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Objective: Acknowledging that coach communication about concussion increases the likelihood of athletes reporting concussive symptoms, the goal of this study was to examine factors affecting such communication, in order to develop a conceptual model that would inform the design of future educational interventions. Participants: Division I contact sport coaches. Methods: We conducted structured qualitative interviews with coaches and analyzed interviews using Thematic Analysis, viewed through the lens of the Theory of Planned Behavior nested within the Social Ecological Model. Results: Coaches had good knowledge of concussion and understood the dangers of playing with symptoms. However, they also discussed the lack of objective criteria for concussion diagnosis, and pressure to win in order to remain employed, both of which created barriers to concussion communication. Ultimately, most coaches reported not engaging in significant concussion communication as they did not feel this was their role, instead deferring to medical staff. Conclusions: Educational interventions might benefit from a focus on the importance of coach concussion safety-supportive coach communication, with a goal of increasing the likelihood of athlete concussion reporting.

Objectives: Determine whether Pre-Game Safety Huddles, a novel and low-resource approach to concussion education, increase the expected likelihood of concussion reporting for youth athletes., Methods: A cluster-randomised trial compared Safety Huddles to usual care. Safety Huddles bring together athletes and coaches from both teams before the start of each game for coaches to briefly affirm the importance of speaking up if a concussion is suspected. Participants were athletes from 22 competitive community-based American football and girls and boys soccer teams (ages 9-14), and randomisation into intervention or control occurred at the level of the bracket (group of teams that compete against each other during the regular season). The primary outcome was expected likelihood of reporting concussion symptoms to the coach, measured via validated athlete survey at the beginning and end of the season., Results: Of 343 eligible participants, 339 (99%) completed baseline surveys and 303 (88%) completed surveys at season end. The mean (SD) age was 11.4 (1.1) years, 26% were female soccer athletes, 27% were male soccer athletes and 47% were football athletes. In adjusted analyses accounting for baseline values and clustering by sport and team via random effects, expected likelihood of concussion reporting at the end of the season was significantly higher in the intervention group compared to controls (mean difference=0.49, 95% CI 0.11 to 0.88; Cohen's d=0.35)., Conclusions and Relevance: Pre-Game Safety Huddles increased the expected likelihood of athletes reporting concussion symptoms. While further study is warranted, sport organisations should consider this approach a promising low-resource option for improving concussion safety in their setting., Trial Registration Number: NCT04099329., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)