concussions among youth athletes. Sports officials can help set the tone for safe play, thereby decreasing athletes’ risk for concussion (Harmon et al., 2019), while athletic trainers are often on the front lines in responding to and managing a concussion among athletes. Their roles are increasingly recognized as important to concussion safety. According to the National Conference of State Legislatures, several of the 50 state-level sports concussion laws that passed since 2009 explicitly mention a role for sports officials and athletic trainers in concussion protocols (National Conference of State Legislatures, 2018). Sports officials and athletic trainers can therefore be a critical partner to clinicians in being first responders to potential sports-related concussion among youth.

While most of the previous research assessing concussion knowledge has focused on coaches (Daugherty, DePadilla, & Sarmiento, 2019; McLeod, Schwartz, & Bay, 2007; Mrazik, Bawani, & Krol, 2011), and the athletes themselves (Cournoyer & Tripp, 2014; Kurowski, Pomerantz, Schaiper, & Gittelman, 2014; Register-Mihalik et al., 2013), this is one of the first studies to assess concussion knowledge and attitudes among sports officials and athletic trainers. This study showed that overall, sports officials and athletic trainers entered the training with strong baseline knowledge and attitudes consistent with concussion management strategies supported by research and consensus statements about concussion. For more than half of the knowledge questions, 90% of both sports officials and athletic trainers were able to answer the pre-test question correctly. All questions showed statistically significant improvement and 11 of the 13 demonstrated practical improvement between pre- and post-test based on effect size. The findings also show that the training is particularly effective in improving sports officials’ and athletic trainers’ knowledge regarding concussion protocols and recovery (such as when to return an athlete to play and the average time of concussion symptom resolution). For example, only about 60–68% of respondents answered the pre-test the questions on concussion protocols and recovery correctly. The percentages of correct responses improved to 80–90% in the post-test. These results demonstrate that first, education in these areas may be needed, and second, that the CDC HEADS UP training was effective in transmitting this information.

There were only two knowledge questions (“What percentage of athletes do researchers think try to hide their concussion symptoms from their coach?” and “Athletes who are removed from play because of a possible concussion should return to play only after they are back to their regular school activities”) in which less than half of the participants responded correctly on the pre-test. Sports officials and athletic trainers in this study performed similarly to coaches when asked these same questions as part of a separate study of the effectiveness of the HEADS UP online training on coaches knowledge, attitudes, and behavioral intentions (Daugherty et al., 2019). That analysis found that only 43% of coaches answered the question about the percentage of athletes who try to hide their concussion symptoms from coaches correctly on the pre-test and only 32% of coaches answered the question about athletes returning to play after they have resumed their normal school activities correctly (Daugherty et al., 2019). In the current study and the study of coaches, the percentage of correct responses improved by approximately 20 percentage points for each group between the pre- and post-test. Still, while participants in this study showed improvement in answering these two questions correctly after taking the training, there was a sizeable proportion of respondents who answered these questions incorrectly in the post-test. This could indicate a need for further, more in-depth education and training on these topics, including in the HEADS UP training, and clearly identifying why sports officials and athletic trainers should be aware of these issues.

Self-efficacy (i.e., confidence in one’s ability to enact a behavior) has been theorized to be an important determinant of intentions and behaviors (Sheeran et al., 2016). Findings from this study suggest that the training led to improved concussion-related self-efficacy—with significant and practical improvements in responses to attitude-related questions immediately after taking the training. For example, the questions, “I am confident in my ability to recognize concussion symptoms in youth athletes,” and, “I am confident in my ability to help an athlete with the return to play process,” showed a high practical significance level of improvement immediately after taking the training as indicated by effect size. While these findings are promising, HEADS UP training could be expanded to include and examine additional components of health behavior theories, such as perceived benefits and barriers, to inform updates and potential improvements to the training (Sheeran et al., 2016). In addition, future updates to the HEADS UP online training could consider integrating adult learning theories to help ensure uptake of the information presented (Rice & Curtis, 2019).

Finally, this study was the first to examine the effectiveness of a large-scale educational intervention on sports officials’ and athletic trainers’ knowledge, attitudes, and intentional behavioral intentions. However, the online format of the training did not allow for an assessment of how real-life social and environmental factors, affect participants’ concussion attitudes and behaviors (Sarmiento et al., 2017). Thus, to better understand how concussion recognition and response play out in real life situations, including among sports officials and athletic trainers, “CDC” is funding two large-scale research studies. The first study conducted by Seattle Children’s Hospital and Georgia Southern University is assessing the effectiveness of pre-game safety huddles on concussion reporting and response (Seattle Pediatric Concussion Research Collaborative, 2019). Sports officials and athletic trainers are often involved in these huddles, which focus on values of sportsmanship (i.e., not engaging in dangerous and illegal collisions); and shared responsibility that no athlete play while concussed. The second study utilizes the Popular Opinion Leader model and will test an intervention focused on preventing concussion among middle school athletes across five sports (football, boys’ soccer, girls’ soccer, boys’ basketball, and girls’ basketball; Kerr et al., 2018). The goal of this study is to demonstrate the effectiveness of a local concussion prevention program on knowledge, attitudes, behaviors, and health outcomes in these youth sports. Once completed, the results from these studies will be incorporated into future refinements of the HEADS UP training.