Factors Influencing the Underreporting of Concussion in Sports: A Qualitative Study of Minor Hockey Participants

Objective: The present study is to identify factors contributing to underreporting of concussion in adolescent athletes. Design: Qualitative interviews. Setting: Participants were interviewed in an office environment. Participants: Interviews were conducted with 31 minor hockey players, 10 parents, 6 coaches, 4 trainers, 2 managers, and one game official. Players were 13 to 15 year old. With selective sampling, an inductive approach of analyzing the interviews was undertaken and themes were identified and analyzed. Assessment of Risk Factors: Underreporting is a complex phenomenon. A number of risk factors related to hockey culture, players, reference others, and rules of play were assessed. Main Outcome Measures: Reasons not reporting concussion is accepted in minor hockey. Results: Aspects of hockey culture such as an overemphasis on winning games and upheld misperceptions about the risks associated with concussion were identified as relevant to the underreporting of concussions. Various factors relevant to the underreporting of concussions include player's motivation to win, group membership dynamics such as a player's role as the team's "enforcer," coaches' own motivation to win to further their own opportunities in the sport, and parents' personal financial interest or alternative agenda in terms of time commitments and their child's future career prospects. Conclusions: Our findings indicate that underreporting of concussion among those players interviewed appears to be prevalent and associated with misconceptions about injury risk, and a culture that both reinforces and encourages underreporting with tacit or overt complicity of parents and coaches. Our findings support the need to alter the culture of violence and tough play in hockey by education, rule changes, economic measures, and changes in governance of the sport. Interviewing more stakeholders and policy makers would shed light on such potential interventions.