Improving concussion-reporting behavior in National Collegiate Athletic Association Division I football players: Evidence for the applicability of the socioecological model for athletic trainers

Context: Few researchers have examined the views of important stakeholders in football student-athletes' spheres of influence and whether their views map well in a systems approach to understanding concussion-reporting behavior (CRB). Objective: To examine the extent to which stakeholders' beliefs about what influences football players' CRBs reflect system-level influences that go beyond individual-level factors. Design: Qualitative study. Setting: Four National Collegiate Athletic Association Division I university athletic programs. Patients or Other Participants: A total of 26 individuals (athletic directors ¼ 5, athletic trainers [ATs] ¼ 10, football coaches ¼ 11). Data Collection and Analysis: Semistructured interviews with stakeholders were transcribed and analyzed using the socioecological model according to the Miles and Huberman coding methods. Results: Stakeholders largely identified individual-level factors (attitudes), followed by exosystem-level factors (university policies and support for ATs), with fewer microsystem- and mesosystem-level factors (coach influence and communication between coaches and ATs, respectively) and almost no macrosystem-level factors (media influence, cultural norms about aggression and toughness in football). Conclusions: Promising evidence indicates growing stakeholder awareness of the importance of exosystem-level factors (eg, medical personnel and CRB policies) in influencing CRB rates. However, frontline stakeholders and policy makers may benefit from practices that bridge these influences (eg, coach involvement and communication), allowing for a more integrated approach to influence student-athletes' willingness to improve their CRBs.