Background
Ice hockey is one of North America’s most popular sports. Youth hockey like other sports is played at various levels ranging from recreational to highly competitive, with hours of training and competition varying accordingly. The high speed and physical nature of hockey combined with hard surfaces from the ice and hits with other players contribute to hockey being a leading cause of sport-related concussions (Pfister, Pfister, Hagel, Ghali, & Ronksley, Reference Pfister, Pfister, Hagel, Ghali and Roksley2015). Concussions are often termed an ‘invisible epidemic’ due to the difficulties in accurate and timely diagnosis. The rates of concussion among young Indigenous hockey players are not known. In Ontario close to 30 000 doctor visits for all paediatric concussion occur annually (Zemek et al., Reference Zemek, Grool, Rodriguez Dugue, DeMatteo, Rothman, Benchimol and Macpherson2017) which is four times higher than rates reported in 2003 (Fridman et al., Reference Fridman, Scolnik, Macpherson, Rothman, Guttmann, Grool and Zemek2018). Youth involved in organised sports are six times more likely to experience concussion than those involved in other physical activities (Browne & Lam, Reference Browne and Lam2006); as such youth are vulnerable to concussion.
Traumatic brain injuries (TBI) are a growing health concern in Canada (Deepa, McFaull, Thompson, & Gayatri, Reference Deepa, McFaull, Thompson and Gayatri2018; Karmali et al., Reference Karmali, Laupland, Harrop, Findlay, Kirkpatrick, Winston and Hameed2005). A concussion is also termed a mild TBI; however, it is a complicated syndrome of microsturural injury and functional impairment (Kenzie et al., Reference Kenzie, Parks, Bigler, Lim, Chesnutt and Wakeland2017; Topolovec-Vranic et al., Reference Topolovec-Vranic, Zhang, Wong, Lam, Jing, Russell and Cusimano2015). New animal models and imaging studies are beginning to show that metabolic and neurovascular resolution may actually take longer than symptomatic recovery (Kamins & Giza, Reference Kamins and Giza2016). Also, there is growing evidence that exposure to multiple concussions, in spite of what appears to be return to baseline, may increase risk for neurological symptoms later in life (Kamins & Giza, Reference Kamins and Giza2016). Similar to other TBIs, if a concussion is missed and not managed it may result in disability or even death (McCrory et al., Reference McCrory, Meeuwisse, Aubry, Cantu, Dvořák, Echemendia and Turner2013). Concussions represent 70%–90% of all TBIs (Kenzie et al., Reference Kenzie, Parks, Bigler, Lim, Chesnutt and Wakeland2017) and are characterised by pathophysiological alterations affecting brain function resulting from biomechanical forces (McCrory et al., Reference McCrory, Meeuwisse, Aubry, Cantu, Dvořák, Echemendia and Turner2013).
Participation of young females in hockey has steadily increased over the past few years (Covassin & Elbin, Reference Covassin and Elbin2011), with females reporting a two times higher risk of concussion than males in the same sport (Covassin, Swanik, & Sachs, Reference Covassin, Swanik and Sachs2003). Understanding young hockey players’ awareness of concussion is critical to the medical management of the concussed player and to the design of interventions for prevention (Cusimano et al., Reference Cusimano, Topolovec-Vranic, Zhang, Mullen, Wong and Ilie2017). Unidentified and underreported concussions can lead to an increased risk of repeat concussions that can potentially result in more severe TBI, second impact syndrome with severe neurological deficits or death (Kamins & Giza, Reference Kamins and Giza2016).
Young people are susceptible to post-concussion syndrome (PCS) which affects 33% of youth who sustain a concussion (Davis et al., Reference Davis, Anderson, Babl, Gioia, Giza, Meehan and Zemek2017). PCS can result in longer-term impairments to cognitive, physical, emotional and sleep domains as well as to behaviour and to social aspects of life (Sady, Vaughan, & Gioia, Reference Sady, Vaughan and Gioia2011). Sex has been documented as an important factor in concussion outcomes. Studies have found that females report more symptoms after concussion than males (Bazarian, Blyth, Mookerjee, He, & McDermott, Reference Bazarian, Blyth, Mookerjee, He and McDermott2010), and they are at greater risk of developing PCS (Bay, Sikorskii, & Saint-Arnault, Reference Bay, Sikorskii and Saint-Arnault2009; Bazarian et al., Reference Bazarian, Blyth, Mookerjee, He and McDermott2010; Styrke, Sojka, Bjornstig, Bylund, & Stalnacke, Reference Styrke, Sojka, Bjornstig, Bylund and Stalnacke2013), have higher rates of health care utilisation after concussion (Kristman et al., Reference Kristman, Côté, Yang, Hogg-Johnson, Vidmar and Rezai2014) and higher suicide rates post-concussion (Fralick, Thiruchelvam, Tien, & Redelmeier, Reference Fralic, Thiruchelvam, Tien and Redelmeier2016; Teasdale & Engberg, Reference Teasdale and Engberg2001) as compared to males. A study conducted with youth residing in the northern country of Denmark found that after concussion, girls had a higher risk of epilepsy compared to boys (Christensen et al., Reference Christensen, Pedersen, Pedersen, Sidenius, Olsen and Vestergaard2009). Further research with young hockey players found underreporting of concussion symptoms with lower reporting rates in boys than girls (Cusimano et al., Reference Cusimano, Topolovec-Vranic, Zhang, Mullen, Wong and Ilie2017), yet recovery patterns were identical (Ono et al., Reference Ono, Burns, Bearden, McManus, King and Reisner2016). Nevertheless, a recent systematic review suggested the evidence on sex and concussion is limited, is conflicting and warrants further investigation (Cancelliere, Donovan, & Cassidy, Reference Cancelliere, Donovan and Cassidy2016).
A better understanding of sex-related differences in concussion awareness for youth has implications for identification, management and prevention given the differences in biological and psychological factors. Understanding if differences in Indigenous youth knowledge and attitudes towards concussion by sex exist is important. Relying on the patient reporting symptoms of concussion is a vital first step towards an early diagnosis and early treatment (Cassidy et al., Reference Cassidy, Carroll, Peloso, Borg, von Holst and Holm2004; McCrory et al., Reference McCrory, Meeuwisse, Aubry, Cantu, Dvořák, Echemendia and Turner2013). Medical and sport experts concur that concussion awareness is the most important factor in early recognition, timely management and effective prevention (Cassidy et al., Reference Cassidy, Carroll, Peloso, Borg, von Holst and Holm2004; Ellis et al., Reference Ellis, Ritchie, McDonald, Cordingley, Reimer, Nijjar and Russell2017; Mrazik, Perra, Brooks, & Naidu, Reference Mrazik, Perra, Brooks and Naidu2015). Indigenous youth experience substantial and persistent health disparities compared to their mainstream peers (Greenwood & DeLeeuw, Reference Greenwood and de Leeuw2012; King, Smith, & Gracey, Reference King, Smith and Gracey2009). A clear characterisation of sex differences among Indigenous youth could assist in tailoring future education programmes for prevention and management of concussion. Data collected on knowledge, attitudes, reporting behaviour and sources of information about concussion by sex can help to build customised health education programmes for Indigenous young boys and girls to promote health. Targeted health education programmes have demonstrated effectiveness in Indigenous populations (Beckett, Firestone, McKnight, Smylie, & Rotondi, Reference Beckett, Firestone, McKnight, Smylie and Rotondi2018; Smylie et al., Reference Smylie, O’Brien, Xavier, Anderson, McKnight, Downey and Kelaher2018).
The study was conducted in partnership with a First Nations’ chief, Indigenous members of her health team, a First Nations’ policy analyst with experience in youth hockey and members of an academic head injury clinic. Early collaborations of face-to-face meetings and teleconferences allowed the team to establish processes for working together, formalise a research agreement and set the objectives of the research study. The purpose of this study was to compare and contrast concussion knowledge, attitudes, reporting behaviour and concussion resources among First Nations male and female youth (aged 10–18 years) participating in a recreational hockey tournament. These study data were drawn from a larger project that has been reported in the literature (Hunt et al., Reference Hunt, Michalak, Johnston, Lefkimmiatis, Macumber, Jocko and Ouchterlony2018).
Methods
The cross-sectional study included Indigenous boys and girls between the ages of 10 and 18 years of age who were competing in a provincial First Nations hockey tournament held in a large arena complex in southern Ontario, Canada, in March 2016. In Canada, researchers engaging with Indigenous peoples are expected to adhere to principles of Ownership, Control, Access and Possessions (OCAP, 2014). Our research approach was informed by and followed OCAP principles. First, we collaborated with our First Nations partners to determine the appropriate methods for the study. This included the study setting, the method of data collection (pen-and-paper survey), the survey content and data ownership. Ethical approval for the study was received from the First Nations Chief and Band Council, the hockey tournament organisation and the participating academic hospital Review Ethics Board.
Study posters were placed on the hockey website in advance of the tournament to raise awareness about the study. At the tournament, participant recruitment was undertaken with Indigenous members of the study team. Recruitment posters were set up at one end of the arena with desks and chairs supervised by Indigenous research staff, and participants were invited to complete the survey. The pen-and-paper survey was modified from a study tool by Mrazik et al. (Reference Mrazik, Perra, Brooks and Naidu2015), who studied minor hockey players that included boys and girls from 10 to 17 years of age living in the province of Alberta, Canada. The modifications to the survey tool have been reported elsewhere (Hunt et al., Reference Hunt, Michalak, Johnston, Lefkimmiatis, Macumber, Jocko and Ouchterlony2018). The survey was modified to reduce the number of questions to provide a brief tool that could be completed within a short period of time since the study setting was a busy arena during a youth hockey tournament. Our team conducted pilot testing of our modified survey with five young Indigenous players (three girls and two boys) to ensure test suitability. Youth completed the survey in 10 to 15 min. As an incentive to participate, subjects were invited to enter a draw for an i-PAD by submitting their name in a box separate from the questionnaire.
In this paper we report the findings from five knowledge questions, six behaviour reporting and attitudes questions and a single question asking participants what resources they accessed to learn about concussion. In addition, demographic information was collected which included age, sex and place of residence (northern or southern Ontario). Participants were also asked if they had any previous concussion(s). We conducted descriptive statistics for age, residence, and self-reported concussion history to better understand our sample of study participants. We calculated frequencies and percentages for knowledge, attitude and resource response for girls and boys. Chi-square analysis was used to investigate any relationships between girls and boys responses. Analysis was performed using SPSS (ver. 24), statistical significance set at p ≤ 0.05.
Results
Participant characteristics
In Canada, the largest numbers of people with Indigenous ancestry live in the province of Ontario (Statistics Canada, 2013). Although Indigenous communities are located across the province, one in four Ontario First Nations is a small, remote community, accessible only by air year-round or by ice road in the winter (Ministry of Indigenous Affairs, 2012). Ontario has more remote First Nations than any other region in Canada (Ministry of Indigenous Affairs, 2012). Two-thirds of our study participants resided in northern Ontario. More girls attending the hockey tournament participated in the study as compared to boys, see Table 1 (girls n = 46, boys n = 29). Almost half of the girls participating were classified as Bantam players based on their age of 13–14 years (47.8%), while the numbers of boys participating were more evenly distributed across the three age groups of hockey players. Close to three-quarters of the girls had not reported a concussion (73.9%), whereas over one half of the boys (58.6%) reported a previous concussion. In the study characteristics described there was no statistical difference between girls and boys.
Characteristics of Study Participants
Hockey concussion knowledge
Frequencies and percentages of knowledge questions are summarised in Table 2. There was a slight difference in mean hockey concussion knowledge scores by sex. Girl’s hockey concussion knowledge score for the five questions was (mean ± standard deviation) 3.22 ± 1.24, (95% confidence interval = 2.85, 3.59) and boys 3.28 ± 1.28, (95% confidence interval = 2.79, 3.76). The highest percentage of incorrect responses was regarding the usual length of concussion in hockey. Girls tended to overestimate the length of time for recovery after concussion compared to boys, although it was not statistically significant.
Number and Percentage of Responses to Hockey Concussion Knowledge Questions
Knowledge of concussion symptoms
Participants were asked to identify symptoms most people would experience with concussion. (See Fig. 1.) Headache was the symptom correctly recognised by the highest percentage of girls (89.1%) and boys (86.2%). Tiredness was the concussion symptom that was correctly recognised by the lowest percentage of girls (32.2%). Throwing up/nausea was correctly recognised by the lowest percentage of boys (31.0%). Breathing problems were incorrectly identified as a symptom of concussion (by girls 23.9% and boys 3.4%). In addition, diarrhoea was also incorrectly identified by both sexes. Breathing problem was the only statistically significant symptom that differed by sex (p = 0.023 Fisher’s Exact test).
Comparison of girls’ and boys’ knowledge about symptoms of concussion.
Attitudes and reporting behaviour
Over three-quarters of both girl and boy participants responded that if they had a concussion they should stop playing and that they would ‘stop playing and tell and adult’. (See Table 3.) Concussion was viewed by the greatest percentage of girls ‘as serious as other injuries’ (51%), whereas the greatest percentage of boys responded concussion was ‘more serious’ (50%) as compared to other injuries. Reasons for not reporting a concussion for the majority of boys was ‘afraid I will be benched’ (59%). Girls also had the greatest proportion of responses to fear of being benched (44%) but also had a large percentage of responses and other reasons selected were, ‘do not know for sure this I have a concussion’ (30%). A greater proportion of boys considered a concussion ‘likely’ when playing hockey (30%); however, in contrast the largest proportion of girls considered that a concussion to be ‘somewhat likely’ when playing hockey (51%). One quarter of both boys and girls considered it ‘unlikely’ to get a concussion while playing hockey. A slightly greater percentage of boys than girls were ‘very worried’ about getting a concussion while playing hockey (10%) vs. girls (7%). Most respondents were ‘a little bit’ worried about getting a concussion playing hockey (girls 46% vs. boys 48%). There were no statistical differences in the attitudes and reporting behaviour responses between girls and boys.
Comparison of Girls’ and Boys’ Behaviour Reporting Attitudes towards Concussion
Resources accessed to learn about concussion
Girls and boys both learned about concussion from multiple sources (see Fig. 2). The leading source of information for both groups was parents/guardians, followed by coach/managers and then school/teacher. Teammates/friends were the least-accessed resource for boys. The internet was accessed by a greater proportion of boys than girls. TV/movie was a resource least accessed by girls compared to boys. This resource was the only one where the difference by sex was statistically significant (X 2 = 7.830, p = 0.005).
How did you learn about concussion? (Multiple response were possible so total responses do not equal 100).
Discussion
A new collaborative partnership was established with First Nations’ leaders and a tertiary care concussion clinic to examine concussion awareness among youth participating in provincial First Nations hockey tournament. The study team sought to explore sex differences that could suggest important areas to consider for future health education on concussion specifically for Indigenous youth playing hockey. For Indigenous peoples in Canada, existing data gaps mean a missed opportunity to fully benefit from evidence-based interventions (Smylie & Firestone, Reference Smylie and Firestone2015), such as concussion education for youth. We are at a critical time in Canada with real opportunities to address health inequity for Indigenous youth. Together with our research partnership we can respond to the Commission of Canada’s Truth and Reconciliation calls to action report (Truth and Reconciliation, 2015) to support the health of Indigenous youth.
In five hockey knowledge questions, scores were similar for girls and boys (3.2/5). A large proportion of girls overestimated the usual duration of concussion symptoms. Reasons for this response are unclear. One study of college-aged athletes found females with a history of concussion had symptoms lasting longer than males with a similar history (Sicard, Moore, & Ellemberg, Reference Sicard, Moore and Ellemberg2018) which may play a part in girls’ higher estimation of concussion symptom duration. Others speculate the female response to pain may differ from the male response due to biological (sex hormones) and psychological factors (Cancelliere et al., Reference Cancelliere, Donovan and Cassidy2016) and as such may begin to explain differences in the response to symptom duration.
Among our study findings on concussion symptoms knowledge, shortfalls were observed in both groups. Half of the girls and boys studied were unable to identify prominent signs and symptoms of concussion such as blurred vision, vomiting/nausea, memory problems, fatigue. The extent to which concussion symptoms were recognised varied by sex (although none were statistically significant). The study information highlights the gap in concussion awareness for Indigenous youth participating in recreational hockey. It is disheartening to see that in our study sample the majority of young Indigenous participants missed critical symptoms of concussion and therefore could be placing themselves in danger when continuing to play hockey or other sports. Normal growth and development associated with young hockey players, such as intensity of peer approval and developing cognitive abilities, may further place youth at risk (Mrazik et al., Reference Mrazik, Perra, Brooks and Naidu2015).The findings of low symptom awareness were consistent with Canadian studies of non-Indigenous youth (Cusimano et al., Reference Cusimano, Topolovec-Vranic, Zhang, Mullen, Wong and Ilie2017; Mrazik et al., Reference Mrazik, Perra, Brooks and Naidu2015). Indigenous youth are less likely to have access to sports medicine resources, and therefore there is a greater reliance on young Indigenous hockey players to self-report symptoms.
Surprisingly, a greater proportion of boys compared to girls reported concussion as more serious than other sports injuries. Reasons for this finding require further study. Others have reported the under-appreciation of health risks posed by concussion in hockey among boys (Cusimano et al., Reference Cusimano, Topolovec-Vranic, Zhang, Mullen, Wong and Ilie2017).
A slightly greater proportion of girls compared to boys were more likely to report concussion symptoms to an adult, a finding similar to another report focused on high school athletes’ sex differences on reporting behaviour (Wallace, Covassin, & Beidler, Reference Wallace, Covassin and Beidler2017). In our study the most common reason for not reporting a concussion was fear of being benched, with a greater proportion of boys than girls favouring this response. The culture of sport and particularly hockey has been associated with heroism suggested in terms such as ‘ice warrior’, whereby the behavioural traits of toughness and roughness may be encouraged (Cusimano et al., Reference Cusimano, Topolovec-Vranic, Zhang, Mullen, Wong and Ilie2017) and may be contributing to the reason for this response. Clinicians agree that a hockey player should not return to play while symptomatic of concussion. It is noteworthy that one-third of the girls responded that they would not report symptoms to the coach as they do not know for sure that they have symptoms of concussion. Findings from a qualitative study of girls and boys soccer teams similarly reported that players stated they would continue to play soccer despite concussion symptoms because they found it hard to tell if they were actually injured (Chrisman, Quitiquit, & Rivera, Reference Chrisman, Quitiquit and Rivara2013). Other research which aligns with the trends in our study trends towards sex differences in behaviour around concussion reporting suggests internal motivators may play a role. Boys who underreport symptoms of concussion may feel pressure to play through symptoms and pain to win, as the boys tend to identify with athletic self-image and help-seeking behaviours tend to be viewed as a sign of weakness (Tanveer, Zecavati, Delasobera, & Oyegbile, Reference Tanveer, Zecavati, Delasobera and Oyegbile2017). Girls also have their own athletic identity, but their reasons for not reporting concussion to their coach may be motivated differently than boys. For some teams attending the hockey tournament with fewer team players and having a player on the bench could have meant a disadvantage for their team and may be another reason for not reporting symptoms.
Recent provincial concussion safety legislation makes Ontario a national leader in concussion management and compels schools to participate in concussion awareness and implement ‘return to learn’ protocols’ (Ontario Ministry of Health and Long Term Care, 2018). This new legislation is aimed to help ensure the safety of students in school settings to prevent concussions and to support their return to school. Less than one-quarter of First Nations youth identified schools/teachers as a resource which suggests schools could more actively engage in concussion knowledge dissemination. However, others suggest with educators the lack of physical symptoms of concussion may make it difficult for them to appreciate the injury and to address classroom-based interventions (Graff & Caperell, Reference Graff and Caperell2016). Few participants responded that teammates/friends were resources of concussion information which indicates a potentially underutilised resource. However, an assumption may also be made that teammates/friends are not a good resource for concussion information as their own knowledge may reflect that of our study participants with knowledge gaps. However, teammates/friends may play a supportive role in creating a culture of safe play (McKay, Meeuwisse, & Emery, Reference McKay, Meeuwisse and Emery2014).
Although not statistically significant, sex differences were observed regarding reasons for not reporting symptoms to the coach, signifying concussion education warrants tailoring for girls and boys. Our findings suggest girls could benefit from more of a focus on symptom recognition by building trust and confidence to share symptoms with the coach and other adults. In contrast, boys could benefit from information structured to support team participation and a reduced emphasis on heroism and winning. Qualitative studies should investigate additional reasons why Indigenous youth do not report concussion symptoms. Without this information Indigenous youth, their families and their communities will continue to suffer health disparities from concussion.
Others studies suggest concussion education should extend beyond players to include parents and coaches to strengthen the focus on creating a culture of safe sport and where reporting concussion symptoms can be supported (Hunt et al., Reference Hunt, Michalak, Johnston, Lefkimmiatis, Macumber, Jocko and Ouchterlony2018). The team building approach aligns well with Indigenous culture of community engagement and community building (Smylie et al., Reference Smylie, Kaplan-Myrth, McShane, Ontario, Nation and Centre2008). Qualitative studies should include focus groups of youth hockey players, their parents, team coaches and community elders. Indigenous elders can help to better understand what it means to draw on and to share Indigenous knowledge, to make research matter within the Indigenous ways of knowing (Smylie et al., Reference Smylie, O’Brien, Xavier, Anderson, McKnight, Downey and Kelaher2018). Future research questions should explore experiences with concussion, to better understand the barriers and potential facilitators to concussion symptom reporting. Indigenous leaders must lead the focus groups in order to capture the unique cultural factors that may impact symptom reporting.
Limitations
There are a number of limitations with our study. The small convenience sample with unequal number of males and females introduces errors and limits the generalisability of the study results. The study instrument was modified for our study purpose. Self-report and single questions from a short survey also contribute to the study bias. Youth completed the survey in the arena at the time of the hockey tournament. As such, their parents were nearby, and this factor may have influenced youth responses. The young players who participated in the study may have had a higher level of concussion knowledge as compared to other Indigenous youth, as a result of previous safe play training earlier in the hockey season, and this further limits the generalisability to others.
Conclusions
One of the defining aspects of our study was the partnership between the Indigenous chief and other First Nation leaders with the academic research team. In Canada, for research to adequately and respectfully engage and serve Indigenous peoples, we adhere to the principles of OCAP. Our research objective was to better understand concussion awareness in First Nations girls and boys participating in a hockey tournament. Our collaborative research team addressed an important gap where data are needed to improve health for Indigenous youth playing hockey. Despite the benefits of exercise from ice hockey, both knowledge and self-reporting behaviour of symptoms is necessary to optimise recovery and decrease the risk of long-term negative outcomes from concussion. We found sex differences in hockey concussion knowledge, knowledge of concussion symptoms, attitudes, concussion symptom reporting behaviour and resources accessed to learn about concussion. The study highlights the urgency for concussion education for young Indigenous hockey players. In addition, the findings identified a need for interventions tailored by sex, as gaps in concussion awareness varied between girls and boys.
Current resources that Indigenous youth access to learn about concussion do not appear to be sufficient to sustain knowledge nor guide concussion symptom reporting behaviour for them to safely play hockey. Resources to develop concussion education interventions should include parents, coaches and schools/teachers. Teammates and friends need interventions to build and sustain a culture of safe play.
A key Indigenous research principle in Canada is that researchers must meaningfully engage with Indigenous people to ensure Indigenous ‘ways of knowing’ is shared in a respectful way. Findings from our study were translated by the Indigenous leaders who were members of our research team and placed on the Indigenous hockey tournament website for knowledge dissemination. The respectful integration of non-Indigenous and Indigenous leaders in research has the capacity to generate new solutions to address health inequities borne by Indigenous youth. Future research will include continued engagement with Indigenous peoples, both elders and youth, so that culturally sensitive educational interventions for concussion awareness will have a greater chance of improving the health and well-being of First Nations youth.
Acknowledgements
Thank you to the First Nations youth who kindly participated in this study.
Financial support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Conflict of interest
C. Hunt has no conflicts of interest to disclose, A. Michalak has no conflicts of interest to disclose, E. Johnston has no conflicts of interest to disclose, L. Macumber has no conflicts of interest to disclose, T. Jocko has no conflicts of interest to disclose, D. Ouchterlony has no conflicts of interest to disclose.
Ethical standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.
