Calculated Clinical Incidence of Sport-Related Concussion in Rural Communities with Barriers to Health Care

Background: Previous research has noted barriers to recognizing sport-related concussions (SRC) among rural populations and secondary schools without access to an athletic trainer (AT). These populations have lower emergency care utilization for concussions and are less likely to report concussions, respectively. Because most SRC-based epidemiological studies use health records or AT-driven databases, rural communities with limited healthcare access are underrepresented. This study aimed to estimate clinical incidence of concussion among high school football athletes in rural communities with healthcare barriers. Hypothesis: The clinical incidence of concussion will be lower in rural schools and schools without AT access. Methods: A prospective cohort design was used to evaluate the clinical incidence of SRC among 10 Alabama high school football teams (four urban, six rural) over two consecutive competitive seasons. Inclusion criteria for SRC were (1) occurring during participation in a football activity (e.g., practice, competition, conditioning, weightlifting, etc.) and (2) diagnosed by a licensed healthcare professional (i.e. AT/physician). A weekly SRC count was recorded at each school, coordinated by a research liaison using community-engaged methods. Distributions of SRC were examined by count per team-season and time in season (e.g., preseason, regular season). One-season SRC risk was calculated as the sum of concussed athletes divided by the sum of participating athletes across all seasons. Subsequent clinical incidence ratios (RR) were calculated by rurality and AT access. Results: There were 32 concussions reported across 1,001 athlete-seasons, resulting in an overall one-season SRC risk of 3.2% (95%CI: 2.1-4.3%). Sixteen SRCs (50.0%) occurred in team-seasons from rural high schools (one-season risk=3.2%; 95%CI: 1.6-4.7%). Sixteen SRCs (50.0%) occurred in team-seasons from urban high schools (one-season risk=3.2%; 95%CI: 1.7-4.8%). The resultant risk-ratio was not statistically significant (RR=0.99; 95%CI: 0.50-1.96). Overall, 24 SRCs (75.0%) occurred in team-seasons from high schools with an AT presence (one-season risk=4.4%; 95%CI: 2.7-6.1%). Eight SRCs (25.0%) occurred in team-seasons from high schools without an AT presence (one-season risk=1.8%; 95%CI: 0.6-3.0%). AT presence was associated with SRC risk, with a higher reported incidence found in schools with an AT (RR=2.49; 95%CI: 1.13-5.49; large effect size). Conclusion: An estimated concussion risk of 3.2% translates to 3-4 of every 100 football athletes will report a SRC per season. However, risk varied widely, with one-fifth of teams reporting none and others reporting 9-10 per 100 athletes. Findings signify the need for AT services in rural communities with healthcare barriers, particularly since AT presence may help encourage SRC reporting.