The influence of coping, perceptions of limitations, interference, and locus of control on concussion care-seeking intentions in collegiate athletes

Background: Athletes who delay seeking care for a suspected concussion can experience longer recovery outcomes. Concussion care-seeking intentions may be influenced by several understudied factors; coping, perceptions of limitations, perceptions of interference, and locus of control. Aim: The aim of the study was to describe and compare coping, perceptions of limitations, perceptions of interference, and locus of control and determine whether these variables influence symptom and concussion care-seeking intentions in collegiate student-athletes. Methods: Collegiate student-athletes (n=204; female=54.9%) reported demographic information (i.e., sex, division, and contact level), symptom and concussion care-seeking intentions, coping (approach, social, and avoidance), perceptions of limitations, perceptions of interference, and locus of control ratings (internal, powerful others, and chance). Non-parametric statistics was conducted to compare all outcomes between groups (α=0.05). Multiple linear regressions were used to predict symptom and concussion care-seeking intentions based on each of the variables. Spearman rank-order correlations supplemented the regression models. Results: Females had significantly higher symptom care-seeking intentions (P=0.04) and greater powerful other ratings (P=0.04) than males. Non-contact student-athletes had significantly higher symptom care-seeking intentions (P<0.00) compared to collision sport athletes. Coping, perceptions of limitations, perceptions of interference, and locus of control did not significantly predict symptom or concussion care-seeking intentions. There was a weak positive association between perceptions of limitations and symptom care-seeking intentions (rs(198)=0.23, P<0.01) and concussion care-seeking intentions (rs(198)=0.15, P<0.05). Conclusions: We may not need to focus extensively on coping, perceptions of limitations, perceptions of interference, and locus of control ratings when creating concussion education since none of these variables significantly predicted care-seeking intentions. Relevance for Patients: Care-seeking intentions for concussion do not appear to be influenced largely by these variables.


Introduction
Sport-related concussions continue to present a public health burden for student-athletes at all levels of participation [1]. Although concussion rates are rising at all levels of play care from a trained health-care professional. Researchers have attempted to identify reasons for the discrepancy in the estimated prevalence of concussion versus actual prevalence by examining factors such as perceived pressure from stakeholders, ability to recognize symptoms, sex disclosure, and attitudes toward care seeking [6][7][8][9][10][11][12]. However, most studies explain only small proportion of concussion care-seeking intentions, suggesting that this health behavior is multifactorial. To improve concussion careseeking intentions, we must continue to determine why studentathletes choose to not seek care following concussion. This study will focus on the potential influence of three unstudied factors: Coping behaviors, perceptions of interference, perceptions of limitations, and locus of control on concussion care-seeking intentions.
Student-athletes with fewer coping resources may encounter greater difficulty with concussion care seeking. Following concussion, student-athletes often report feelings of isolation, depression, and anxiety and are often limited from or experience worsened symptoms with their usual coping resources (e.g., strenuous exercise and social interactions with peers and teammates) [13]. Inadequate coping mechanisms may influence a student-athlete to conceal his or her concussion. Similarly, studentathletes may perceive that care seeking for a suspected concussion could result in a health-care provider limiting some of their routine daily activities, such as work, school, or sports participation [6,[14][15][16]. A falsely amplified perception of how limited they would be if they report a concussion may deter an athlete from seeking care. To the best of our knowledge, there is a current lack of literature addressing how athletes perceive limitations following concussion and how those limitations might influence their concussion careseeking intentions. An athlete who perceives she or he may be severely limited while completing both social and physical activities following a concussion may be less likely to seek medical care.
Finally, locus of control is the fundamental appraisal of one's self and is commonly used in personality psychology [17]. A person's "locus" is the belief that either internal (a belief that one can control one's own life) or external factors (i.e., how much others have power or chance) control the outcomes in their lives. Locus of control is one of the four dimensions of a person's fundamental appraisal of themselves and is predictive of behaviors (i.e., addiction and exercise) and performance (e.g., work productivity) [17,18]. Concussed student-athletes with lower ratings of the internal locus of control subscale may experience greater difficulties with selfregulating and making the difficult decision of care seeking their concussion(s), but this relationship has not been studied.
We aimed to (1) describe and compare athlete coping, perceptions of limitations, perceptions of interference, and locus of control across demographic factors (division level, contact level, and sex) and (2) determine whether these variables influence symptom and concussion care-seeking intentions in collegiate student-athletes. We hypothesize that coping, perceptions of limitations, perceptions of interference, and locus of control will be significantly different between division level, contact level, and sex. In addition, we hypothesize that coping, perceptions of limitations, perceptions of interference, and locus of control will be positively correlated with symptom and concussion careseeking intentions.

Participants
Student-athletes participating in National Collegiate Athletics Association (United States) sanctioned sports at three universities across three divisions of play ([university names blinded for peer review]: Division I, [x]: Division II, [x]: Division III, [x]:) were recruited to participate in the study during their annual concussion education session administered through an online module. During this time, athletes provided demographic information (i.e., sex, sport, and division level). All participants completed an Institutional Review Board approved consent form. Athletes who consented to be part of the research study received a series of monthly surveys through text messages that were sent on the 1 st day of every month from July to September 2018. The three surveys from this study were administered separately across three sequential months in the following order; perceptions of limitations and perceptions of interference, Brief Cope, and locus of control. Combined survey duration was estimated to last approximately 15 min. An additional text message reminder was sent to those who did not complete survey 2 days following initial distribution. All student-athletes who completed at least 80% of the 12 monthly surveys received a small monetary incentive.

Brief Cope
Participants completed the Brief Cope survey (Appendix A) [19]. This construct has been used to assess coping strategy type for patients with health-related issues such as cancer [20] as well as orthopedic injuries [13]. The Brief Cope survey consists of 28 items, with each item stating a short description of a particular way of coping with a stressor. Examples of statements include "I've been turning to work or other activities to take my mind off things." Participants were instructed to rate each item or description on a 4-point Likert scale ranging from "1=I haven't been doing this at all" to "4=I have been doing this a lot." For this study, the collapsed scoring for the Brief Cope was used: Approach (10 items), avoidance (8 items), and social (4 items) [21] (Table 1). Each of the three subscores is computed by adding scores resulting in a range between 4 and 40.

Perceptions of limitations
We developed a survey to assess how limited an athlete thought that they would be after sustaining a concussion (Appendix B). Participants reported how limited they believed they would be following a concussion with an 11-item measure (e.g., attending class and working at a job) on a 5-point Likert scale with responses ranging from "1=not at all limited" to "5=extremely limited." Scores were summed across all items with a higher score implicating the belief of being extremely limited following a concussion.

Perceptions of interference
Participants reported how much they believed partaking in a list of activities would interfere with concussion recovery with a 15-item measure (e.g., socially drinking, using recreational drugs) (Appendix B). Participants responded on a 5-point Likert scale with responses ranging from "1=none at all" to "5=a great deal." Responses were summed together to get a total perception of interference score. A higher total score suggested a greater degree of perceived interference that their life would have on concussion recovery.
The perceptions of limitations and perceptions of interference survey tools were developed by the lead author and reviewed for content and face validity by coauthors who have expertise in concussion. Reliability of the survey was conducted among 30 university students who completed the survey 2 times approximately 2 weeks apart, revealing high internal consistency and reliability for perceptions of limitations (11 items, α=0.95, ICC 2,1 =0.92) and perceptions of interference (15 items, α=0.97, ICC 2,1 =0.94).

Locus of control
Locus of control was measured using Levenson's Multidimensional Locus of Control scale (Blau, 1984). This 6-point Likert scale (1="strongly disagree," 6="strongly agree") survey includes 24 items (Appendix C) separated into the following subscores: Internal control, powerful others, and chance ( Table 2). The internal control (I) scale measures the extent to which an individual believes that they have control over the outcomes in their lives. An example of a statement specific to internality is "When I make plans, I am almost certain to make them work." The powerful others (P) scale deals with how much control an individual believes that other people in power have control over the outcomes in their lives, for example, "In order to make plans work, I make sure they fit in with the desires of the people who have power over me." Finally, the chance (C) scale addresses the extent to which an individual believes the outcomes in their lives is up to fate and they have no control over what happens, for example, "It is not wise for me to plan too far ahead because many things turn out to be a matter of good or bad luck."

Concussion care-seeking intentions
Participants completed a survey on their symptom care-seeking intentions and concussion care-seeking intentions (Appendices D and E). All items were scored using a 7-point Likert scale with responses ranging from 1="strongly disagree" to "7="strongly agree." Eight questions addressed symptom care-seeking intentions (e.g., "I would stop playing and report my symptoms if I sustained an impact that caused me to see stars") and the remaining three questions assessed concussion care-seeking intentions (e.g., "I intend to report"). Responses were summed for concussion care-seeking intentions (three items) and symptom care-seeking intentions (eight items) with a higher score indicating better careseeking intentions on each measure of intentions. These measures were derived by Kroshus et al. (2016) and Register-Mihalik (2013) and have high internal consistency (Cronbach's α=0.89) [5,7,22].

Analyses
To address our first aim, frequencies and descriptive statistics were used to describe sex, division, and contact level. Student-athletes were classified into three categories for their sport (i.e., collision, limited contact, and non-contact) [23]; however, collision and limited-contact groups were later collapsed for analyses where sample size was not sufficient. Kruskal-Wallis tests were used to determine if Brief Cope scores, perceptions of interference, perceptions of limitations, or locus of control ratings differed between divisions (I, II, and III), and level of contact (contact and non-contact). Mann-Whitney U-tests were used to compare whether there were differences between males and females for Brief Cope scores (three dependent variables of avoidance, approach, and social), perceptions of interference and limitations, and locus of control ratings (three dependent variables of internal control, powerful others, and chance).
To address our second aim, multiple linear regressions were calculated to predict symptom and concussion care-seeking intentions based on Brief Cope scores, perceptions of interference and limitations, and locus of control ratings. A series of Spearman rank-order correlations were also conducted to determine if coping, perceptions of limitations, perceptions of interference, and locus of control were positively correlated with symptom and concussion careseeking intentions. Data were analyzed using IBM SPSS Statistics (Version 24.0.00, IBM Corp., Armonk, NY) with an a priori α=0.05.

Demographics
A total of 204 student-athletes (92 males [45.1%] and 112 females [54.9%]) completed at least one of the three surveys. Student-athlete descriptive and demographic data are presented in Table 3.

Results from perceptions of limitations and perceptions of interference survey
Student-athletes most commonly perceived that a concussion would extremely limit their ability to complete a test or examination (extremely limited=119/212, 56.1%) and participate in sports (extremely limited=127/211, 59.9%). Student-athletes most commonly perceived that a concussion would interfere a great deal with their ability to watch an electronic screen for a long period of time (e.g., using mobile devices and watching television) (would interfere a great deal=75/212, 35.4%) and perform vigorous physical  Figure 1.

Care-seeking intentions across sex, division level, and contact level
Female student-athletes had significantly higher symptom careseeking intentions (Table 3); however, we did not observe this difference in concussion care-seeking intentions (P=0.51). Symptom care-seeking intentions (P=0.64) and concussion care-seeking intentions (P=0.82) did not significantly differ between division levels. Student-athletes who participated in non-contact sports and limited-contact sports had significantly higher symptom careseeking intentions (P<0.001) than student-athletes in collision sports; however, there were no significant differences between concussion care-seeking intentions and contact level (P=0.22). All comparisons between groups and care-seeking intentions are presented in Table 3.

Group comparisons for sex, contact level, and division level
Contact athletes reported higher ratings of social (P=0.05) and approach (P=0.02) coping than non-contact athletes. Non-contact athletes reported that a concussion would much more greatly limit their daily activities than contact athletes (P=0.04). Finally, female student-athletes reporting significantly greater powerful other ratings (P=0.04) than males. There were no significant differences between division level and any of the survey responses (P>0.05). All group comparisons are presented in Table 3.

Discussion
Overall, the key finding of this study is that care-seeking intentions for students-athletes were not significantly predicted by any of the subscore on the Brief Cope, locus of control, or the perceptions of limitations and perceptions of interference survey. However, our research did yield several interesting findings, specifically differences between males and females and contact level, outlined in the following sections. This study supports existing literature that found that many factors influence studentathletes intentions to report a suspected concussion to sports medicine professionals [6][7][8]11,12,[14][15][16]24].

Care-seeking intentions and survey response differences between males and females
Females had higher ratings on the locus of control powerful others subscore than males. This implies that female studentathletes felt that they had less control over the outcomes in their own lives than their male student-athlete counterparts. Females tend to have larger social support networks and, therefore, may be more inclined to believe that external factors such as powerful others have more control over the outcomes in their lives [25]. It is important to note that higher ratings on the external locus of control scale do not necessarily imply worse health outcomes and have actually been documented to be advantageous [25]. Females are more likely to seek medical care which may result in earlier diagnosis, treatment, and better prognoses [22,26,27]. Specifically, female athletes have been documented to be more likely to report concussion symptoms to an authoritative figure [10][11][12]22] and the current study yielded similar results with our finding that female student-athletes had significantly higher intentions to seek care for their concussion symptoms than males.

Differences between contact levels
Differences in personality characteristics between contact and non-contact student-athletes have been well-documented [28][29][30] and may explain differences we observed between contact levels and responses for care-seeking intentions [22]. Individuals tend to self-select participating in activities that meet their training needs with aggressive people actively seeking contact sport and less aggressive people choosing to participant in non-contact sport [29]. Contact student-athletes reported being more likely to use social and approach coping behaviors than non-contact athletes. Contact athletes often self-report as being more combative on and off the field [30], are more extraverted [28], and perceive anger to be facilitative to their performance [29]. This tendency toward aggression may explain why contact athletes are more likely to utilize approach coping behaviors rather than avoidance like their

Perceptions of limitations and perceptions of interference
Student-athletes reported that, in general, a concussion would at least somewhat limit their ability to complete all 14 activities listed on the perceptions of limitations survey. Specifically, athletes reported that they would be most limited in the classroom and completing school-specific activities with nearly 60% of athletes reporting that a concussion would extremely limit their ability to take a test. Based on these concerns related to academic performance following concussion, it is critical that we educate athletes and stakeholders on the importance of return to learn after concussion as well as make sure that academic accommodations and adjustments are provided when needed [33]. Athlete perceptions of limitations scores were weakly correlated with both symptom and concussion care-seeking intentions. This finding indicates that the degree to which a student-athlete believes a concussion would interfere with their everyday life may have a small influence on their intentions to seek care. However, it should be noted that these correlation values were weak and perceptions of limitations were not a predictor within our larger regression model. Continuing to educate all athletes on how concussion symptoms can affect their day-to-day life may, in turn, positively influence the number of athletes who non-contact sport counterparts. These characteristics are then often reinforced within the sport. Non-contact and limited-contact student-athletes had significantly higher symptom care-seeking intentions than contact athletes (Table 3). In addition, limitedand non-contact student-athletes believed that they would be significantly more limited following a concussion than contact athletes. This difference between contact levels could explain why student-athletes in these groups also had greater symptom careseeking intentions than athletes in collision sports.
Despite not reaching significance, we found an interesting trend between contact level and internality ratings for locus of control (P=0.06). Contact student-athletes reported on average lower mean internality ratings than non-contact athletes (Table 3). This finding indicates that contact athletes may not believe that they have as much control over the outcomes in their lives compared to non-contact athletes. Many contact sports rely on working with teammates to achieve an objective (e.g., scoring a goal) and, regardless of the strength of an individual athlete, the final outcome of the event depends on the actions of the group, not the individual [30]. Conversely, non-contact sports are often based on the performance of the individual (e.g., cross-country, tennis, swim, and dive) [29,31] with these athletes reporting higher internal locus of control ratings [17,32]. seek care following a suspected injury. Individuals who are more knowledgeable about the severity of an injury or illness are significantly more likely to seek medical care [27]. Sports medicine professionals should continue to educate all athletes on the serious nature of concussions and possible ramifications of failing to report an injury (e.g., increased number of days before returning to play [34,35]).

Limitations
This study is not without limitations. Our care-seeking intentions survey was administered pre-season at a single time point and the three follow-up surveys were distributed over the course of 1 year. It is possible that student-athletes care-seeking intentions evolved and changed overtime. While we accounted for concussions that occurred over the course of the data collection period, we did not account for a previous history of concussion which could have inflated an athlete's knowledge of the injury. Specifically, previous exposure to concussion may alter an athlete perception of how limited they would be following a concussion and may have greatly influenced their survey responses [36]. In addition, our sample of Division I, II, and III student-athletes was limited to a specific part of the United States and, therefore, our findings may not be generalizable to other regions.

Conclusions
The results of our study reveal that many student-athletes believe that a concussion would limit their ability to do well at a variety of sport-related and non-sport-related activities. Our findings are clinical and translation due to our integration of psychological constructs to help explain concussion-reporting intentions in a sample of college-aged student-athletes. There are several significant differences between contact level and care-seeking intentions which need to be further investigated to determine how much this influences actual concussionreporting behaviors. Our findings indicate that while these things may not influence concussion reporting and we might not need to focus on them extensively in concussion education. By doing so, a multifaceted approach to increase care-seeking intentions can be implemented which may lead to better recovery outcomes.

Appendix A: Brief Cope
These items deal with ways you have been coping with the stress in your life since you found out you were going to have to have this operation. There are many ways to try to deal with problems. These items ask what you have been doing to cope with this one. Obviously, different people deal with things in different ways, but I am interested in how you have tried to deal with it. Each item says something about a particular way of coping. I want to know to what extent you have been doing what the item says. How much or how frequently. Do not answer on the basis of whether it seems to be working or not -just whether or not you are doing it. Use these response choices. Try to rate each item separately in your mind from the others. Make your answers as true FOR YOU as you can. 1=I have not been doing this at all 2=I have been doing this a little bit 3=I have been doing this a medium amount 4=I have been doing this a lot 1. I have been turning to work or other activities to take my mind off things 2. I have been concentrating my efforts on doing something about the situation I am in 3. I have been saying to myself "this isn't real" 4. I have been using alcohol or other drugs to make myself feel better 5. I have been getting emotional support from others 6. I have been giving up trying to deal with it 7. I have been taking action to try to make the situation better 8. I have been refusing to believe that it has happened 9. I have been saying things to let my unpleasant feelings escape 10. I have been getting help and advice from other people 11. I have been using alcohol or other drugs to help me get through it 12. I have been trying to see it in a different light, to make it seem more positive 13. I have been criticizing myself 14