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Gaps in adequate traumatic brain injury (concussion) assessment amongst college students

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Gaps in Adequate Traumatic Brain Injury (Concussion) Assessment Amongst College
Students
by
Lisa Jo Keefer

Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education

December 2020

© Copyright by Lisa Jo Keefer 2020
All Rights Reserved

The Committee for Lisa Jo Keefer certifies the approval of this Dissertation

David Cash
Daniel Nation
Patricia Tobey, Committee Chair

Rossier School of Education
University of Southern California
2020

iv

Abstract
Traumatic brain injury (TBI) and mild traumatic brain injury (mTBI) also known as concussion,
is a significant problem in U.S. college communities. There is a lack of concussion knowledge,
assessment, and treatment outside of the athletic community. The purpose of this study is to
assess the knowledge, motivational, and organizational influences (KMO) surrounding
concussion in the college community utilizing an adapted form of Clark and Estes’s (2008)
framework. This study will examine: (1.) The knowledge, motivation, and organizational
influences that interfere with achieving concussion awareness, education, prevention,
assessment, treatment, and follow-up; (2.) The recommended knowledge, motivation, and
organizational solutions that can help instigate a concussion management plan to help with
outreach and education as well as prevention, assessment, treatment, and follow-up for non-
athlete students. The college community consisting of students, faculty, and staff 18 years of age
and over completed a voluntary and anonymous online concussion survey to assess their
knowledge (perceived and factual) of concussion, motivational factors, and organizational
support. A modified gap analysis was used to help clarify goals as well as identify gaps between
the actual and perceived performance levels. This gap analysis was adapted for needs analysis.
Assumed knowledge, motivation, and organizational needs were produced based on individual
knowledge and connected literature. For motivational factors, the study found that the majority
of the college community did not feel confident regarding their concussion knowledge following
concussion training. There were also gaps in concussion knowledge such as types of
concussions, signs and symptoms of concussions, and the populations at highest risk for
concussion. In terms of organizational confidence, the study found the majority of the college
community felt confident in their ability to recognize concussions but had very low confidence in
v

the rest of the college community’s ability. Further outreach, education, and organizational
support such as instigating a concussion management plan would be very helpful to the college
community.
Keywords: Concussion, traumatic brain injury (TBI), post-concussion syndrome, coup
contrecoup, return to learn, return to play

vi

Dedication
To all those who have endured a traumatic brain injury and suffered in silence. You are heard
and I am fighting for you.

vii

Acknowledgements
This research is near and dear to my heart. I would like to give a special thanks to my
wonderful, supportive, and kind Dissertation Chair, Dr. Patricia Tobey, who encouraged me to
move forward with my dissertation idea which was unique for my program. Together we were
able to use an educational leadership approach, which complemented the program. I would also
like to thank the other important members of my amazing dream-team dissertation committee,
Dr. David Cash whose inspiring leadership helped me grow as an educational leader and Dr.
Daniel Nation, whose guidance and expertise in Neuropsychology was an inspiration to my
research and future career path.
The support and wisdom I gained from my professors, staff and classmates will never be
forgotten and is much appreciated. Thank you to Dr. Kenneth Yates for showing us the world of
the Gap Analysis and Dr. Christopher Mattson who is extremely knowledgeable and supportive
in the writing process. To my Advisor, Jordan Brown, I thank you for answering all of my
questions throughout the years with a happy disposition. Much appreciation to all those who
helped me to get my concussion survey out to the college community and to all those who took
the time to take the survey.
My gratitude to my friend and colleague Kristi Culpepper who has been such an
inspiration to me throughout my work and studies at USC. A special shout out to Michael
McDowell and Kenneth Hill, you two were my lifeline through the trials and tribulations of
dissertation writing during a pandemic (YSD). To my dissertation group, thank you for your
prayers and encouragement.
In closing, I would like to thank my wonderful mom, my family and God, without you,
none of this would be possible.

viii

Table of Contents
Abstract .......................................................................................................................................... iv
Dedication ...................................................................................................................................... vi
Acknowledgements ....................................................................................................................... vii
List of Tables ................................................................................................................................. xi
List of Figures .............................................................................................................................. xiii
List of Abbreviations ................................................................................................................... xiv
Chapter One: Overview of the Study .............................................................................................. 1
Background of the Problem ................................................................................................ 1
Organizational Context and Mission .................................................................................. 2
Statement of the Problem .................................................................................................... 3
Organizational Performance Status..................................................................................... 4
Organizational Performance Goal....................................................................................... 4
Study Population ................................................................................................................. 5
Purpose of the Project and Questions ................................................................................. 9
Significance of the Study .................................................................................................... 9
Conceptual and Methodological Framework .................................................................... 10
Definition of Terms........................................................................................................... 11
Organization of the Dissertation ....................................................................................... 11
Chapter Two: Review of the Literature ........................................................................................ 13
Prevalence of Concussion ................................................................................................. 13
Causes of Concussion ....................................................................................................... 15
Signs and Symptoms of Concussion ................................................................................. 18

ix

Concussion Assessment in Student-Athletes .................................................................... 19
General (Non-Athlete) College Student Population Assessment Factors ......................... 20
Concussion Treatment ...................................................................................................... 22
Post-Concussion Syndrome .............................................................................................. 22
Psychological Symptomatology Post-Concussion ............................................................ 23
Return to Play/ Learn ........................................................................................................ 24
Conclusion ........................................................................................................................ 24
Chapter Three: Methodology ........................................................................................................ 26
Survey ............................................................................................................................... 26
Sample and Population ..................................................................................................... 27
Data Collection and Instrumentation ................................................................................ 27
Data Analysis .................................................................................................................... 34
Limitation and Delimitations ............................................................................................ 34
Chapter Four: Results and Findings .............................................................................................. 35
Participating Stakeholders ................................................................................................ 36
Survey participants............................................................................................................ 36
Results and Findings ......................................................................................................... 39
Summary of Results Overall ............................................................................................. 79
Summary of Results by Affiliation ................................................................................... 80
Summary of Findings ........................................................................................................ 90
Chapter Five: Discussion and Recommendations......................................................................... 92
Organizational Context and Mission ................................................................................ 92
Organizational Performance Status................................................................................... 92

x

Description of Stakeholder Groups/Study Population ...................................................... 93
Purpose of the Project and Questions ............................................................................... 93
Strengths and Weaknesses of the Approach ..................................................................... 94
Limitations and Delimitations........................................................................................... 95
Recommendations for Practice to Address KMO Influences Utilizing the Kirkpatrick
Model .................................................................................................................... 95
Future Research .............................................................................................................. 102
Conclusion ...................................................................................................................... 102
References ................................................................................................................................... 103
Appendix A: Information Sheet .................................................................................................. 110
Appendix B: Gender by Affiliation ............................................................................................ 111
Appendix C: Ethnicity by Affiliation ......................................................................................... 112
Appendix D: Age-Range by Affiliation ...................................................................................... 113
Appendix E: Correct Symptoms of Concussion by Affiliation .................................................. 115
Appendix F: College Athlete vs Non-Athlete Assumed Risk of Concussion by Affiliation...... 117
Appendix G: Biological Sex Risk of Concussion by Affiliation ................................................ 118

xi

List of Tables
Table 1: Organizational and Stakeholder Goals-Knowledge 6
Table 2: Organizational and Stakeholder Goals-Motivation 7
Table 3: Organizational and Stakeholder Goals-Organizational Support 8
Table 4: Summary of Survey Selections and Questions 28
Table 5: Descriptive Statistics of Survey Respondents-Demographics 37
Table 6: Self-Perceived Concussion Knowledge Influence Item 1: Level of Confidence 40
Table 7: Self-Perceived Concussion Knowledge Influence Item 2: Level of Confidence 42
Table 8: Self-Perceived Concussion Knowledge Influence Item 3: Level of Confidence 44
Table 9: Self-Perceived Concussion Knowledge Influence Item 4: Level of Confidence 46
Table 10: Self-Perceived Concussion Knowledge Influence Item 5: Level of Confidence 48
Table 11: Organizational Confidence Item 1 50
Table 12: Organizational Confidence Item 2 52
Table 13: Organizational Confidence Item 3 54
Table 14: Factual Knowledge Item 1 56
Table 15: Factual Knowledge Item 2 58
Table 16: Factual Knowledge Item 3 60
Table 17: Factual Knowledge Item 4 63
Table 18: Factual Knowledge Item 5 65
Table 19: Factual Knowledge Item 6 67
Table 20: Factual Knowledge Item 7 69
Table 21: Motivation Item 1 71
Table 22: Motivation Item 2 73
Table 23: Organizational Support Item 1 75
Table 24: Organizational Support Item 2 77
Table 25: Knowledge Met or Need Determined by Data Analysis 82
Table 26: Outcomes, Metrics, Methods and Proposed Time for External and Internal Outcomes 97
Table 27: Critical Behaviors, Metrics, Methods, and Timing for Evaluation 99
Table 28: Learning, Metrics, Methods, and Timing for Evaluation 100
Table 29: Components to Measure Reaction in Concussion Training 101

xii

Table B1: Gender by Affiliation 111
Table C1: Ethnicity by Affiliation 112
Table D1: Age-Range by Affiliation 113
Table E1: Correct Symptoms of Concussion by Affiliation 115
Table F1: College Athlete vs Non-Athlete Assumed Risk of Concussion by Affiliation 117
Table G1: Biological Sex Risk of Concussion by Affiliation 118

xiii

List of Figures
Figure 1: Gap Analysis KMO Concussion Assessment Factors 11
Figure 2: Types of Traumatic Brain Injury (Concussion) 17
Figure 3: Level of Confidence: Define Concussion 41
Figure 4: Level of Confidence: Define TBI 43
Figure 5: Level of Confidence: How Concussions Are Acquired 45
Figure 6: Level of Confidence: Signs & Symptoms of Concussion 47
Figure 7: Level of Confidence: Knowledge after Concussion Training 49
Figure 8: Level of Confidence: College Community Recognition of Concussions 51
Figure 9: Level of Confidence: Student Health Center Properly Assess Concussions 53
Figure 10: Level of Confidence: Student Health Center Properly Treat Concussions 55
Figure 11: Factual Knowledge: Is a Concussion a TBI? 57
Figure 12: Types of Traumatic Brain Injury (Concussion) 59
Figure 13: Recognition of TBI (Concussion) Signs and Symptoms 62
Figure 14: Definition of Concussion 64
Figure 15: Do Concussions Always Cause Loss of Consciousness? 66
Figure 16: Assumed College Athlete vs Non-Athlete Concussion Incidence 68
Figure 17: Assumed Gender Risk for Concussions 70
Figure 18: Number of Concussion Trainings 72
Figure 19: Method of Concussion Training 74
Figure 20: Location of Concussion Training 76
Figure 21: Method of Concussion Training 78
Figure 22: Ability to Recognize a Concussion 91
Figure B1: Gender by Affiliation 111
Figure C1: Ethnicity by Affiliation 112
Figure D1: Age-Range by Affiliation 114
Figure E1: Correct Symptoms of Concussion by Affiliation 116
Figure F1: College Athlete vs Non-Athlete Assumed Risk of Concussion by Affiliation 117
Figure G1: Biological Sex Risk of Concussion by Affiliation 118

xiv

List of Abbreviations
BESS: Balance Error Scoring System
CR: Concussion Rate
GSC: Graded Symptom Checklist
LOC: Loss of Consciousness
mTBI: Mild Traumatic Brain Injury
PCSS: Post-Concussion Symptom Scale
PWI: Predominately White Institution
RTP: Return to Play
RTL: Return to Learn
SAC: Standardized Assessment of Concussion
SCAT5: Sport Concussion Assessment Tool 5
th
Ed.
SRC: Sport-Related Concussion
SOT: Sensory Organization Test
TBI: Traumatic Brain Injury

1

Chapter One: Overview of the Study
Traumatic brain injury (TBI) and mild traumatic brain injury (mTBI), both known as a
concussion, are significant problems throughout the world and especially in the United States. A
concussion is a traumatic brain injury that affects brain function (Mayo Clinic, 2020). According
to the Diagnostic and Statistical Manual (DSM-5), traumatic brain injury results from an impact
or rapid movement to the head or a displacement of the brain within the skull (American
Psychiatric Association, 2013). In the United States, TBI’s account for 1/3 of all deaths resulting
from an injury (Faul et al., 2013).
The Consensus Statement on Concussion in Sport-the 4
th
International Conference on
Concussion had the following definition: “Concussion is a brain injury and is defined as a
complex pathophysiological process affecting the brain, induced by biomechanical injury
constructs” (McCrory et al., 2013, p. 256). While during the 5
th
International Conference on
Concussion the Consensus Statement on Concussion was modified to: “Sport related concussion
is a traumatic brain injury induced by biomechanical forces” (McCrory, et al., 2017, p. 839).
Concussion is a subset of TBI and mTBI, and the terms are often used interchangeably (McCrory
et al., 2013). For the purpose of this study, concussion will be used for fluidity and consistency
purposes when speaking about traumatic brain injury (TBI), mild-traumatic brain injury (mTBI),
and concussions including for the cited research.
Background of the Problem
Concussions are more prevalent amongst college students and more likely to occur
outside of college sports (Breck et al., 2019). There are approximately 340 concussions
diagnosed annually among 30,000 U.S. public university undergraduates and the incidence are
slightly higher among females (Breck et al., 2019). Concussions can have a detrimental effect on
2

physical and mental health including academic success, so it is imperative that concussed
students are identified and treated immediately.
Many students, including college students who play sports, are at high risk for
concussions. Concussions are often underreported, which is likely contributed to a lack of
knowledge about traumatic brain injury (Fedor & Gunstad, 2015). When there is a lack of
reporting, concussions cannot be adequately assessed or treated. College students, athletes, and
non-athletes do not have adequate knowledge about the signs, symptoms, and consequences of a
concussion, so they do not always seek treatment (Knollman-Porter et al., 2018). There is a lack
of empirical research and policy efforts pertaining to concussions in recreational athletes and
non-athletes. This lack is most likely due to the absence of formal monitoring of head-injuries in
these populations (Knollman-Porter et al., 2018).
Organizational Context and Mission
Western Shore University (WSU) is a pseudonym for a large four-year university in the
Western United States. This university has a diverse student, faculty and staff population
(college community). Western Shore University has a significant enrollment of international
students adding to its culture. The university is research based, offering both undergraduate and
graduate degrees. The central mission of WSU is to evolve its members as well as advance
society through education as well as development of intellect and disposition. The fundamental
means by which the mission is achieved is through instruction, research, innovation, qualified
training, and selected forms of service to the community.

3

Statement of the Problem
Not all people know that a concussion is a traumatic brain injury, so general populations
such as the college community may not adequately or accurately report them (McKinlay et al.,
2011). In a study by Beidler et al. (2018) of the 410 club sport athletes, their study found 59% of
participants who had experienced concussions also reported that they did not have a brain/head
injury. The study also found that at 40.3%, the most common reason for underreporting or not
reporting a concussion, was the individuals’ inability to recognize signs and symptoms or that it
was a serious injury.
The 2019 National College Health Assessment (ACHA-NCHA III) showed the lack of
knowledge between the two terminologies when students who reported having a concussion also
reported having fewer traumatic brain injuries (ACHA, 2020). Studies have shown that non-
medical populations also do not know the variety of ways one can acquire a concussion
(McKinlay et al., 2011). For example, many people assume that a person has to hit their head on
an object through a direct impact in order to have a concussion. When in fact a violent jolt, shake
or blast to the head or neck area can cause a concussion (Mayo Clinic, 2020). Also, many assume
that an individual has to have lost consciousness in order to have a concussion, although this is a
symptom for some, it is not a requirement to acquire a concussion (Ruff & Jamora, 2009).
It is imperative that the college community become educated about concussions so that
they can identify concussions in themselves as well as in others. Within every concussion
management plan, prompt and comprehensive assessment and treatment is imperative for
concussion recovery (Giza et al., 2013; Hall et al., 2015). Concussions may cause a variety of
problems with memory and cognition (McCrory et al., 2013 & 2017; Mayo Clinic 2020; CDC,
2015). This can be detrimental to a college student who is trying to comprehend assignments and
4

successfully pass their classes. Understanding the gaps in knowledge, motivation, and
organizational support (Clark and Estes, 2008) can help improve identification, assessment,
treatment, and recovery for concussions in the college community. This study will then explore
the reasons why approved and thorough concussion education, assessment and protocol is
needed on all college campuses.
Organizational Performance Status
There are many resources available to college athletes through the Athletics Department
such as concussion education, avoidance-training, base-line testing, assessment, treatment, and
gradual return to play/learn (NCAA, 2013). However, these resources are not commonly
available to non-athlete students. Research has shown that concussions among college students
are more likely to occur off the playing field versus on the playing field (Breck et al., 2019). The
researchers in this study discovered concussions were more commonly found to be caused by
non-sport related activities as opposed to sport-related activities. The data shows that the general
student population is underrepresented and underserved in concussion education, prevention and
assessment. A clear and comprehensive concussion management plan needs to be developed so
that all of the college community has access to concussion mitigation resources.
Organizational Performance Goal
By 2021, the goal is to have data from an adapted gap analysis available to university
leadership that outlines the gaps in concussion knowledge, motivation, assessment, and
organizational support as it pertains to the college community. These data will provide a starting
point for enhanced education and outreach to students, faculty, staff, and the surrounding
community. Understanding the systematic gaps can help structure new educational orientations,
target outreach initiatives, and implement university-wide concussion protocol. At this time,
5

there is limited data available. The objective is to improve concussion awareness, education,
assessment, and organizational support so as to attain better outcomes and reduce the harmful
effects of post-concussive symptomology in both physical, psychological, educational, career,
and athletics.
Study Population
Although a complete analysis of the problem of practice would include all stakeholder
groups and multiple U.S. college campuses, for practical purposes, this study will focus on
students, faculty, and staff at a single U.S. campus. This study will examine knowledge,
motivational factors, and organizational support as related to concussion in the college
community. This will show where there are gaps so that mitigation, education, and outreach can
be implemented.
6

Table 1
Organizational and Stakeholder Goals-Knowledge
Organizational Mission
A large four-year research university in the Western United States. This university has a diverse
student, faculty, and staff population. The central mission of WSU is to evolve its members as well
as advance society through education and development of the intellect and disposition. The
fundamental means by which the mission is achieved is through instruction, research, innovation,
qualified training and selected forms of service to the community.
Organizational Global Goal
By 2021, the goal is to have data from an adapted gap analysis available to university leadership
that outlines the gaps in knowledge of concussions in the college community.
Stakeholder 1
Students
Stakeholder 2
Faculty
Stakeholder 3
Staff
Stakeholder 1
Proficiencies/Competencies
• Answer survey questions
to assess level of
knowledge of
concussions.
Stakeholder 2
Proficiencies/Competencies
• Answer survey
questions to assess
level of knowledge of
concussions.
Stakeholder 3
Proficiencies/Competencies
• Answer survey
questions to assess
level of knowledge of
concussions.
7

Table 2
Organizational and Stakeholder Goals-Motivation
Organizational Mission
A large four-year research university in the Western United States. This university has a diverse
student, faculty, and staff population. The central mission of WSU is to evolve its members as
well as advance society through education and development of the intellect and disposition. The
fundamental means by which the mission is achieved is through instruction, research,
innovation, qualified training, and selected forms of service to the community.
Organizational Global Goal
By 2021, the goal is to have data from an adapted gap analysis available to university leadership
that outlines the gaps in concussion motivation as it pertains to the college community.
Stakeholder 1*
Students
Stakeholder 2
Faculty
Stakeholder 3
Staff
Stakeholder 1
Proficiencies/Competencies
• Answer survey
questions to assess level
of motivation to seek or
encourage assessment
of suspected
concussion.
Stakeholder 2
Proficiencies/Competencies
• Answer survey
questions to assess
level of motivation to
seek or encourage
assessment of
suspected concussion.
Stakeholder 3
Proficiencies/Competencies
• Answer survey
questions to assess
level of motivation to
seek or encourage
assessment of
suspected concussion.
8

Table 3
Organizational and Stakeholder Goals-Organizational Support
Organizational Mission
A large four-year research university in the Western United States. This university has a diverse
student, faculty, and staff population. The central mission of WSU is to evolve its members as well
as advance society through education and development of the intellect and disposition. The
fundamental means by which the mission is achieved is through instruction, research, innovation,
qualified training, and selected forms of service to the community.
Organizational Global Goal
By 2021, the goal is to have data from an adapted gap analysis available to university leadership
that outlines the gaps in concussion organizational support as it pertains to the college
community.
Stakeholder 1
Students
Stakeholder 2
Faculty
Stakeholder 3
Staff
Stakeholder 1
Proficiencies/Competencies
• Answer survey questions
to assess level of
organizational support
and concussion resources
for the college
community.
Stakeholder 2
Proficiencies/Competencies
• Answer survey
questions to assess
level of organizational
support and concussion
resources for the
college community.
Stakeholder 3
Proficiencies/Competencies
• Answer survey
questions to assess
level of organizational
support and concussion
resources for the
college community.
9

Purpose of the Project and Questions
The purpose of this study is to assess the college community’s understanding of
concussions, prevention, signs, symptoms, assessment, and organizational support.
Understanding where there are gaps can help determine where improvements need to be made in
outreach, education, assessment, and protocol. The information gained by this study can help
improve new student and employee training, as well as the development of a concussion
checklist for novice first responders (students, faculty, staff, and public safety). The information
obtained from this study can also facilitate discussions for a concussion management plan for the
entire student population.
This study will utilize the Clark and Estes (2008) gap analysis model to perform a needs
analysis for possible knowledge, motivation, and organizational (KMO) gaps that could lead to
greater reliability and validity for concussion assessment. As such, the research questions that
guide this study are as follows:
1. What are the knowledge, motivation, and organizational influences that interfere with
achieving concussion awareness, education, prevention, assessment, treatment and
follow-up?
2. What are the recommended knowledge, motivation, and organizational solutions that can
help instigate a concussion management plan to help with outreach and education as well
as prevention, assessment, treatment, and follow-up for non-athlete students?
Significance of the Study
This study will assess the general college community’s understanding of concussions and
how one acquires a concussion. By doing so, this will help with outreach efforts to educate the
public and also to diminish myths on how people can acquire concussions. The study will also
10

help to find gaps in concussion assessment among lay first responders. This will help with future
training for first responders which include fellow students, faculty, and staff at the college
campus. The data gathered from the study will help to show the knowledge gaps in concussion
and motivation as well as possible resources available to encourage assessment. This can help
with policy change including new employee (including student-worker) and new student
orientation training modules. The study will also point out weaknesses and strengths in perceived
and factual knowledge and concussion resources to see if further outreach and education needs to
be implemented for students, faculty, and staff.
Conceptual and Methodological Framework
The Clark and Estes (2008) methodological approach includes a gap analysis that helps to
clarify an institution’s goals as well as identify gaps between the actual preferred performance
levels. The authors of this approach emphasize that once goals are presented and the gaps
between the goals and current performance are assessed, then transparency to the knowledge,
motivation and organizational transformation needed for improvement and goal attainment can
be attained. This gap analysis will be adapted for needs analysis. The methodological framework
is a quantitative study. Assumed knowledge, motivation, and organizational needs (KMO) will
be produced based on individual knowledge and connected literature. The needs will be validated
by utilizing online surveys, literature review, and content analysis. Suggestions for research-
based solutions will be assessed and presented in an all-inclusive manner.

11

Definition of Terms
Concussion: A clinical syndrome of biomechanically induced alteration of brain function,
typically affecting memory and orientation, which may involve loss of consciousness (Giza et
al., 2013).
Traumatic Brain Injury: Traumatic brain injury results from an impact or rapid movement to the
head or a displacement of the brain within the skull (American Psychiatric Association, 2013).
Organization of the Dissertation
The organization of this dissertation includes five chapters. This chapter provides the
reader with the key concepts and terminology commonly found in a discussion about concussion
assessment. The college’s mission, goals, and stakeholders including initial hypotheses of the
adapted gap analysis will be introduced. In chapter two the reader will find a review of current
literature surrounding the coverage and focus of the study. Topics of concussion knowledge, at-
Gaps in Concussion
Assessment
Organizational
Knowledge
Motivation
Figure 1
Gap Analysis KMO Concussion
Assessment Factors:

12

risk college populations, gaps, causes, symptomology, assessment and treatment resources, and
returning to play/learn will be addressed. Chapter Three will provide details of how the study
will be conducted as well as methodology, participants, inclusion criteria, data collection, and
analysis. In Chapter Four, the data and results will be assessed and analyzed. Chapter Five
provides answers, based on the data collected and literature. These data will help to close
perceived gaps and make recommendations to college leadership for an education, outreach, and
concussion management plan inclusive for all college students.

13

Chapter Two: Review of the Literature
Concussions negatively affect millions of Americans each year, several of whom
continue to live with the lasting effects of a brain injury (Langlois et al., 2006). A large number
of college students acquire concussions each year (Breck et al., 2019). For many college
students, concussions are underreported (Wiese-Bjornstal, 2010; Davis & Bird, 2015).
This chapter will start with a review of concussion knowledge, facts, and figures, the
prevalence of concussion including important findings from the National College Health
Assessment (ACHA, 2020) and gaps from the Centers for Disease Control and Prevention,
Traumatic Brain Injury Report (CDC, 2015). Next, causes, signs and symptoms of concussions,
assessment, treatment, post-concussion syndrome, psychological symptomatology post-
concussion, and return to play/learn will be examined. Lastly, the chapter will analyze
motivation and organizational influences of the college community as related to concussions.
Prevalence of Concussion
According to the Centers for Disease Control and Prevention (CDC, 2015) approximately
3.2-5.3 million Americans live with long-term health effects of traumatic brain injury.
Approximately one in 75 college students acquire a concussion each year (Breck et al., 2019).
Upwards of 5.3 million people in the United States live with a concussion-related disability
(Langlois et al., 2006). Understanding the long-term effects of concussions and the prevention of
recurrent traumas is a challenge for medicine (Danna-Dos-Santos et al., 2018).
Most people with concussions admitted to U.S. Emergency Rooms (ERs) reported having
long-term concussion-related life difficulties (Nelson et al., 2019). Most of these concussed
individuals received no follow-up care after discharge from the E.R. (Seabury et al., 2018). It
14

was also found that less than half of people hospitalized with concussions received concussion
educational materials at discharge or following up with a medical provider (Seabury et al., 2018).
Approximately one-third of concussion patients exhibit moderate to severe post-
concussive symptoms, yet 48% of these patients did not follow-up with a medical provider
(Seabury et al., 2018). A concussion can result from a direct blow to the head or jolt to the
surrounding area that transmits a forceful action to the head with or without loss of
consciousness, resulting in rapid onset of neurological impairment (McCrory et al., 2013 &
2017). Although neuropathological changes can occur for more severe traumatic brain injury,
most concussion symptoms exhibit functional clinical and cognitive symptoms versus structural
injury which is why it is difficult to see if a person has a concussion on standard neuroimaging
such as CT’s and MRI’s (McCrory et al., 2017).
National College Health Assessment Findings
In 2019, the National College Health Assessment (ACHA-NCHA III) reported that 2.8%
of students surveyed reported being diagnosed with a concussion by a healthcare professional
within a 12-month time period (ACHA, 2020). Of those students who reported a concussion,
53.9% said it negatively affected class performance and 12.1% mentioned that it had delayed
progression toward their degree (ACHA, 2020).
Interestingly, within the same survey, 1.0% of students mentioned that they had been
diagnosed with a TBI and there was no timeframe associated with this question (ACHA, 2020).
This shows that the respondents had varying knowledge that concussions were a form of
traumatic brain injury and therefore, having a concussion constitutes having a traumatic brain
injury. Being that concussion is a traumatic brain injury, one would expect these reported
numbers to be at least equal to that of a concussion. The assessment also showed there was no
15

time limit for reporting traumatic brain injuries as there was for concussions. Additionally, of the
students who were diagnosed with a TBI/Concussion, 56.3% were told by a healthcare or mental
health professional that they did not need treatment (ACHA, 2020).
CDC Traumatic Brain Injury Report: Gaps
The Centers for Disease Control and Prevention (2015) Report to Congress on Traumatic
Brain Injury in the United States: Epidemiology and Rehabilitation, outlined many limitations in
available reliable concussion data. The report outlined gaps in determining incidence of
concussion, including the lack of data of those who do not seek treatment resulting in
underreported, undercounted results. In addition, the report revealed gaps in demographics data
including subpopulations, race and ethnicity data as well as representation from all states, and
non-native English speakers.
The CDC report shows that gaps exist in athletic vs non-athletic surveillance data, due to
the limitations in medical coding. Because of this, little information is available to describe the
mode of concussion injury and whether it was a sport-related or recreational induced injury.
Current surveillance only captures professional and student athletics data. There are gaps in
concussion related disability and outcome measures data which limit the effectiveness of
interventions and progress. The report also found gaps in the ability to evaluate the effectiveness
of concussion rehabilitation due to factors such as the variability in symptomology and the lack
of baseline pre-injury knowledge for comparison (CDC, 2015).
Causes of Concussion
Concussions can occur from falls such as from bike, skateboard, scooter crashes as well
as from direct hits, such as fighting, accidentally hitting one’s head or from motor vehicle
accidents (Breck et al., 2019; Faul et al., 2013). Falls are the leading cause of concussions (Faul
16

et al., 2013). In a study by Breck et al. (2019), it was found that 64% of concussions were non-
sport related amongst college undergraduate populations, with 38% resulting from falls, while
8.5% resulted from hits to the head, and 6.5% from motor vehicle accidents. The study also
found that 41% of students diagnosed with a concussion reported having had between one and
three concussions with 5% reporting four or more concussions.
Females may be more susceptible to concussions due to neck strength, head mass, and
hormones (Breck et al., 2019). Preliminary evidence shows that biological differences such as
neck strength and hormone levels for example, progesterone may predispose females to
concussions and longer recovery (Resch et al., 2017). In a study by Broshek et al. (2005), 155
high school and college athletes who sustained concussions, 25% of which were female; it was
found that female-athletes experienced greater cognitive deficits and an increase in negative
symptoms as compared with male athletes. Tierney et al. (2008) found that females are also at an
increased risk of concussions due to a decreased head and neck mass resulting in increased
acceleration after potential concussive impact which corresponds to Newton’s Second Law of
Motion (F = ma).
The human brain has a gelatinous consistency and is cushioned from everyday jolts and
bumps by cerebrospinal fluid between the brain and the skull. However, certain violent injuries
that range from direct impact to jolts and blasts to the brain can cause a concussion (Mayo
Clinic, 2020).
According to the Mayo Clinic (2020) concussions can be a result of:
• A physical forceful impact to the head, neck or upper body can cause the brain to slide
back and forth powerfully against the inner walls of the skull.
17

• The sudden acceleration or deceleration of the head caused by events such as a car crash,
whiplash, blast injury or being violently shaken.
These types of traumas can cause brain injury such as coup-contrecoup. El Sayed et al.
(2008) describes coup injures as those that occur from the brain and skull colliding; while
contrecoup injures follow from the effects of the brain bouncing back from the inner posterior
skull. The coup-contrecoup effect can be seen in Figure 2 by way of the acceleration-
deceleration injury.

Figure 2
Types of Traumatic Brain Injury (Concussion)

Note. Used with permission of Mayo Foundation for Medical Education and Research, all rights
reserved.

18

Signs and Symptoms of Concussion
Assessment and diagnosis of a concussion can be complex and oftentimes overlooked.
Individuals who experience concussions may experience somatic symptomology such as
headaches, nausea, dizziness balance, visual, sensitivity to light and sound, fatigue, dazed, and
stunned (Halstead & Walter, 2010). Concussions can also cause cognitive difficulties such as
impaired concentration and memory loss, forgetfulness, feeling “mentally foggy,” slowed down,
and confused (Halstead & Walter, 2010). Sleep disturbances and changes in mood such as
depression, anxiety, and heightened emotions are also present in individuals with concussions
(Halstead & Walter, 2010). Severe damage, such as chronic traumatic encephalopathy
(CTE) thought to be caused by repeated concussions should be considered in evaluation but is
still being studied (McCrory et al., 2017)
Many factors come into play when assessing a concussion. Clinical symptoms such as
somatic (i.e., headache), cognitive (i.e., feeling in a mental fog) and/or emotional (i.e.,
heightened moods); physical (i.e., loss of consciousness, neurological deficit), behavioral (i.e.,
irritability), cognitive impairment (i.e., delayed reaction time) and sleep (i.e., insomnia) are signs
of a concussion (McCrory et al., 2013 & 2017). According to Mayo Clinic (2020), in addition to
these symptoms, other symptoms of a concussion may include:
• Ringing in the ears
• Blurred vision
• Sensitivity to light and sound
• Dizziness and/ or balance problems
• Seeing stars
• Nausea
19

• Fatigue
• Confusion
• Amnesia
• Slurred speech
• Delayed response
• Mental function or physical coordination difficulties
• Dazed
• Forgetful
• Concentration and memory problems
• Changes in personality
• Disturbances in sleep
• Psychological adjustment problems and/or depression
• Taste and smell disorders
In summary, concussions present themselves in numerous ways as seen in this section.
There are a variety of concussion symptom scales available which will be discussed in the next
section. Each scale has its’ own strengths and limitations therefore, clinicians need to be aware
before including them in their concussion assessment protocol (McLeod & Leach, 2012). Self-
report post-concussion symptom scales are the most widely used method of assessment and
monitoring of recovery, there is currently not an ideal symptomology scale (Randolph et al.,
2009).
Concussion Assessment in Student-Athletes
Guidelines for concussion assessment vary from institution to institution. Many athletic
focused universities establish concussion protocols and management plans. Based on the
20

National Collegiate Athletic Association (NCAA, 2013; as cited in Hall et al., 2015)
recommendations, many schools have their student-athletes undergo pre-season baseline
assessments so that in the event they obtain a concussion, they have a reference of how the
student-athletes’ pre-injury status was before the injury for comparison. Once injured, an
immediate assessment which is based on the concussion protocol of the institution can include
several physical, cognitive, and memory evaluations.
Diagnostic tools such as Post-Concussion Symptom Scale (PCSS), Graded Symptom
Checklist (GSC), Standardized Assessment of Concussion (SAC), Neuropsychological testing,
balance, sensory tests, and neuroimaging can help identify individuals with concussions (as cited
in Giza et al., 2013). Other common assessment tools include the Immediate Post-Concussion
Assessment and Cognitive Test (ImPACT), King-Devick test, Standardized Concussion
Assessment Tool (SCAT) and several other scales (Broglio, et al., 2018). Interestingly,
reliability for these diagnostic assessments has been found to be less than optimal, yet these tools
are still utilized as the best practice until better tools can be developed (Broglio, et al., 2018).
Despite the concussion protocols in student-athletes, socio-cultural influence such as the
expectations for them to be “tough” and “carry on” when injured, downplaying or not reporting a
head injury due to fear of being taken out of the game or not thinking it is severe enough to
report regardless of the negative impact it has on the athletes’ health and performance (Wiese-
Bjornstal, 2010).
General (Non-Athlete) College Student Population Assessment Factors
Much of the research focuses on collegiate sport-concussions, which occurs while a
student is taking part in organized sports, while non-sport concussions in college students occur
during activities of everyday living: traffic or work-related accidents, falls, recreation, acts of
21

violence, and explosions (Sojka, 2011). College campuses also have many other activities that
can lead to concussions such as bicycle, skateboard, scooter, and vehicle collisions, falls, and
intoxication (Kinder et al., 2012).
College students who were inebriated were more likely to experience self-inflicted injury
as well as cause injury to others (O’Brien et al., 2006). These risky behaviors listed by Kinder et
al. (2012) and O’Brien et al. (2006) may be a result of college parties and risky behavior from
students being on their own for the first time which may lead to accidents and increase
concussion risk. Studies have also found that collegiate athletes, as compared to non-athletes
have better acute outcomes; this may be due to their increased physical health, stronger necks,
physical agility or their increased motivation to return to play (Rabinowitz et al., 2014).
Being that concussion education and outreach as well as research and resources are
available predominately in athletic arenas, many college students in the general population go
underserved. A study conducted on collegiate student-athletes found that half did not report
suspected concussions in teammates and a little less than half did not report suspected
concussions in themselves (Davies & Bird, 2015). The study also found that the primary reason
for the underreporting of a suspected concussion was that that they believed that the injury was
not serious enough to report. If a student does not know they have a concussion, perhaps they
will treat their concussion symptoms such as a headache with an over the counter pain reliever,
but then go on to try to do their normal schedule. A normal schedule for college students can
include highly cognitive activities and perhaps physical activities as well which can inhibit
recovery from a concussion and cause heightened symptomology (Dansby-Giles et. al., 2018;
Wasserman et al., 2016).
22

Assessment and proper diagnosis are keys to detecting a concussion and attaining proper
treatment and interventions for a collegiate student and/or athlete. There are many assessments
that one undergoes, especially college athletes, for a concussion. There is a need for concussion
outreach and a simplified assessment or checklist geared towards the lay responder (student,
athlete, staff, public safety, faculty, athletics personnel, etc.).
Concussion Treatment
While concussions resulting in severe traumatic brain injury may result in life-threatening
conditions that need to be treated medically and surgically, many concussions have a more
symptom-based treatment modality. The best practice for concussion treatment is physical and
cognitive rest (McCrory et al., 2013 & 2017). Cognitive rest requires the concussed student to
refrain from activities that involve mental exertion, for example working on the computer,
schoolwork, watching television, reading, playing video games, and texting (McLeod & Gioia,
2010). Upon assessment by a qualified medical practitioner, physical and cognitive rest until the
acute symptoms reside with a gradual return to learn and stepwise return to play, is often the
cornerstone for concussion management (McCrory et al., 2013 & 2107).
Post-Concussion Syndrome
Post-Concussion Syndrome is the cause of persistent clusters of cognitive, memory,
somatic, and behavioral symptoms following a concussion (Dansby-Giles et. al., 2018). One of
the assessment tools for post-concussion syndrome is the Rivermead Post-Concussion Symptom
Questionnaire (RPQ). The RPQ is a self-report diagnostic tool used to help in the diagnosis and
severity of post-concussive symptoms following a TBI (King et al., 1995). Concussion
symptoms that last greater than 10 days are prevalent in approximately 10%-15% of concussions
23

(McCrory et al., 2013). Academic impairment was found among students, especially females and
students with multiple prior concussions (Wasserman et al., 2016).
Cognitive impairment is the hallmark symptom of concussion, however, impairment in
areas such as learning, behavior, emotion, and somatic symptoms can also result (CDC, 2015).
Having cognitive and memory impairments can be distressing for the average person and can be
even more devastating for a student in higher education. A number of individuals report chronic
memory and attention difficulties following a concussion (Geary et al., 2010). Memory, both
short and long-term as well as cognitive functions are vital neurological processes that
undergraduate and graduate college students rely upon for their studies. Having an injury that
causes a deficit can impair a student’s ability to succeed as well as be very frustrating and
limiting to the student.
Psychological Symptomatology Post-Concussion
Mental health can become vulnerable post-concussion. Psychological symptoms in
concussed individuals can be attributed to both pre-injury risk factors and post-injury factors
such as neurochemical changes in the brain, psychological stressors and response to concussion
as well as concussion management (Sandel et al., 2017). Oftentimes concussed individuals
frequently experience symptoms such as post-traumatic stress disorder (PTSD) attentional
difficulties, anxiety, and sleep disturbances (McCrory et al., 2017). Broshek et al. (2015) found
in their review of the literature, that some individuals are at increased risk for neurobiological
depression and/or anxiety post-concussion. It was also found that having a history of anxiety
may increase concussion recovery time due to cognitive biases and misattribution of symptoms
(Broshek et al., 2015). A study by Yang et al. (2015) found that depression and anxiety are
common post-concussion and often co-occur; depression was also found to lead to increased
24

state anxiety (i.e., anxiety about event) regardless of trait anxiety (i.e., personal anxiety level).
Concussions often affect psychological well-being and can result in depression, anxiety, tension,
and/or fear, especially when catastrophizing symptomatology, fear of re-injury or
“kinesiophobia” fears of pain and movement resulting in delayed recovery (Wiese-Bjornstal,
2010).
Return to Play/ Learn
Hall et al. (2014) found in their research that just as there is a return to play for athletes
who have sustained a concussion, there also should be a return to learn. After a concussion,
medical experts recommend rest in patients for both their bodies and their minds (Hall et al.,
2014). Cognitive rest requires the avoidance of activities that many college students do on a daily
basis, such as schoolwork, video games, being online, and texting (Gibson et al., 2013) yet many
students return to these activities too early and stress their brains without proper rest.
It is vital to recovery and management of a concussion, that the injured person has
physical and cognitive rest (McCrory et al., 2013 & 2017). There is currently a lack of empirical
research on the benefits of rest post-concussion. There is also a gap in evidence-based
recommendations and guidelines beyond the acute stage of 24-48 hrs of rest post-injury, for a
student’s gradual return to school, social activities, and play (sports) that would not aggravate
their post-concussion symptoms and recovery (McCrory et al., 2013 & 2017).
Conclusion
In summary, the literature has shown that there is much to be learned about concussions
in the non-athlete college student population. This research study seeks to identify areas where
there are gaps in self-perceived knowledge of concussions such as what level of confidence
respondents in the college community have towards concussion knowledge and resources.
25

Factual knowledge, such as types of concussions, signs and symptoms, and concussion facts will
be assessed. Organizational support factors such as resources, education, assessment, and
training will be looked at, based on the literature showing there are possible deficiencies in these
areas.

26

Chapter Three: Methodology
This study for the purposes of this paper will require a quantitative approach utilizing
measures to collect, analyze and interpret the data (Creswell & Creswell, 2018). Quantitatively,
data will be collected and analyzed to compare and contrast numerical data. A modified Gap
Analysis (Clark and Estes, 2008) will be conducted to evaluate the knowledge, motivation and
organizational deficiencies so as to pinpoint where intervention and education need to occur.
Survey
E-mails and will be sent to the WSU college community with IRB approval. This will
allow study recruitment to be seen in a variety of areas around campus. The questions will be
given via an anonymous Qualtrics survey link. Convenience sampling will be done due to
availability as a result of the COVID-19 Pandemic. Pilot testing will be considered to produce a
usable survey that improves response rate by eliminating ambiguous questions (Fink, 2013).
The study participants will take an online Likert scale survey so as to collect quantitative
data. The survey will take approximately four minutes to complete. Understanding of
concussions, motivation, assessment, self-perceived and actual knowledge, and organizational
support will be analyzed through a series of online survey questions. Deficits in these areas can
be identified by applying the Scientific Method which will weigh the hypothesis against the data
(McEwan & McEwan, 2003).
Having an online survey makes it more assessable to students which in turn makes
participation levels increase for the study (Fink, 2013). Online surveys can also capture and
analyze the data for efficiently. Being that the survey is anonymous helps to protect participant
privacy while allowing them to answer the questions freely. Other survey measures involve,
anonymizing the participants’ response: The survey will not record any personal information and
27

remove contact association. A tag called Indexing Prevention will be added to the survey to
prevent search engines from indexing it. Participant responses to the survey will be secured, and
password protected.
Sample and Population
The purpose of this study is to conduct a KMO Gap Analysis via an anonymous Qualtrics
survey analyzing the college community's knowledge on concussions. The college community
will include, students, faculty, and staff. The information from the quantitative study will be used
to identify knowledge, motivation, and organizational influences that may impact gaps in
concussion assessment and mitigation (Clark & Estes, 2008). College students, both athlete and
non-athletes, faculty, and staff will be e-mailed an invitation to voluntarily participate in an
anonymous online survey about concussions. Inclusion Criteria: Participants must be a student,
faculty or staff member age 18 years or older at the college.
Data Collection and Instrumentation
A quantitative data gathering approach and analysis will be conducted to assess the
college community in the areas of knowledge, motivation, and organizational resources.
Current college students, faculty, and staff will be surveyed online regarding their knowledge
and understanding of Traumatic Brain Injury/Concussions. The online survey will be anonymous
via Qualtrics. The survey will be voluntary and contain an online consent form (IRB information
sheet) and written instructions.
The online survey will include a Likert scale, rating and ranking scale, free recall and
forced-choice as well as voluntary question formats. Skip logic will be used to allow for easier
and relevant question navigation throughout the survey. Some of the questions will be analyzed
by quantitative analyses so as to analyze results and compare responses among groups.
28

Symptomology from the Sports Concussion Assessment Tool 5
th
Edition (SCAT5) will be
implemented into the survey questions to assess knowledge of concussion symptoms
(Echemendia et al., 2017).
Table 4 provides a summary of the survey sections, demographics, questions relevant to
the study, and question types. Knowledge of TBI/concussions was evaluated through self-
perception, factual knowledge, understanding of how one acquires a TBI/concussion,
symptomology, and treatment. Motivation was surveyed by what motivates them to obtain
treatment for a presumed concussion. Concussion education/organizational support was
evaluated by asking questions pertaining to quality and quantity of training, confidence levels of
non-medical first responders (students, faculty and staff), and Student Health Center competency
ratings. Lastly, respondents were asked to rank their preference of modes for outreach and
education.
Table 4
Summary of Survey Sections and Questions
Topic Total
Questions
Question Format Type of
Measurement
Scale
Question
Demographics 4 • Multiple Choice

• Nominal
• Ordinal
• Interval
• Ratio
• Affiliation (Student
Student-Athlete, Faculty,
Staff)
• Age-range 18-24, 25-29,
30-34, 35-39, 40-44, 45-
49, 50-54, 55-59, 60-64,
65-69, 70-74
• Gender (Male, Female,
Other, Decline to State)
• Ethnicity
African American/Black,
American Indian/Alaska
Native, Asian, Caucasian
or White,
Hispanic/Latino, Native
29

Hawaiian/Pacific
Islander, Other, Decline
to State
• Have you had experience
with concussions (i.e.,
personal experience or
through someone close to
you)? Yes, No, Decline to
State

Self-Perception
of Concussion
Knowledge
4 • Likert Scale (5
indicators)
• 5 indicators-
sliding scale
• Interval
• Ratio
Self-rating of:
• I feel confident that I
could define what a
concussion is: Not
Confident, Neither
Confident nor Not
Confident, Somewhat
Confident, Confident

• I feel confident that I
could define what a
traumatic brain injury is:
Not Confident, Neither
Confident nor Not
Confident, Somewhat
Confident, Confident

• I feel confident that I
know how you can get a
concussion: Not
Confident, Neither
Confident nor Not
Confident, Somewhat
Confident, Confident

• I feel confident that I
would be able to
recognize the signs of a
concussion: Not
Confident, Neither
Confident nor Not
Confident, Somewhat
Confident, Confident
Concussion
Factual
Knowledge
7 • Checkbox
• Multiple Choice
• Nominal
• Ordinal
• Interval

• Is a concussion a
traumatic brain injury?
30

• Likert Scale (5
indicators)
• Ratio *Yes, I don't know, No

• Please chose the way(s) a
person can get a
concussion: Direct Impact
to the Head, Violent
Shake/Movement to the
Head or Neck, Sudden
acceleration or
deceleration of the head,
Blast *all are correct

• What is the definition for
a concussion?

A concussion is not a
traumatic brain injury.
Effects are usually
temporary but can
include headaches and
problems with
concentration, memory,
balance and coordination.
Concussions are usually
caused by hitting one's
head hard on an object
such as the direct impact
from two players in a
football game.

• * A concussion is a type
of traumatic brain
injury—or TBI—caused
by a bump, blow, or jolt
to the head or by a hit to
the body that causes the
head and brain to move
rapidly back and forth.
This sudden movement
can cause the brain to
bounce around or twist in
the skull, creating
chemical changes in the
brain and sometimes
stretching and damaging
brain cells.
31

None of the above

• True or False, a person
always loses
consciousness (passes
out) when they get a
concussion
(*False)

• Are there more college
athletes or college non-
athletes who acquire
concussions each year?

College Athletes
*College Non-Athletes
I don't know

• Are males or females at
higher risk of getting a
concussion?
Males
*Females
I don’t know
Concussion
Factual
Knowledge
1 • Checkbox
• Multiple Choice
• Likert Scale
• Nominal
• Ordinal
• Interval
• Ratio
• What signs/symptoms are
associated with a
concussion (please check
all that apply):
*Headache
*“Pressure in head”
*Neck Pain
*Nausea or vomiting
*Dizziness
*Blurred vision
*Balance problems
*Sensitivity to light
*Sensitivity to noise
*Feeling slowed down
*Feeling like “in a fog“
*“Don’t feel right”
*Difficulty concentrating
*Difficulty remembering
*Fatigue or low energy
*Confusion
*Drowsiness
32

*More emotional
*Irritability
*Sadness
*Nervous or Anxious
*Trouble falling asleep
Concussion
Motivation for
Training
2 • Checkbox
• Multiple Choice
• Likert Scale
• Nominal
• Ordinal
• Interval
• Ratio
• How many concussion
trainings/education have
you had? (0-10)

• Please rank your
preferred method of
concussion education
In-person, Online Live
Classroom (i.e., Zoom,
Google Classroom, Skype),
Online Self-Paced
Modules/Webinars, Other
Concussion
Education/Org
anizational
Support

Motivation
2 • Checkbox
• Multiple Choice
• Likert Scale
• Nominal
• Ordinal
• Interval
• Ratio
• Where did you get these
concussion
trainings/education?
School, School Athletics,
Online, Brochure or
Flyer, Hospital or
Doctor’s Office, Other, I
have not had concussion
training/education

• How were these trainings
given?
In-person, online (live
class such as Zoom,
Google Classroom or
Skype)
Online (previously
recorded
webinar/module)
Hybrid (in-person &
online), Other

• How confident were you
about concussion
knowledge after the
training? Not Confident,
Neither Confident nor
Not Confident,
33

Somewhat Confident,
Confident

• How confident are you
that the non-medical
college community
(students, faculty or staff)
can recognize a
concussion? Not
Confident, Neither
Confident nor Not
Confident, Somewhat
Confident, Confident

• How confident do you
feel that the Student
Health Center could
properly assess a
concussion?
Not Confident, Neither
Confident nor Not
Confident, Somewhat
Confident, Confident

• How confident do you
feel that the Student
Health Center could
properly treat a
concussion?
Not Confident, Neither
Confident nor Not
Confident, Somewhat
Confident, Confident

Note. Concussion symptoms listed are commonly known symptoms and can be found on many
assessment tools such as the SCAT 5 (Echemendia et al., 2017; Mayo Clinic, 2020; CDC,
2019) and several others. Sections of the concussion definition choices were taken from Mayo
Clinic (2020) and CDC (2019).

34

Data Analysis
To summarize the data and find patterns, descriptive statistics/analysis will be used to
find the total, percentage, and breakdown by affiliation (student/student-athlete, faculty, and
staff). Utilizing the most common scale in social science research, total test scores using interval
data will be used to analyze the numerical components (Kurpius & Stafford, 2006). Comparisons
between self-perceived knowledge by way of level of confidence will be examined.
Limitation and Delimitations
Limitations of the study are that we are currently under a COVID-19 Pandemic which
will negatively influence research capabilities including convenience sampling, thus affecting
internal validity. Some of the limitations expected are having to modify the study to be purely
online survey-based. Making the survey online will also include making sure the studies’ data
collection is simplified enough to collect online while being detailed enough for data integrity
and quantitative assessment.
The study will also need to be anonymous so as to be able to deidentify data and not have
a link to the participants’ identification. As so, the online consent will be included as part of the
survey and not as a separate consenting process. Advertising of the study will be very limited
since on-campus access is not allowed at this time. Delimitations will be that the study will only
be on one campus, which may affect the generalizability of the study and issues of external
validity. This will make it difficult to attain a high quantity of participants to take the survey.
Having small numbers can skew the data and run into participant bias. Participants will also not
be fully randomized due to the limited number of participants expected.

35

Chapter Four: Results and Findings
The purpose of this study was to assess the college community’s understanding of
concussions, prevention, signs, symptoms, assessment, and organizational support. The data
collected for purposes of this dissertation focused on a solution-based model specifically
examining the effects of knowledge, motivation, and organizational influences in relation to
concussions in the college community. These data and the information obtained can help assess
where improvements need to be made in outreach, education, assessment, and protocol so as to
provide recommendations for further research, training, and organizational support. To
understand these effects, students, faculty, and staff were surveyed. To comprehend how these
areas impact concussions in the college community, the researcher studied anonymous survey
responses and compared and contrasted the results with information gathered from scientific
literature review.
The comprehensive literature review conducted in chapter 2 provided empirical data to
validate assumed causes and provide merit for the study that was conducted. Chapter 3 presented
details of how the study was to be conducted, including methodology, participants, inclusion
criteria, data collection, and analysis. This chapter discussed how the quantitative data would be
collected to compare and contrast, measure, analyze, and interpret the data. The conceptual
framework was laid out and the results and findings were organized by knowledge, motivation,
and organizational influences. The following two research questions guided this solution-focused
study:
1. What are the knowledge, motivation, and organizational influences that interfere with
achieving concussion awareness, education, prevention, assessment, treatment and
follow-up?
36

2. What are the recommended knowledge, motivation, and organizational solutions that can
help instigate a concussion management plan to help with outreach and education as well
as prevention, assessment, treatment and follow-up for non-athlete students?
Participating Stakeholders
This study focused on students (athlete and non-athlete), faculty, and staff ages 18 years
and older who attended the university. This population will be commonly referred to as the
college community. This study examined the college communities, understanding of
concussions, risk factors, levels of confidence and organizational support, and outreach.
Survey participants
E-mails providing information about the survey were sent to various university
departments, such as Advising, Academic and Learning Centers, Orientations, Innovation,
Organizational Improvement, Human Resources, Identity and Access Management and various
Faculty and Staff Affairs departments asking if they would consider sending information about
the study and a link to the survey through their listservs. This allowed the research to be
completely anonymous and truly voluntary without added pressure on possible respondents to
take the survey. This also kept the researcher completely blind as to who did and did not take the
survey. The study categorized the responses into four different types of college community
members: Students, Student-Athlete, Faculty, and Staff. Upon analyzing the data by affiliation,
only two student athletes responded to the survey. Due to the small sample size of the student
athlete population (n = 2) it was decided to aggregate this population as part of student
population for validity and reliability purposes. The data from this study was collected from N =
232 respondents, 266 individuals viewed the IRB information sheet and agreed to participate in
the research, however, only 232 respondents answered the survey questions. Data collection for
37

the survey occurred over a twenty-day period. Descriptive statistics of participant demographics
are listed.
The study categorized respondents into three college community categories, Student,
Faculty and Staff. Table 1 shows respondents by affiliation (N = 232), followed by gender,
ethnicity, age and experience with concussions (N = 231). The majority of respondents 64.66%
were staff, 75.75% female, 45.65% Caucasian/White, 64.94% between the ages of 18-39 and did
not have experience with concussions 55.17%. More extensive tables and charts showing the
breakdown of variables by affiliation is listed in the appendices (Gender Appendix B, Ethnicity
Appendix C and Age Appendix D).
Table 5
Descriptive Statistics of Survey Respondents-Demographics
Variable Number Percentage
Affiliation (N = 232)
Student 57 24.57%
Faculty 25 10.78%
Staff 150 64.66%

Gender (N = 231)
Male 47 20.34%
Female 175 75.75%
Other 4 1.73%
Decline to State 5 2.16%

Ethnicity
38

African American/Black 5 2.17%
American Indian/Alaska Native 0 0%
Asian 58 25.22%
Caucasian/White 105 45.65%
Hispanic/Latino 46 20.00%
Native Hawaiian/Pacific Islander 0 0%
Other 10 4.34%
Decline to State 6 2.61%

Age (N = 231)
18-39 150 64.94%
40-64 71 30.74%
65-74 10 4.33%

Concussion Experience (N = 232)
Yes 103 44.40%
No 128 55.17%
Decline to State 1 0.43%

Note. Upon analyzing the data by affiliation, only two student athletes responded
to the survey. Due to the small sample size of the student athlete population (n =
2) it was decided to aggregate this population as part of student population for
validity and reliability purposes.
39

Results and Findings
Findings gathered from the data analysis were guided by research questions utilizing
knowledge categories and the assumed causes for each category. Clark and Estes’s (2008)
knowledge, motivation and organizational framework was a pivotal part in structuring and
categorizing the findings pulled from the data. The data gathered, which was guided by this
conceptual framework was supported through a literature review and validated through this
research study. The study’s research questions in addition to the findings that were discovered
through the data analysis will be examined and discussed.
This study categorized the data into three main categories that align with the KMO
framework. For knowledge, the researcher examined the college communities’ self-perception of
concussion knowledge as well as their factual knowledge of concussions. These categories were
also compared to each other to see if they correlated. Motivation was measured by the
respondent’s motivation to seek training as well as confidence ratings regarding the subject
matter. Lastly, organizational support was measured by available concussion outreach and
education opportunities. The following survey questions were categorized into four defining
sections. Self-Perceived Concussion Knowledge, Factual Concussion Knowledge, Motivation
and Organizational Support.

40

Self-Perceived Concussion Knowledge Influence 1: Knowing What a Concussion Is
Survey Results
The college community was asked how confident they were that they “could define what
a concussion is” from a list of four confidence levels. As shown in table 6, 70.56% of
respondents felt “Somewhat Confident to Confident” in their ability to define what a concussion
is. The threshold set for this item is 50% due to the level of confidence the research placed on the
college community’s knowledge of concussions. Therefore, the college community does not
have a need to increase Self-Perceived Concussion Knowledge to define what a concussion is.

Table 6
Self-Perceived Concussion Knowledge Influence Item 1: Level of Confidence
“Define what a concussion is”
Variable n Percent
Not Confident 31 13.42%
Neither Confident nor Not Confident 37 16.02%
Somewhat Confident 128 55.41%
Confident 35 15.15%

41

Summary
Of the N = 231 survey respondents, 70.56% rated their self-perceived ability to define
what a concussion is at a Somewhat Confident to Confident level exceeding the 50% threshold.
As the survey results suggest, the college community demonstrates appropriate Self-Perceived
Concussion Knowledge to define what a concussion is; this knowledge influence has been met.

Figure 3
Level of Confidence: Define Concussion

0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
Not Confident Neither
Confident nor
Not Confident
Somewhat
Confident
Confident
42

Self-Perceived Concussion Knowledge Influence 2: Defining a Traumatic Brain Injury
Survey Results
The college community was asked how confident they were that they “could define what
a traumatic brain injury is” from a list of four confidence levels. As shown in table 7, 56.28% of
respondents (N = 231) felt “Somewhat Confident to Confident” in their ability to define what a
traumatic brain injury is. The threshold set for this item is 50% due to the level of confidence the
research placed on the college community’s knowledge of concussions. Therefore, the college
community does not have a need to increase their Self-Perceived Concussion Knowledge to
define what a concussion is.

Table 7
Self-Perceived Concussion Knowledge Influence Item 2: Level of Confidence
“I feel confident that I could define what a traumatic brain injury is”
Variable n Percent
Not Confident 53 22.94%
Neither Confident nor Not Confident 48 20.78%
Somewhat Confident 89 38.53%
Confident 41 17.75%

43

Summary
Of the N = 231 survey respondents, 56.28% rated their self-perceived ability to define
what a traumatic brain injury is at a “Somewhat Confident to Confident” level exceeding the
50% threshold. As the survey results suggest, the college community demonstrates appropriate
Self-Perceived Concussion Knowledge to define what a traumatic brain injury is; this knowledge
influence has been met.

Figure 4
Level of Confidence: Define TBI

0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
Not Confident Neither
Confident nor
Not Confident
Somewhat
Confident
Confident
44

Self-Perceived Concussion Knowledge Influence 3: Acquiring a Concussion
Survey Results
The college community was asked how confident they were that they “know how you can
get a concussion” from a list of four confidence levels. As shown in table 8, 86.15% of
respondents felt “Somewhat Confident to Confident” in their ability to understand how a
concussion is acquired. The threshold set for this item is 50% due to the level of confidence the
research placed on the college community’s knowledge of concussions. Therefore, the college
community does not have a need to increase their Self-Perceived Concussion Knowledge to
understand how a concussion is acquired.

Table 8
Self-Perceived Concussion Knowledge Influence Item 3: Level of Confidence
“I feel confident that I know how you can get a concussion”
Variable n Percent
Not Confident 12 5.19%
Neither Confident nor Not Confident 20 8.66%
Somewhat Confident 134 58.01%
Confident 65 28.14%

45

Summary
Of the N = 231survey respondents, 86.15% rated their self-perceived ability to “know
how you can get a concussion” at a “Somewhat Confident to Confident” level exceeding the
50% threshold. As the survey results suggest, the college community demonstrates appropriate
Self-Perceived Concussion Knowledge of how a concussion is acquired; this knowledge
influence has been met.

Figure 5
Level of Confidence: How Concussions Are Acquired

0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
Not Confident Neither
Confident nor
Not Confident
Somewhat
Confident
Confident
46

Self-Perceived Concussion Knowledge Influence 4: Signs and Symptoms of a Concussion
Survey Results
The college community was asked how confident they were that they “would be able to
recognize the signs of a concussion” from a list of four confidence levels. As shown in table 9,
58.95% of respondents felt “Somewhat Confident to Confident” in their ability to understand
how a concussion is acquired. The threshold set for this item is 50% due to the level of
confidence the research placed on the college community’s knowledge of concussions.
Therefore, the college community does not have a need to increase their Self-Perceived
Concussion Knowledge to recognize the signs and symptoms of a concussion.

Table 9
Self-Perceived Concussion Knowledge Influence Item 4: Level of Confidence
“I feel confident that I would be able to recognize the signs of a concussion”
Variable n Percent
Not Confident 51 22.27%
Neither Confident nor Not Confident 43 18.78%
Somewhat Confident 108 47.16%
Confident 27 11.79%

47

Summary
Of the N = 229 survey respondents, 58.95% rated their self-perceived ability to
“recognize the signs of a concussion” at a “Somewhat Confident to Confident” level exceeding
the 50% threshold. As the survey results suggest, the college community demonstrates
appropriate Self-Perceived Concussion Knowledge to recognize the signs and symptoms of a
concussion; this knowledge influence has been met.

Figure 6
Level of Confidence: Signs & Symptoms of Concussion

0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
50.00%
Not Confident Neither
Confident nor
Not Confident
Somewhat
Confident
Confident
48

Self-Perceived Concussion Knowledge Influence 5: Concussion Knowledge After Training
Survey Results
The college community was asked how confident they were “about concussion
knowledge after the training” from a list of four confidence levels. As shown in table 10, 48.59%
of respondents felt “Somewhat Confident to Confident” in their ability to understand how a
concussion is acquired. The threshold set for this item is 50% due to the level of confidence the
research placed on the college community’s knowledge of concussions. Therefore, the college
community has a need to increase their Self-Perceived Concussion Knowledge following a
concussion training.

Table 10
Self-Perceived Concussion Knowledge Influence Item 5: Level of Confidence
“How confident were you about concussion knowledge after the training?”
Variable n Percent
Not Confident 14 13.08%
Neither Confident nor Not Confident 41 38.32%
Somewhat Confident 38 35.51%
Confident 14 13.08%

49

Summary
Of the survey respondents (N = 107) 48.59% rated their self-perceived knowledge “after
the training” at a “Somewhat Confident to Confident” level falling below the 50% threshold. As
the survey results suggest, the college community does not demonstrate appropriate Self-
Perceived Concussion Knowledge following a concussion training; this knowledge influence is
considered a need.

Figure 7
Level of Confidence: Knowledge after Concussion Training

0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
Not Confident Neither
Confident nor
Not Confident
Somewhat
Confident
Confident
50

Organizational Confidence Influence:1 Level of Confidence: College Community
Recognition of Concussions
Survey Results
The college community was asked how confident they were “that the non-medical
college community (students, faculty or staff) can recognize a concussion” from a list of four
confidence levels. As shown in table 11, 15.43% of respondents felt “Somewhat Confident to
Confident” in concussion confidence in non-medical college community. The threshold set for
this item is 50% due to the level of confidence the research placed on the college community’s
knowledge of concussions. Therefore, there is a need to increase Organizational Confidence in
the non-medical college community.

Table 11
Organizational Confidence Item 1
“How confident are you that the non-medical college community (students, faculty or staff) can
recognize a concussion?”
Variable n Percent
Not Confident 94 46.77%
Neither Confident nor Not Confident 76 37.81%
Somewhat Confident 29 14.43%
Confident 2 1.00%

51

Summary
Of the (N = 201) survey respondents, 15.43% rated “that the non-medical college
community (students, faculty or staff) can recognize a concussion” at a “Somewhat Confident to
Confident” level falling below the 50% threshold. As the survey results suggest, the college
community does not demonstrate appropriate Organizational Confidence in the non-medical
college community; this knowledge influence is considered a need.

Figure 8
Level of Confidence: College Community Recognition of Concussions

0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
50.00%
Not Confident Neither
Confident nor
Not Confident
Somewhat
Confident
Confident
52

Organizational Confidence Influence 2: Student Health Center Concussion Assessment
Survey Results
The college community was asked how confident they were “that the Student Health
Center could properly assess a concussion” from a list of four confidence levels. As shown in
table 12, 79.12% of respondents felt “Somewhat Confident to Confident” in the Student Health
Center’s ability to properly assess a concussion. The threshold set for this item is 50% due to the
level of confidence the research placed on the college community’s knowledge of concussions.
Therefore, the college community does not have a need to increase Organizational Confidence in
the Student Health Center’s ability to properly assess a concussion.

Table 12
Organizational Confidence Item 2
“How confident do you feel that the Student Health Center could properly assess a concussion?”
Variable n Percent
Not Confident 6 2.91%
Neither Confident nor Not Confident 37 17.96%
Somewhat Confident 89 43.20%
Confident 74 35.92%

53

Summary
Of the (N = 206) survey respondents, 79.12% rated “that the Student Health
Center could properly assess a concussion” at a “Somewhat Confident to Confident” level
exceeding the 50% threshold. As the survey results suggest, the college community demonstrates
appropriate Organizational Confidence in the Student Health Center’s ability to properly assess a
concussion; this knowledge influence has been met.

Figure 9
Level of Confidence: Student Health Center Properly Assess Concussions

0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
Not Confident Neither
Confident nor
Not Confident
Somewhat
Confident
Confident
54

Organizational Confidence Influence 3: Student Health Center Concussion Treatment
Survey Results
The college community was asked how confident they were “that the Student Health
Center could properly treat a concussion” from a list of four confidence levels. As shown in table
13, 72.31% of respondents felt “Somewhat Confident to Confident” in the Student Health
Center’s ability to properly treat a concussion. The threshold set for this item is 50% due to the
level of confidence the research placed on the college community’s knowledge of concussions.
Therefore, the college community does not have a need to increase Organizational Confidence in
the Student Health Center’s ability to properly treat a concussion.

Table 13
Organizational Confidence Item 3
“How confident do you feel that the Student Health Center could properly treat a concussion?”
Variable n Percent
Not Confident 15 7.28%
Neither Confident nor Not Confident 42 20.39%
Somewhat Confident 84 40.78%
Confident 65 31.53%

55

Summary
Of the (N = 206) survey respondents, 72.31% rated “that the Student Health Center could
properly treat a concussion” at a “Somewhat Confident to Confident” level exceeding the 50%
threshold. As the survey results suggest, the college community demonstrates appropriate
Organizational Confidence in the Student Health Center’s ability to properly treat a concussion;
this knowledge influence has been met.

Figure 10
Level of Confidence: Student Health Center Properly Treat Concussions

0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
Not Confident Neither
Confident nor
Not Confident
Somewhat
Confident
Confident
56

Factual Knowledge Influence 1. Concussion Being a Traumatic Brain Injury
Survey Results
The college community was asked if a concussion was a traumatic brain injury from a list
of three choices. As shown in table 14, the accuracy in identifying the correct answer choice was
73.7%. The threshold set for this item is 70 % due to the level of knowledge the research placed
on the college community’s knowledge of concussions. Therefore, there is not a need for college
community members to have an increase in Factual Knowledge of identifying if a concussion is
a traumatic brain injury.

Table 14
Factual Knowledge Item 1
“Is a concussion a traumatic brain injury?”
Variable n Percent
Yes 170 73.59%
I Don’t Know 44 19.05%
No 17 7.36%

57

Summary
Of the (N = 231) survey respondents, 73.59% successfully identified that a concussion is
a traumatic brain injury, exceeding the 70% threshold. As the survey results suggest, the college
community demonstrates appropriate Factual Knowledge about concussions being a traumatic
brain injury; this knowledge influence has been met.

Figure 11
Factual Knowledge: Is a Concussion a Traumatic Brain Injury?

0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
Yes I Don’t Know No
58

Factual Knowledge Influence 2: Types of Acquired Concussions
Survey Results
The college community was asked to “chose the way(s) a person can get a concussion”
from a list of four choices. As shown in table 15, the accuracy in identifying the correct answer
choice was 88.36% overall mean score. The threshold set for this item is 70% due to the level of
knowledge the research placed on the college community’s knowledge of concussions.
Therefore, there is not an overall need for college community members to have an increase in
factual knowledge of identifying ways in which a person can acquire a concussion.

Table 15
Factual Knowledge Item 2
“Please choose the way(s) a person can get a concussion”
Variable n Percent
Direct Impact to Head 229 98.71%
Violent Shake/Movement to Head or Neck 214 92.24%
Sudden Acceleration or Deceleration of the Head 195 84.05%
Blast 182 78.45%
Overall Mean Score 205 88.36%

Note. Types of Concussion Injuries taken from Mayo Clinic (2020).

59

Summary
Of the (N = 232) survey respondents, 88.36% overall successfully identified ways in
which a person can acquire a concussion, exceeding the 70% threshold. As the survey results
suggest, the college community demonstrates appropriate Factual Knowledge overall about
concussions being a traumatic brain injury; this knowledge influence has been met.

Figure 12
Types of Traumatic Brain Injury (Concussion)

0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
60

Factual Knowledge Influence 3: Signs and Symptoms of Concussions
Survey Results
The college community was asked to choose “what signs/symptoms are associated with a
concussion” from a list of twenty-two choices. As shown in table 16, the accuracy in identifying
the correct answer choice was 69.00% for the overall mean score. The threshold set for this item
is 70% due to the level of knowledge the research placed on the college community’s knowledge
of concussions. Therefore, there is an overall need for college community members to have an
increase in Factual Knowledge of identifying signs and symptoms of a concussion. Assessment
of the independent variables shows the areas that have the most need.

Table 16
Factual Knowledge Item 3
“What signs/symptoms are associated with a concussion (please check all that apply)?”
Variable n Percent
Headache 223 96.12%
Dizziness 211 90.95%
Blurred vision 209 90.09%
Nausea or vomiting 201 86.64%
Difficulty concentrating 198 85.34%
Balance problems 197 84.91%
Confusion 194 83.62%
Difficulty remembering 191 82.33%
"Don’t feel right” 182 78.45%
61

“Pressure in head” 181 78.02%
Feeling like “in a fog“ 178 76.72%
Sensitivity to light 171 73.71%
Drowsiness 161 69.40%
Sensitivity to noise 148 63.79%
Feeling slowed down 143 61.64%
Fatigue or low energy 143 61.64%
Irritability 119 51.29%
Neck Pain 116 50.00%
Trouble falling asleep 94 40.52%
Nervous or Anxious 92 39.66%
More emotional 90 38.79%
Sadness 80 34.48%
Overall Mean Score 160.09 69.00%

Note. Concussion symptoms listed are commonly known symptoms and can be found on many
assessment tools such as the SCAT 5 (Echemendia et al., 2017; Mayo Clinic, 2020; CDC, 2019)
and several others.

62

Summary
Of the N = 232 survey respondents, 69.00% overall accurately chose “what
signs/symptoms are associated with a concussion” falling below the 70% threshold. As the
survey results suggest, the college community does not demonstrate appropriate Factual
Knowledge in Signs and Symptoms of Concussions; this knowledge influence is considered a
need.

Figure 13
Figure M: Recognition of TBI (Concussion) Signs and Symptoms

0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
Headache
Dizziness
Blurred vision
Nausea or vomiting
Difficulty concentrating
Balance problems
Confusion
Difficulty remembering
"Don’t feel right”
“Pressure in head”
Feeling like “in a fog“
Sensitivity to light
Drowsiness
Sensitivity to noise
Feeling slowed down
Fatigue or low energy
Irritability
Neck Pain
Trouble falling asleep
Nervous or Anxious
More emotional
Sadness
63

Factual Knowledge Influence 4: Knowing the Definition of a Concussion
Survey Results
The college community was asked “what is the definition for a concussion?” based on
three answer choices. As shown in table 17, the accuracy in identifying the correct answer choice
was 87.28%. The threshold set for this item is 70% due to the level of knowledge the research
placed on the college community’s knowledge of concussions. Therefore, there is not a need for
college community members to have an increase in Factual Knowledge of identifying the correct
definition of a concussion.
Table 17
Factual Knowledge Item 4
“What is the definition for a concussion?
Variable n Percent
A concussion is not a traumatic brain injury. Effects are
usually temporary but can include headaches and problems
with concentration, memory, balance, and coordination.
Concussions are usually caused by hitting one's head hard on
an object such as the direct impact from two players in a
football game. 29 12.72%
*A concussion is a type of traumatic brain injury—or TBI—
caused by a bump, blow, or jolt to the head or by a hit to the
body that causes the head and brain to move rapidly back and
forth. This sudden movement can cause the brain to bounce
around or twist in the skull, creating chemical changes in the
brain and sometimes stretching and damaging brain cells. 199 87.28%

Note. Sections of the concussion definition choices were taken from Mayo Clinic (2020) and
CDC (2019).

64

Summary
Of the (N = 228) survey respondents, 87.28% successfully identified the correct
definition of a concussion, exceeding the 70% threshold. As the survey results suggest, the
college community demonstrates appropriate Factual Knowledge about concussion definitions;
this knowledge influence has been met.

Figure 14
Definition of Concussion

0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
A concussion is not a traumatic brain
injury. Effects are usually temporary but
can include headaches and problems with
concentration, memory, balance and
coordination. Concussions are usually
caused by hitting one's head hard on an
object such as the dire
*A concussion is a type of traumatic
brain injury—or TBI—caused by a
bump, blow, or jolt to the head or by a hit
to the body that causes the head and brain
to move rapidly back and forth. This
sudden movement can cause the brain to
bounce around or twist i
65

Factual Knowledge Influence 5: Concussion and Loss of Consciousness
Survey Results
The college community was asked if it was true or false that “a person always loses
consciousness (passes out) when they get a concussion”. As shown in table 18, the accuracy in
identifying the correct answer choice was 98.26%. The threshold set for this item is 70% due to
the level of knowledge the research placed on the college community’s knowledge of
concussions. Therefore, there is not a need for college community members to have an increase
in Factual Knowledge of identifying loss of consciousness in concussions.

Table 18
Factual Knowledge Item 5
“True or False, a person always loses consciousness (passes out) when they get a concussion”
Variable n Percent
True 4 1.74%
False 226 98.26%

66

Summary
Of the (N = 230) survey respondents, 98.26% successfully identified the correct answer
choice for whether “a person always loses consciousness (passes out) when they get a
concussion,” exceeding the 70% threshold. As the survey results suggest, the college community
demonstrates appropriate Factual Knowledge about loss of consciousness and concussions; this
knowledge influence has been met.

Figure 15
Do Concussions Always Cause Loss of Consciousness?

0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
True False
67

Factual Knowledge Influence 6: More College Athletes or College Non-Athletes Acquire
Concussions Each Year
Survey Results
The college community was asked to choose if there were more “college athletes or
college non-athletes who acquire concussions each year” from a list of three answer choices. As
shown in table 19, the accuracy in identifying the correct answer choice was 14.66%. The
threshold set for this item is 70% due to the level of knowledge the research placed on the
college community’s knowledge of concussions. Therefore, there is an overall need for college
community members to have an increase in Factual Knowledge of college non-athletes acquiring
more concussions.

Table 19
Factual Knowledge Item 6
“Are there more college athletes or college non-athletes who acquire concussions each year?”
Variable n Percent
College Athletes 99 42.67%
College Non-Athletes* 34 14.66%
I Don’t Know 99 42.67%

Note. * Correct Answer

68

Summary
Of the N = 232 survey respondents, 14.66% overall accurately chose that College Non-
Athletes acquired more concussions each year, falling below the 70% threshold. As the survey
results suggest, the college community does not demonstrate appropriate Factual Knowledge of
college non-athletes acquiring more concussions; this knowledge influence is considered a need.

Figure 16
Assumed College Athlete vs Non-Athlete Concussion Incidence

0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
College Athletes College Non-
Athletes*
I Don’t Know
69

Factual Knowledge Influence 7: Male or Female Risk of Concussion
Survey Results
The college community was asked “are males or females at higher risk of getting a
concussion” from a list of three answer choices. As shown in table 20, the accuracy in
identifying the correct answer choice was 5.19%. The threshold set for this item is 70% due to
the level of knowledge the research placed on the college community’s knowledge of
concussion. Therefore, there is an overall need for college community members to have an
increase in Factual Knowledge of females being at a higher risk of acquiring concussions.

Table 20
Factual Knowledge Item 7
“Are males or females at higher risk of getting a concussion?”
Variable n Percent
Males 109 47.19%
Females* 12 5.19%
Don’t Know 110 47.62%

Note. * Correct Answer

70

Summary
Of the (N = 231) survey respondents, 5.19% overall accurately chose that “females” are
at higher risk of acquiring concussions, falling below the 70% threshold. As the survey results
suggest, the college community does not demonstrate appropriate Factual Knowledge of females
being at higher risk of acquiring concussions; this knowledge influence is considered a need.
Figure 17
Assumed Gender Risk for Concussions

0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
50.00%
Males Females* Don’t Know
71

Motivation Influence 1: Number of Concussion Trainings
Survey Results
The college community was asked “how many concussion trainings/education” they had
from a list of 11 answer choices. As shown in table 21, 56.34% of respondents had “0”
concussion trainings. The threshold set for this item is 50% due to the level of confidence the
research placed on the college community’s knowledge of concussions. Therefore, there is a
need to increase Motivation to attend concussion trainings/education.

Table 21
Motivation Item 1
“How many concussion trainings/education have you had?”
Variable n Percent
0 80 56.34%
1 27 19.01%
2 18 12.68%
3 9 6.34%
4 3 2.11%
5 1 0.70%
6 1 0.70%
7 1 0.70%
8 0 0%
9 0 0%
10 2 1.41%
72

Summary
Of the N = 142 survey respondents, 56.34% answered that they have attended “0”
concussion trainings/education putting their Motivation level below the 50% threshold. As the
survey results suggest, the college community does not demonstrate appropriate Motivation
following for concussion training/education; this knowledge influence is considered a need.

Figure 18
Number of Concussion Trainings

0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
Zero One Two Three Four Five Six Seven Eight Nine Ten
73

Motivation Influence 2: Preferred Method of Concussion Education
Survey Results
The college community was asked to “rank your preferred method of concussion
education” from a list of four options. As shown in table 22, 51.70% of respondents chose
Online Self-Paced as their preferred method of concussion training. The threshold set for this
item is 50% due to the level of confidence the research placed on the college community’s
knowledge of concussions. Therefore, there is not a need to increase Motivation to attend
concussion trainings but a desire to attend Online Self-Paced Concussion Education.

Table 22
Motivation Item 2
“Please rank your preferred method of concussion education”
Variable n Percent
In-Person 43 24.43%
Online Live Class 40 22.73%
Online Self-Paced 91 51.70%
Other 2 1.14%

74

Summary
Of the N = 176 survey respondents, 51.70% answered that there preferred method of
concussion education was “Online Self-Paced” putting their Motivation level above the 50%
threshold. As the survey results suggest, the college community demonstrates appropriate
Motivation following for Online Self-Paced Concussion Education; this knowledge influence is
considered met and the modality a preferred method of learning.

Figure 19
Method of Concussion Training

0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
In-Person Online Live
Class
Online Self-
Paced
Other
75

Organizational Support Influence 1: Location of Concussion Trainings/Education
Survey Results
The college community was asked where they received “these concussion
trainings/education” from a list of seven options. As shown in table 23, 69.91% mentioned that
“I have Not Had Concussion Training/Education”. The threshold set for this item is 50% due to
the level of confidence the research placed on the college community’s knowledge of
concussions. Due to the variable of exceeding 50% threshold being that of a lack in
training/education, the inverse is true resulting in a need to increase Organizational Support to
attend concussion trainings.

Table 23
Organizational Support Item 1
“Where did you get these concussion trainings/education?”
Variable n Percent
School 33 14.60%
School Athletics 22 9.73%
Online 14 6.19%
Brochure or Flyer 5 2.21%
Hospital or Doctor’s Office 17 7.52%
Other 11 4.87%
I have Not Had Concussion Training/Education 158 69.91%

76

Summary
Of the N = 226 survey respondents, 69.91% answered that that “I have Not Had
Concussion Training/Education” putting their need for Organizational Support level above the
50% threshold. As the survey results suggest, the college community does not demonstrate
appropriate Organizational Support due to lack of Concussion Training/Education; this
knowledge influence is considered a need.

Figure 20
Location of Concussion Training

0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
77

Organizational Support Influence 2: Modality of Concussion Training
Survey Results
The college community was asked “How were the concussion trainings given?”
from a list of five options. As shown in table 24, 52.44% mentioned that they took concussion
training “In-Person”. The threshold set for this item is 50% due to the level of confidence the
research placed on the college community’s knowledge of concussions. Therefore, there is not a
need for college community members to have an increase in Organizational Support for In-
Person concussion trainings.

Table 24
Organizational Support Item 2
“How were the concussion trainings given?”
Variable n Percent
In-Person 43 52.44%
Online-Live 0 0%
Online Pre-recorded 8 9.76%
Hybrid 5 6.10%
Other 26 3.17%

78

Summary
Of the N = 82 survey respondents, 52.44% chose that they attended “In-Person”
concussion training exceeding the 50% threshold. As the survey results suggest, the college
community demonstrates Organizational Support for in-person concussion; this knowledge
influence has been met, however, other modes of training should be explored per Motivation item
2.

Figure 21
Method of Concussion Training

0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
In-Person Online-Live Online Pre-
recorded
Hybrid Other
79

Summary of Results Overall
For Self-Perceived Concussion Knowledge, with a threshold set at 50%, the majority of
respondents 70.56% felt “Somewhat Confident to Confident” in their ability to know what a
concussion is, define a traumatic brain injury 56.28%, know how a concussion is acquired
86.15% and recognize signs and symptoms of a concussion 58.95%. However, when it came to
respondents’ level of confidence in regard to concussion knowledge following a concussion
training, only 48.59% felt “Somewhat Confident to Confident”.
In regard to Factual Knowledge, the threshold was set at 70% due to the level of
knowledge the research placed on the college community’s understanding of concussions. Of the
respondents, 87.28% were able to identify the correct definition of a concussion and 98.26%
understood that concussions could occur without loss of consciousness and 73.59% correctly
identified concussions as a traumatic brain injury. Overall, 88.36% identified the types of
traumatic brain injuries (concussions). When given a list of signs and symptoms related to a
concussion only 12 of 22 symptoms were identified within the passing parameters. Only 14.66%
answered that college non-athletes acquired more concussions each year and only 5.19% thought
that females were at higher risk of concussion.
As for Organizational Confidence, only 15.43% felt that the college community could
recognize a concussion, however, they felt “Somewhat Confident to Confident” that the Student
Health Center could properly assess 79.21% and treat 72.31% a concussion. The majority of
respondents 69.91% have no concussion training, the ones that have, took the training in-person
52.44% but the preferred mode of training 51.70% was online self-paced.

80

Summary of Results by Affiliation
The majority of respondents did not have experience with concussions (55.17%, n= 128).
When asked about Self-Perceived Confidence of concussions as measured by the respondents’
perceived ability to define what a concussion is, most across all affiliations responded that they
were “Somewhat Confident” 55.41% (n = 128). When asked to choose the correct definition of a
concussion, 87.28% (n = 199) identified the correct definition which included that it “is a type of
traumatic brain injury”.
When asked about confidence in the ability to define what a traumatic brain injury was,
most of the ratings overall were the same, “Somewhat Confident” 38.53% (n = 89), except for
faculty who increased to “Confident”. When asked if a concussion is a traumatic brain injury,
overall 73.59% (n = 170) mentioned that a concussion was a TBI. When looked at by affiliation,
92.00% of the faculty, 64.29% of the students and 74.00% of the staff answered correctly.
When asked if there were more college athletes or college non-athletes who acquire
concussions each year, only 7.12% of the students, 36.00% of the faculty and 14.00% of the staff
thought that college non-athletes were at higher risk (Appendix F). Along the same lines, when
asked if males or females were at higher risk of getting a concussion, only 1.75% of students,
4.00% of faculty and 6.71% of staff thought females were at higher risk (Appendix G). These
data supported by the literature show a gap in knowledge of these two at-risk populations.
When asked about self-perceived knowledge of how one acquires a concussion, the
majority of responses 58.01% (n = 134) were in the “Somewhat Confident” range. When tested
on factual knowledge, overall there was an 88.36% accuracy rate. There was some divergence
amongst students, faculty, and staff, especially in outreach and education for “blast” and
“acceleration or deceleration of the head” as means of causing a concussion.
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When asked about self-perceived knowledge of the ability to recognize signs of a
concussion, most 47.16% (n = 108) were “Somewhat Confident” with faculty increasing their
overall rating to “Confident”. The overall rating was 69.00% accuracy rate for identifying signs
and symptoms. Overall, 98.26% (N = 226) understood that a person could have a concussion
without losing consciousness. Overall, respondents were able to identify 12 of the 22 concussion
symptoms over the 70% threshold. Appendix E lists numerous commonly found concussion
symptoms and shows the overall number and percentage that were identified by affiliation.
Students were able to identify 11 of the 22 (50.00%) symptoms, faculty were able to identify 16
of the 22 (72.72%) symptoms and staff were able to identify 13 of the 22 (59.09%) symptoms
within the 70.00% threshold.
Organizational Support was shown by way of outreach via concussion trainings, the non-
medical college community, and care from the student health center. Most respondents had 0-1
training with 69.91% stating they did not have any concussion training. Only 14.60% responded
that they received these trainings at school and 9.73% in School Athletics. Of the concussion
trainings received, 52.44% were in-person training. Only 13.08% of respondents were
“Confident” about their concussion knowledge after the training. Overall, Online Self-Paced
Modules/Webinars were the preferred method of concussion training
Only 1.00% of respondents were “Confident” that the non-medical college community
(students, faculty or staff) could recognize a concussion. When asked if they felt the student
health center could properly assess a concussion, 35.92% were “Confident”. When asked how
“Confident” they felt that the student health center could properly treat a concussion, 31.53%
responded they were “Confident”. These scores show where areas of outreach and training can
be implemented.
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Table 25

Knowledge Met or Need Determined by Data Analysis

Topic Question Assumed Knowledge
Influence
Context-Specific
Recommendation
Met
or
Need
Self-Perception
of Concussion
Knowledge
I feel confident
that I could
define what a
concussion is:
Not Confident,
Neither
Confident nor
Not Confident,
Somewhat
Confident,
Confident

Confidence in ability
to define what a
concussion is.
College community must
receive clear definition of
a concussion with visual
aids. See other
recommendations in
factual knowledge below.
Met
I feel confident
that I could
define what a
traumatic brain
injury is:
Not Confident,
Neither
Confident nor
Not Confident,
Somewhat
Confident,
Confident

Confidence in ability
to define what a
traumatic brain injury
is.
College community must
receive clear definition of
what a traumatic brain
injury is with visual aids.
See other
recommendations in
factual knowledge below.
Met
I feel confident
that I know how
you can get a
concussion: Not
Confident,
Neither
Confident nor
Not Confident,
Somewhat
Confident,
Confident

Confidence in
knowing how a
concussion is
acquired.
College community must
receive visual aids and
explanatory text showing
example. See other
recommendations in
factual knowledge below.
Met
I feel confident
that I would be
Confidence in
knowing signs and
College community must
be given written example
Met
83

able to recognize
the signs of a
concussion: Not
Confident,
Neither
Confident nor
Not Confident,
Somewhat
Confident,
Confident.
symptoms of
concussion.
with visual aids. See
other recommendations
in factual knowledge
below.

Organizational
Confidence
How confident
are you that the
non-medical
college
community
(students, faculty
or staff) can
recognize a
concussion? Not
Confident,
Neither
Confident nor
Not Confident,
Somewhat
Confident,
Confident

Confidence in college
communities’ ability
to recognize a
concussion.
Encourage college
community to find
creative and motivating
ways to educate the non-
medical college
community about
concussions.
Need
How confident
do you feel that
the Student
Health Center
could properly
assess a
concussion?
Not Confident,
Neither
Confident nor
Not Confident,
Somewhat
Confident,
Confident

Confidence that
Student Health
Center can properly
assess a concussion.
Educate the college
community about the
services available at the
Student Health Center
and what the proper
protocol would be for
concussion assessment
while on campus.
Met
84

How confident
do you feel that
the Student
Health Center
could properly
treat a
concussion?
Not Confident,
Neither
Confident nor
Not Confident,
Somewhat
Confident,
Confident

Confidence that
Student Health
Center can properly
treat a concussion.
Educate the college
community about the
services available at the
Student Health Center
and what the proper
protocol would be for
concussion treatment
while on campus.
Met
How confident
were you about
concussion
knowledge after
the training? Not
Confident,
Neither
Confident nor
Not Confident,
Somewhat
Confident,
Confident

Feel confident in
knowledge after
concussion training
Survey college
community as to what
obstacles they are facing
with past concussion
trainings that made their
confidence levels of
knowledge obtained
lower.

Have college community
come up with ideas and
recommendations that
would help them retain
the knowledge they
learned.
Need

Factual
Knowledge

Is a concussion a
traumatic brain
injury?
*Yes, I don't
know, No

Know that a
concussion is a
traumatic brain
injury.
Give a written
explanation and show a
video about how a
concussion is a traumatic
brain injury and the
different levels of
traumatic brain injury.
Met
Please chose the
way(s) a person
can get a
concussion:

Direct Impact to
the Head,
Violent
Knows the ways
concussions are
acquired.
Show a video of the
different types of
concussions.
Met
85

Shake/Movemen
t to the Head or
Neck, Sudden
acceleration or
deceleration of
the head, Blast
*all are correct

What is the
definition for a
concussion?

A concussion is
not a traumatic
brain injury.
Effects are
usually
temporary but
can include
headaches and
problems with
concentration,
memory, balance
and coordination.
Concussions are
usually caused
by hitting one's
head hard on an
object such as
the direct impact
from two players
in a football
game.

* A concussion
is a type of
traumatic brain
injury—or
TBI—caused by
a bump, blow, or
jolt to the head
or by a hit to the
body that causes
the head and
brain to move
rapidly back and
Knows definition of
concussion.
Show a written definition
of a concussion as well
as an interactive segment
highlighting the key
aspects of a concussion
and clear up any
misconceptions.
Met
86

forth. This
sudden
movement can
cause the brain to
bounce around or
twist in the skull,
creating
chemical
changes in the
brain and
sometimes
stretching and
damaging brain
cells.
•
None of the
above

True or False, a
person always
loses
consciousness
(passes out)
when they get a
concussion
(*False)

Knows that a person
does not have to pass
out to have a
concussion.
Show a video about
common misconceptions
and the correct answer of
loss of consciousness
being a possible
symptom but not a
required symptom of a
concussion.
Met
Are there more
college athletes
or college non-
athletes who
acquire
concussions each
year?

College Athletes
*College Non-
Athletes
I don't know

Knows that there are
more college non-
athletes who acquire
concussions each
year.
Video and audio with
written facts at end
pointing to the science of
college non-athletes
acquiring more
concussions each year on
college campus Give
and show examples of
these possible
contributing risks.
Need
Are males or
females at higher
risk of getting a
concussion?

Males
Knows that females
are at higher risk of
concussions.
Video and audio with
written facts at end
pointing to the science of
females being at higher
risk. Give and show
examples of these risks.
Need
87

*Females
I don’t know

What
signs/symptoms
are associated
with a
concussion
(please check all
that apply):

*Headache
*Dizziness
*Blurred vision
*Nausea or
vomiting
*Difficulty
concentrating
*Balance
problems
*Confusion
*Difficulty
remembering
*"Don’t feel
right”
*“Pressure in
head”
*Feeling like “in
a fog“
*Sensitivity to
light
*Drowsiness
*Sensitivity to
noise
*Feeling slowed
down
*Fatigue or low
energy
*Irritability
*Neck Pain
*Trouble falling
asleep
*Nervous or
Anxious
*More emotional
Knows the signs and
symptoms of a
concussion.
After college community
choses what they
consider signs and
symptoms of
concussions, show all of
the symptoms and give a
brief rationale as to why
these are symptoms and
the frequency they occur.
Need
88

*Sadness

Concussion
Motivation for
Training
How many
concussion
trainings/educati
on have you had?
(0-10)

Has attended
concussion
trainings/education.
Survey college
community to see what
the circumstances were
as to the deficiency in
concussion
trainings/education.

Ask what would motivate
them to attend future
trainings.
Need
Please rank your
preferred method
of concussion
education
In-person,
Online Live
Classroom (i.e.,
Zoom, Google
Classroom,
Skype), Online
Self-Paced
Modules/
Webinars, Other

The preferred method
of education is the
method in which they
have attended most
frequently.
Ask for brief rationale as
to why this is their
preferred modality of
concussion education.

Utilize these responses
when instigating a
concussion training
program so as to cater to
the community’s needs.
Need

Organizational
Support
Where did you
get these
concussion
trainings/educati
on?

School, School
Athletics,
Online, Brochure
or Flyer,
Hospital or
Doctor’s Office,
Other, I have not
had concussion
training/
education

Location is a school. See best practices from
areas that provided these
concussion trainings.

Utilize proven methods
in concussion
training/education
program.
Need
89

How were these
trainings given?
In-person, online
(live class such
as Zoom, Google
Classroom or
Skype) Online
(previously
recorded
webinar/module)

The preferred method
of education is the
method in which they
have attended most
frequently.
Compare preferred
method of concussion
training with previous
method of training to see
where there are gaps that
need to be improved.
Need

Note. Concussion symptoms listed are commonly known symptoms and can be found on many
assessment tools such as the SCAT 5 (Echemendia et al., 2017; Mayo Clinic, 2020; CDC, 2019)
and several others. Sections of the concussion definition choices were taken from Mayo Clinic
(2020) and CDC (2019).

90

Summary of Findings
This chapter presented a summary of the data collected through a quantitative analysis
with the objective of analyzing the gaps and assessing the needs. The key findings are illustrated
throughout the chapter through the tables and figures. The KMO approach guided and organized
the study questions.
Most concussion research is done on professional and collegiate sports leaving a gap in
the non-sport related general population and college community (CDC, 2015). Research has
shown that women are at higher risk of acquiring concussions than men (Breck et al., 2019).
However, only 5.19% of survey respondents thought that females were at higher risk of
concussions. Research also suggests that there are more non-sport related concussions each year
among college students (Breck et al., 2019). The survey showed that only 14.66% of the college
community thought that more student non-athletes acquired concussions each year. There was
also a gap in factual knowledge of the signs and symptoms of concussions. This shows a great
need for concussion outreach for the general non-athlete college community.
There are also inconsistencies in Self-Perceived Knowledge vs Factual Knowledge. Self-
Perceived Concussion Knowledge was higher for the respondent but very low for how the
respondents rated the college community, of which they were a member, Figure 22.

91

Figure 22
Ability to Recognize a Concussion

The level of confidence for concussion knowledge was low following training, which
would warrant revising concussion trainings. There were many gaps in knowledge areas of
traumatic brain injury/concussions where further outreach and education would be beneficial.
Some of these areas would be clearly identifying what a concussion is, the ways in which
concussions can be acquired in the college community outside of athletics, biological sex
differences in regard to concussion/TBI risk, signs and symptoms, post-concussion syndrome,
and how concussions can affect learning. Further demographic data is provided in the
appendices.
Chapter five will analyze the data for each category and compare and contrast the results.
The strengths and weaknesses of the study will be reviewed. Recommendations will be made
based on the findings. Kirkpatrick’s Four Levels of Training Evaluation (2016) will be used to
guide the recommendations. Future research recommendations will be made based on the results
of the study and limitations.
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
50.00%
Not Confident Neither Confident
nor Not Confident
Somewhat Confident Confident
Self- Perceived Confidence Confidence in College Community
92

Chapter Five: Discussion and Recommendations
Chapter five addresses the final research question: “What are the recommended
knowledge, motivation, and organizational solutions that can help instigate a concussion
management plan to help with outreach and education as well as prevention, assessment,
treatment and follow-up for non-athlete students?” This chapter will make recommendations and
provide solutions to address the gaps in knowledge, motivation and organizational support. The
chapter will conclude with proposed implementations to address the needs as well as areas where
future outreach and research would be helpful.
Organizational Context and Mission
Western Shore University (WSU) is a pseudonym for a large four-year university in the
Western United States. This university has a diverse student, faculty, and staff population
(college community). Western Shore University has a significant enrollment of international
students adding to its culture. The university is research-based, offering both undergraduate and
graduate degrees. The central mission of WSU is to evolve its members as well as advance
society through education and development of intellect and disposition. The fundamental means
by which the mission is achieved is through instruction, research, innovation, qualified training
and selected forms of service to the community.
Organizational Performance Status
There are many resources available to college athletes through the Athletics Department
such as concussion education, avoidance-training, base-line testing, assessment, treatment, and
gradual return to play/learn (NCAA, 2013). However, these resources are not commonly
available to non-athlete students. Research has shown that concussions among college students
are more likely to occur off the playing field versus on the playing field (Breck et al., 2019).
93

Researchers of this study discovered concussions were more commonly found to be caused by
non-sport related activities as opposed to sport-related activities. The data shows that the general
student population is underrepresented and underserved in concussion education, prevention and
assessment. A clear and comprehensive concussion management plan needs to be developed so
that all of the college community has access to concussion mitigation resources.
Description of Stakeholder Groups/Study Population
Although a complete analysis of the problem of practice would include all stakeholder
groups and multiple U.S. college campuses, for practical purposes this study will focus on
students, faculty, and staff at a single U.S. campus. This study will examine knowledge,
motivational factors, and organizational support as related to concussion in the college
community. This will show where there are gaps so that mitigation, education and outreach can
be implemented.
Purpose of the Project and Questions
The purpose of this study is to assess the college community’s understanding of
concussions, prevention, signs, symptoms, assessment, and organizational support.
Understanding where there are gaps can help determine where improvements need to be made in
outreach, education, assessment, and protocol. The information gained by this study can help
improve new student and employee training, as well as the development of a concussion
checklist for novice first responders (students, faculty, staff, and public safety). The information
obtained from this study can facilitate discussions for a concussion management plan for the
entire student population.
This study will also utilize the Clark and Estes (2008) gap analysis model to perform a
needs analysis for possible knowledge, motivation, and organizational (KMO) gaps that could
94

lead to greater reliability and validity for concussion assessment. As such, the research questions
that guide this study are as follows:
1. What are the knowledge, motivation, and organizational influences that interfere with
achieving concussion awareness, education, prevention, assessment, treatment, and
follow-up?
2. What are the recommended knowledge, motivation, and organizational solutions that can
help instigate a concussion management plan to help with outreach and education as well
as prevention, assessment, treatment, and follow-up for non-athlete students?
Strengths and Weaknesses of the Approach
Having an anonymous, voluntary, quick and easy online survey increased response and
completion rates. Incentives such as gift cards were not offered for participants to take the
survey. This was because the researcher wanted the survey to be as anonymous as possible and
not have the e-mail addresses of the respondents. Not offering an incentive may have reduced
response rates. The survey was sent out through proxy listservs’ so that the researcher would not
know who may have taken the survey and also so that there was no pressure on the university
community to take the survey. This was a strength in anonymity and ethics; however, it gave less
control to the researcher not knowing which departments to follow-up with for further
recruitment. There was a learning curve to attain the knowledge of what the university guidelines
and protocols were to distribute IRB approved research surveys to the college community. It was
difficult to get the survey out to the broad college community. It is recommended that colleges
create a centralized office to help educate researchers about the survey process and help facilitate
survey outreach/solicitation in a manner that follows university as well as IRB protocol and
guidelines.
95

Limitations and Delimitations
Due to the current COVID-19 pandemic, study recruitment was limited. Although the
survey was sent out to a broad diverse range of students, faculty and staff, certain populations
completed the survey at higher rates than others. The majority of respondents identified as
Caucasian/white, female and staff members. There was also a low rate of student-athletes, so
comparison of responses with the non-athlete student population could not be done. The survey
was voluntary, so candidates were able to read the IRB-approved study information sheet before
deciding if they wanted to partake in the study. Of the 266 respondents who viewed the study
information sheet, only 232 completed the survey in its entirety. Because the survey did not have
“forced questions” some of the questions were not answered by the respondents. Upon analyzing
the data by affiliation, only two student athletes responded to the survey. Due to the small
sample size of the student athlete population (n = 2) it was decided to aggregate this population
as part of student population for validity and reliability purposes.
Recommendations for Practice to Address KMO Influences Utilizing the Kirkpatrick
Model
The New World Kirkpatrick Model (Kirkpatrick & Kirkpatrick, 2016) is utilized to direct
the evaluation and implementation of recommendations for improvement. Four levels of the
Kirkpatrick Model starting with level 4 (Results), then moving on to Level 3 (Behavior), Level 2
(Learning), and then ending with Level 1 (Reaction). The results section will show if the
recommended concussion training worked by analyzing targeted outcomes. In this study, the
respondents had low levels of confidence in concussion knowledge following previous
concussion training. The respondents also mentioned that they preferred online self-paced
methods of learning, however, past training(s) were in-person.
96

The Behavior section will focus on the motivational gaps in concussions. What motivates
the college community to acquire concussion knowledge and training? What will motivate this
community to seek assessment and care if a potential concussion were to occur? What motivates
the college community to recognize concussions in others and intervene?
The Learning section will focus on the gaps in the college communities’ knowledge of
concussions. Learning plans should be designed to address gaps and provide methods that enable
students to comprehend and retain concussion knowledge after the training.
The reaction section will explore how to improve current modalities and learning
platforms that have been utilized to teach concussion awareness. New ways of learning will also
be looked at to see what the college community finds more favorable. These components of The
New World Kirkpatrick Model will help guide the improvement and expansion of future
concussion training and outreach. Table 26 shows the external and internal outcomes associated
with The New World Kirkpatrick Model, Level 4 (Results) including metrics and methods
utilized in evaluating the outcomes.
Level Four: Results and Leading Indicators
Universities can implement a concussion learning module as part of the new student and
new employee training. This training program will transfer knowledge and provide resources for
everyday college life. Leading indicators provide personalized targeted outcomes as a result of
the training to analyze if the needs or objectives of the training have been met (Kirkpatrick &
Kirkpatrick, 2016).
Internal Outcomes include organizational support for resources, learning and assessment
in regard to concussions for members of the college community. The college community will
reflect this level has been met by proof of positive feedback of new and annual required training
97

via evaluations. External outcomes include higher levels of confidence, clearer protocols and
more concussion learning opportunities. This level will be met by showing that trainings are
working by adherence to concussion management plan and policy. A collaborative effort
between university offices to collect de-identified data while following FERPA and HIPAA
guidelines.
Integrated Implementation and Evaluation Plan
Table 26

Outcomes, Metrics, Methods and Proposed Time for External and Internal Outcomes

Outcome Metric(s) Method(s) Timeframe
External Outcomes: Organizational Support
Increased
satisfaction rate of
students
Number of positive
evaluations during
annual required
trainings
Student Affairs data
collected as part of
annual training. This
training will be
attached as one of
the required learning
modules.
Every year as part of
annual trainings.
Increased
satisfaction rate of
new employees
Number of positive
evaluations during
annual required
trainings
HR data collected as
part of required
annual training. This
training will be
attached as one of
the required
learning.
Every year as part of
annual required
trainings.
Implement New
Student Concussion
Trainings at
Orientation.
Required Online
Module as part of New
Student Orientation.
Resulting in
Certificate.
Data from
Orientations and
Student Affairs.
Aim to have this
implemented within
one year’s time.
Implement New
Faculty and Staff
Concussion
Trainings at
Orientation.
Required Online
Module as part of New
Faculty and Staff
Orientation. Resulting
in Certificate.
Data from Human
Resources.
Aim to have this
approved and
implemented within
one year’s time.
Internal Outcomes: Organizational Support
Policy to
implement
Concussion
Publish a Concussion
Management Plan and
Devise committee,
research current and
best practices.
Within1 year, assess
and revise yearly and
as needed.
98

management plan
for students, faculty
and staff.
Policy for Campus
Community.

Provide Outreach and
training for new
measures and
guidelines.
Write up and have
approved a
Concussion
Management Plan
and Policy for
Campus
Community.
100% of faculty
and staff engage
yearly concussion
training program.
Number of positive
reviews and
improvement in
retention of
knowledge.
Data in forms of
evaluations and test
scores collected
from HR and
training platform.
Annually as part of
required trainings and
recertifications.
100% of students
engage yearly
concussion training
program.
Number of positive
reviews and
improvement in
retention of
knowledge.
Data in the form of
evaluations and test
scores collected
from Student Affairs
and training
platform.
Annually as part of
required trainings and
recertifications.
100% of students
who have possible
concussion follow
university
concussion protocol
Number of students
who are assessed and
treated in Student
Health Center answer
on questionnaire
marked “yes” on
intake form that they
knew to the proper
protocol to be
evaluated for
concussion based on
concussion training
provided by university.
De-identified data in
forms of total
number of students’
who marked “yes”
on intake form when
assessed or treated
for possible
concussion at
Student Health.
Every month numbers
are collected and
analyzed from student
health.
Collaborative Data
from Student
Health and Campus
Safety is collected
on event that lead
to possible
concussion to see
where more
outreach and
prevention needs to
take place.
Activities reported as
part of Student Health
Center intake or
Campus Safety
incident report that
lead to possible
concussion.
Collaborative de-
identified numerical
data entered into
database from
Student Health
Center and Campus
Safety.
Numbers are entered
and submitted every
month.

99

Level Three: Behavior
Critical Behavior is a comprehensive and continuous evaluation that occurs at varying
degrees to which the community actually applies what they have learned (Kirkpatrick &
Kirkpatrick, 2016). Continuous analyzing via pre and post-test motivation ratings to see what
areas the learner has interest and what areas need improvement. Areas that would motivate a
person to seek assessment and treatment as well as barriers will need to be assessed via annual
survey questions.
Table 27

Critical Behaviors, Metrics, Methods, and Timing for Evaluation

Outcome Metric(s) Method(s) Timeframe
Concussion Motivation
Increased
motivation for
concussion
training.
Pre and post-test rating
on motivation to learn
about concussions.
Questionnaire given
at time of training
asking learners what
their level of
motivation is before
training module and
after training
module.
Test at beginning and
end of trainings
Increased
motivation to seek
treatment for
concussion.
Number of learners
who show interest in
seeking assessment
and treatment for
possible concussion.

Ask learners via
survey given at time
of training, what
would be required
for them to seek
treatment for a
possible concussion.
Over a 30-day period.
Questionnaire every
year at time of training.
Decrease barriers to
seeking assessment
and treatment for
possible
concussion.
List of possible
barriers inhibiting one
to seek assessment or
treatment.
Have learners chose
from a list of
possible barriers (as
well as fill in option
for “other”) that
would be possible
barriers that might
prevent them from
seeking assessment
and care for possible
concussion.
Ask at time of
trainings.
100

Level 2: Learning
Learning is the level to which the learner has acquired the required skill, confidence,
knowledge and course objective based on the training (Kirkpatrick & Kirkpatrick, 2016). As
part of the required new and annual training for students, faculty, and staff the learner’s
concussion knowledge both self-perceived and factual will be assessed. Levels of confidence
and knowledge pre and post-training as well as three months later will be evaluated. These
levels will be compared upon annual trainings to see where there are gaps or deficiencies that
need to be addressed in future training and lesson plans. This will also tell the evaluators if the
training is working.

Table 28

Learning, Metrics, Methods, and Timing for Evaluation

Outcome Metric(s) Method(s) Timeframe
Concussion Knowledge
Increased
Concussion
Knowledge in the
College Community
via online training.
Number of new
students/faculty/staff
orientations each
year.
Orientations and
Human Resources data
to confirm.
Within 30 days of new
Student/Faulty/Staff
Orientation and required
annual training.
Increased retention
of concussion
knowledge post
training.
Confidence rating
and post-test quiz.
Have learners
complete training by
taking a post training
quiz to measure their
knowledge.

Voluntary quiz to be
sent out 3 months later
to see what knowledge
has been retained into
long-term memory.
Quiz will be
composed of five
questions in each
category: Knowledge
(Self-Perceived and
Test at time of training
and 3 months later.
101

Factual), Motivation
and Organizational
Support

Level One: Reaction
The reactions that Kirkpatrick & Kirkpatrick (2016) recommend are as follows:
engagement, relevance and satisfaction. This level is one that is the easiest to evaluate while
utilizing formative evaluation methods such as immediate feedback via engagement and
summative evaluations such as surveys and evaluations. Timing such as time spent on each
module and utilizing the training to collect feedback via evaluations, may not have the same
turnout if sent at a later time. Level one evaluation is to be kept easy and simple.

Table 29
Components to Measure Reaction in Concussion Training
Method(s) or Tool(s) Timing
Engagement
Time the learner spends on training Timed training module (internal)
Pre and post-test motivation Before and after training
Voluntary Follow-up test Number of respondents to voluntary 3-month
follow-up evaluation
Relevance
Evaluations After each training
Pre and Post-test motivation Before and after each training
Satisfaction
Evaluations After each training

102

Future Research
Future research in the area of concussion outreach, needs and management plans from
university leadership departments would be recommended. These departments can include,
Student Affairs, Student Health, Human Resources, the President and the Provost. By utilizing
university leadership departments, it is hoped that more diverse and higher response rates can be
attained. Implementing pre and post-test surveys of students, faculty and staff before orientation
concussion awareness training would be a valuable tool. Creating a centralized office within
student and employee health would be beneficial for outreach, research and assessment.
Conclusion
Self-Perceived Concussion Knowledge was higher for the respondent but very low for
how the respondents rated the college community, of which they were a member. The level of
confidence for concussion knowledge was low following training, which would warrant revising
concussion training. The number of concussion trainings(s) the college community had was also
deficient. The modes of concussion training were inconsistent with the preferred methods of
learning. It is important to offer outreach and education that caters to the college community in
order to help with motivation and retention of knowledge.
There were many gaps in knowledge areas of traumatic brain injury/concussions where
further outreach and education would be beneficial. Some of these areas would be clearly
identifying what a concussion is, the ways in which concussions can be acquired in the college
community outside of athletics, sex differences in regard to concussion/TBI risk, signs and
symptoms, post-concussion syndrome, how concussions can affect learning.

103

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110

Appendix A: Information Sheet
University of Southern California
Rossier School of Education
3470 Trousdale Parkway
Waite Phillips Hall (WPH) 404
Los Angeles, CA 90089-4034

INFORMATION SHEET FOR EXEMPT RESEARCH

STUDY TITLE: Concussions in the College Community Survey

PRINCIPAL INVESTIGATOR: Lisa Jo Keefer

FACULTY ADVISOR: Patricia Tobey, Ph.D.

You are invited to participate in a research study. Your participation is voluntary. This document explains
information about this study. You should ask questions about anything that is unclear to you.

PURPOSE
The purpose of this study is to assess the college community’s (i.e. students, faculty and staff)
understanding of concussions, motivational factors and organizational resources. Understanding where
there are gaps can help determine where improvements need to be made in outreach, education,
assessment and protocol. You are invited as a possible participant because you are a student, faculty or
staff member and 18 years old and above.

PARTICIPANT INVOLVEMENT
If you decide to take part, you will be asked to answer questions online via computer, tablet or smart
phone via an anonymous Qualtrics survey that will take approximately 4 minutes to complete

CONFIDENTIALITY
The members of the research team and the University of Southern California Institutional Review Board
(IRB) may access the data. The IRB reviews and monitors research studies to protect the rights and
welfare of research subjects.
The survey will be carried out through an anonymous Qualtrics online survey.

INVESTIGATOR CONTACT INFORMATION
If you have any questions about this study, please contact the investigator: Lisa Jo Keefer
LisaJo@usc.edu or Faculty Advisor: Patricia Tobey, Ph.D.: tobey@usc.edu

IRB CONTACT INFORMATION
If you have any questions about your rights as a research participant, please contact the University of
Southern California Institutional Review Board at (323) 442-0114 or email irb@usc.edu.

Version Date: 9/24/2020

o I agree to participate in this research study. If you do not wish to participate in this research study,
please close your browser now.

111

Appendix B: Gender by Affiliation
Table B1
Gender by Affiliation
Student n Faculty n Staff n
Male 37.5% 2
21
32.00% 8
8
12.00% 1
18
Female 53.57% 3
30
68.00% 1
17
85.33% 1
128
Other 5.36% 3
3
0% 0
0
0.67% 1
1
Decline 3.57% 2
2
0% 0
0
2.00% 3
3
Total 100.00% 56 100.00% 25 100.00% 150

Figure B1
Gender by Affiliation

0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
Male Female Other Decline
Student Faculty Staff
112

Appendix C: Ethnicity by Affiliation
Table C1
Ethnicity by Affiliation
Ethnicity Student n Faculty n Staff n
African American/Black 0.00% 0 0.00% 0 3.33% 5
American Indian/Alaska Native 0.00% 0 0.00% 0 0.00% 0
Asian 50.91% 28 4.00% 1 19.33% 29
Caucasian/White 25.45% 14 76.00% 19 48.00% 72
Hispanic/Latino 18.18% 10 12.00% 3 22.00% 33
Native Hawaiian/Pacific Islander 0.00% 0 0.00% 0 0.00% 0
Other 3.64% 2 0.00% 0 5.33% 8
Decline to State 1.82% 1 8.00% 2 2.00% 3
Total 100.00% 55 100.00% 25 100.00% 150

Figure C1
Ethnicity by Affiliation

0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
Student Faculty Staff
113

Appendix D: Age-Range by Affiliation
Table D1
Age-Range by Affiliation
Age-Range Student n Faculty n Staff n
18-24 66.07% 37 0.00% 0 6.00% 9
25-29 21.43% 12 8.00% 2 17.33% 26
30-34 10.71% 6 12.00% 3 20.67% 31
35-39 0.00% 0 16.00% 4 13.33% 20
40-44 1.79% 1 8.00% 2 9.33% 14
45-49 0.00% 0 8.00% 2 6.67% 10
50-54 0.00% 0 12.00% 3 6.67% 10
55-59 0.00% 0 4.00% 1 8.00% 12
60-64 0.00% 0 24.00% 6 6.67% 10
65-69 0.00% 0 4.00% 1 4.67% 7
70-74 0.00% 0 4.00% 1 0.67% 1
Total 100.00% 56 100.00% 25 100.00% 150

114

Figure D1
Age-Range by Affiliation

0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
18-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74
Student Faculty Staff
115

Appendix E: Correct Symptoms of Concussion by Affiliation
Table E1
Correct Symptoms of Concussion by Affiliation
What signs/symptoms are associated with a concussion (please check all that apply)?
Symptom Student n Faculty n Staff n
Headache 98.25% 56 92.00% 23 96.00% 144
“Pressure in head” 78.95% 45 76.00% 19 78.00% 117
Neck Pain 35.08% 20 48.00% 12 56.00% 84
Nausea or vomiting 73.68% 42 88.00% 22 91.33% 137
Dizziness 87.19% 50 88.00% 22 92.67% 139
Blurred vision 80.70% 46 92.00% 23 93.33% 140
Balance problems 85.96% 49 84.00% 21 84.67% 127
Sensitivity to light 66.67% 38 72.00% 18 76.67% 115
Sensitivity to noise 57.89% 33 64.00% 16 66.00% 99
Feeling slowed down 49.12% 28 80.00% 20 63.33% 95
Feeling like “in a fog“ 71.93% 41 84.00% 21 77.33% 116
"Don’t feel right” 75.44% 43 88.00% 22 78.00% 117
Difficulty concentrating 84.21% 48 92.00% 23 84.67% 127
Difficulty remembering 75.44% 43 92.00% 23 83.33% 125
Fatigue or low energy 49.12% 28 76.00% 19 64.00% 96
Confusion 78.95% 45 88.00% 22 84.67% 127
Drowsiness 57.89% 33 76.00% 19 72.67% 109
More emotional 24.56% 14 60.00% 15 40.67% 61
116

Irritability 28.07% 16 76.00% 19 56.00% 84
Sadness 21.05% 12 52.00% 13 36.67% 55
Nervous or Anxious 21.05% 12 64.00% 16 42.67% 64
Trouble falling asleep 29.82% 17 60.00% 15 41.33% 62
Total Respondents per
Affiliation
57 25 150

Note. Concussion symptoms listed are commonly known symptoms and can be found on
many assessment tools such as the SCAT 5 (Echemendia et al., 2017; Mayo Clinic, 2020;
CDC, 2019) and several others.

Figure E1
Correct Symptoms of Concussion by Affiliation

0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
Headache
“Pressure in head”
Neck Pain
Nausea or vomiting
Dizziness
Blurred vision
Balance problems
Sensitivity to light
Sensitivity to noise
Feeling slowed down
Feeling like “in a fog“
"Don’t feel right”
Difficulty concentrating
Difficulty remembering
Fatigue or low energy
Confusion
Drowsiness
More emotional
Irritability
Sadness
Nervous or Anxious
Trouble falling asleep
Student Faculty Staff
117

Appendix F: College Athlete vs Non-Athlete Assumed Risk of Concussion by Affiliation
Table F1
College Athlete vs Non-Athlete Assumed Risk of Concussion by Affiliation
Are there more college athletes or college non-athletes who acquire concussions each year?
Question Student n Faculty n Staff n
College Athletes 59.65% 34 12.00% 3 41.33% 62
*College Non-Athletes 7.12% 4 36.00% 9 14.00% 21
I don’t know 33.33% 19 52.00% 13 44.67% 67
Total Total 57 Total 25 Total 150
Note * Correct answer from reviewed literature.

Figure F1
College Athlete vs Non-Athlete Assumed Risk of Concussion by Affiliation

0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
Student Faculty Staff
College Athletes *College Non-Athletes I don’t know
118

Appendix G: Biological Sex Risk of Concussion by Affiliation
Table G1
Biological Sex Risk of Concussion by Affiliation
Are males or females at higher risk of getting a concussion?
Question Student n Faculty n Staff n
Males 36.84% 21 52.00% 13 50.34% 75
Females 1.75% 1 4.00% 1 6.71% 10
I don't know 61.40% 35 44.00% 11 42.95% 64
Total Total 57 Total 25 Total 149

Figure G1
Biological Sex Risk of Concussion by Affiliation

0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
Student Faculty Staff
Males Females I don't know

Abstract (if available)

Abstract Traumatic brain injury (TBI) and mild traumatic brain injury (mTBI) also known as concussion, is a significant problem in U.S. college communities. There is a lack of concussion knowledge, assessment, and treatment outside of the athletic community. The purpose of this study is to assess the knowledge, motivational, and organizational influences (KMO) surrounding concussion in the college community utilizing an adapted form of Clark and Estes’s (2008) framework. This study will examine: (1.) The knowledge, motivation, and organizational influences that interfere with achieving concussion awareness, education, prevention, assessment, treatment, and follow-up

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University of Southern California Dissertations and Theses

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Asset Metadata

Creator Keefer, Lisa Jo (author)

Core Title Gaps in adequate traumatic brain injury (concussion) assessment amongst college students

School Rossier School of Education

Degree Doctor of Education

Degree Program Education (Leadership)

Publication Date 12/12/2020

Defense Date 11/10/2020

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag concussion,coup contrecoup,mTBI,OAI-PMH Harvest,post-concussion syndrome,return to learn,return to play,TBI,traumatic brain injury

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Tobey, Patricia (committee chair), Cash, David (committee member), Nation, Daniel (committee member)

Creator Email LisaJo@usc.edu,LisaJoKeefer@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-408995

Unique identifier UC11667573

Identifier etd-KeeferLisa-9201.pdf (filename),usctheses-c89-408995 (legacy record id)

Legacy Identifier etd-KeeferLisa-9201.pdf

Dmrecord 408995

Document Type Dissertation

Rights Keefer, Lisa Jo

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA