Health Literacy and Concussion Disclosure Intentions and Behaviors Among College Students: A Cross-Sectional Study
DOI :
https://doi.org/10.62255/mjhp.v4i2.241Abstract
Concussion under-reporting among college students remains a significant public health concern, and health literacy may influence students’ intentions and willingness to disclose concussion symptoms. This cross-sectional study examined the associations between health literacy and concussion disclosure intentions and behaviors among undergraduate students at a large public institution during Fall 2023. An online survey was completed by 267 students, with health literacy assessed using the Brief Health Literacy Screening Tool (BRIEF) and the Medical Term Recognition Test (METER), while concussion disclosure was evaluated through validated indirect and direct intention scales and corresponding behavioral measures. Multivariable linear and binary logistic regression analyses were conducted in accordance with STROBE reporting guidelines. Participants had a mean age of 20.7 ± 2.2 years, and 59.4% were female. Based on BRIEF scores, 23.2% demonstrated inadequate, 45.3% marginal, and 30.3% adequate health literacy, whereas 97.0% were categorized as having functional health literacy using the METER. Compared with students with inadequate health literacy, those with marginal (? = 0.40, 95% CI: 0.05–0.75, p = 0.028) and adequate (? = 0.51, 95% CI: 0.13–0.89, p = 0.009) BRIEF scores showed significantly higher indirect concussion disclosure intentions. However, health literacy was not significantly associated with direct disclosure intentions or actual disclosure behaviors. These findings suggest that improved health literacy may enhance disclosure intentions but is insufficient alone to influence reporting behavior, highlighting the need for targeted collegiate health interventions.
Downloads
Keywords
References
Abbott, A., Klomhaus, A., Nattiv, A., & Goldman, J. (2025). Concussion Reporting Expectation Screening in the Preparticipation Physical Examination. Sports Health, 18, 401–410. https://doi.org/10.1177/19417381251372975
Altin, S., Finke, I., Kautz-Freimuth, S., & Stock, S. (2014). The evolution of health literacy assessment tools: a systematic review. BMC Public Health, 14. https://doi.org/10.1186/1471-2458-14-1207
Anderson, M., Petit, K., Wallace, J., Covassin, T., & Beidler, E. (2021). Factors Associated With Concussion Nondisclosure in Collegiate Student-Athletes. Journal of Athletic Training, 56 2, 157–163. https://doi.org/10.4085/1062-6050-0102-20
Baer, D., Anderson, J., Vaccaro, C., & Curtis, N. (2024). Predictors of Concussion Symptom Reporting Intention among Collegiate Athletes. Journal of Athletic Training. https://doi.org/10.4085/1062-6050-0065.24
Basch, C., Kollia, B., MacLean, S., & Ahn, S. (2021). Concussion Knowledge, Beliefs, and Behaviors among University Students: Implications for Faculty and Staff. Journal of Public Health, 31, 731–738. https://doi.org/10.1007/s10389-021-01594-y
Beidler, E., Bretzin, A., Schmitt, A., & Phelps, A. (2021). Factors associated with parent and youth athlete concussion knowledge. Journal of Safety Research, 80, 190–197. https://doi.org/10.1016/j.jsr.2021.12.002
Beidler, E., Wallace, J., Alghwiri, A., & O’Connor, S. (2020). Collegiate Athletes’ Concussion Awareness, Understanding, and -Reporting Behaviors in Different Countries With Varying Concussion Publicity. Journal of Athletic Training. https://doi.org/10.4085/1062-6050-0575.19
Black, A., Turcotte, K., Fidanova, A., Sadler, K., Bruin, S., Cheng, P., Karmali, S., Taylor, T., Halliday, D., & Babul, S. (2023). Development of a tailored concussion education program for athletes: a pragmatic multimethods design and integrated knowledge translation approach from needs assessment to design. BMJ Open, 13. https://doi.org/10.1136/bmjopen-2023-075080
Brett, B., Nelson, L., & Meier, T. (2021). The association between concussion history and increased symptom severity reporting is independent of common medical comorbidities, personality factors, and sleep quality in collegiate athletes. The Journal of Head Trauma Rehabilitation, 37. https://doi.org/10.1097/htr.0000000000000724
Conner, M., & Norman, P. (2022). Understanding the intention-behavior gap: The role of intention strength. Frontiers in Psychology, 13. https://doi.org/10.3389/fpsyg.2022.923464
Conway, F., Domingues, M., Monaco, R., Lesnewich, L., Ray, A., Alderman, B., Todaro, S., & Buckman, J. (2020). Concussion Symptom Underreporting Among Incoming National Collegiate Athletic Association Division I College Athletes. Clinical Journal of Sport Medicine?: Official Journal of the Canadian Academy of Sport Medicine, 30 3, 203–209. https://doi.org/10.1097/jsm.0000000000000557
Craig, D., Lininger, M., Wayment, H., & Huffman, A. (2020). Investigation of strategies to improve concussion reporting in American football. Research in Sports Medicine, 28, 181–193. https://doi.org/10.1080/15438627.2019.1586706
Cranmer, G., Tallapragada, M., Bell, T., Bureau, S., Ashworth, M., Rey, R., McGlynn, J., & Johnson, Z. (2025). Using the Theory of Planned Behavior in Considering the Efficacy of Encountering Concussion Intervention Materials Online. Health Communication, 41, 201–211. https://doi.org/10.1080/10410236.2025.2504597
Daneshvar, D., Yutsis, M., Baugh, C., Pea, R., Goldman, S., Grant, G., Ghajar, J., Sanders, L., Chen, C., Tenekedjieva, L. -t., Gurrapu, S., Zafonte, R., & Sorcar, P. (2021). Evaluating the Effect of Concussion Education Programs on Intent to Report Concussion in High School Football. Journal of Athletic Training. https://doi.org/10.4085/509-20
Fleary, S., & Millington, M. (2025). Validation of the Assessments of Adult Health Literacy: a Rasch measurement model approach. Health Promotion International, 40 3. https://doi.org/10.1093/heapro/daaf090
Golshan, F., Bains, S., Francisco, J., Jensen, M., Tourigny, K., Morrison, T., & Mickleborough, M. (2024). Gender differences in concussion-related knowledge, attitudes and reporting behaviors of varsity athletes. The Journal of Sports Medicine and Physical Fitness. https://doi.org/10.23736/s0022-4707.24.15508-9
Hagger, M., & Hamilton, K. (2025). Progress on theory of planned behavior research: advances in research synthesis and agenda for future research. Journal of Behavioral Medicine, 48, 43–56. https://doi.org/10.1007/s10865-024-00545-8
Ingram, B., Kay, M., Callahan, C., Gildner, P., Kerr, Z., & Register-Mihalik, J. (2021). Effects Of An Interactive Concussion Education Platform On Concussion-related Knowledge, Attitudes, Perceived Norms, And Intention To Disclose In Collegiate Club Sport Athletes. Medicine & Science in Sports & Exercise. https://doi.org/10.1249/01.mss.0000763792.67503.4d
Jekauc, D., Voelkle, M., Sniehotta, F., & Nigg, C. (2025). Beyond the cross?section: Rethinking the intention–behaviour gap through a conceptual and methodological lens. British Journal of Health Psychology, 31. https://doi.org/10.1111/bjhp.70046
Kay, M., Hennink-Kaminski, H., Kerr, Z., Gildner, P., Ingram, B., Cameron, K., Houston, M., Linnan, L., Marshall, S., Peck, K., & Register-Mihalik, J. (2021). Factors and expectations influencing concussion disclosure within NCAA Division I athletes: A mixed methodological approach. Journal of Sport and Health Science, 12, 388–397. https://doi.org/10.1016/j.jshs.2021.09.006
Kerr, Z., Ingram, B., Livingston, S., Gildner, P., & Register-Mihalik, J. (2024). An initial assessment of an opinion leader-informed intervention to improve concussion-related outcomes among middle school parents: a randomized controlled trial. Annals of Medicine, 56. https://doi.org/10.1080/07853890.2024.2393760
Kneavel, M., & Ernst, W. (2021). Cognitions That Support Concussion Reporting in Collegiate Athletes: An Analysis of a Worksheet Activity. Health Education & Behavior, 49, 548–559. https://doi.org/10.1177/10901981211046535
Lecci, L., Dugan, K., Woodley, M., & Laney, S. (2024). Validation of a Brief Cognitive Assessment for Concussion Delivered on a Mobile Device. Journal of Pediatric Neuropsychology, 10, 193–201. https://doi.org/10.1007/s40817-024-00159-7
Lecci, L., Freund, C., Ayearst, L., Sitarenios, G., Pickett, B., Crews, F., Dugan, K., Lange, L., Clark, A., Linz, T., Taravath, S., Williams, M., & Keith, J. (2021). Validating a Short Conners CPT 3 as a Screener: Predicting Self-reported CDC Concussion Symptoms in Children, Adolescents, and Adults. Journal of Pediatric Neuropsychology, 7, 169–181. https://doi.org/10.1007/s40817-021-00107-9
Lecci, L., Williams, M., Taravath, S., Frank, H., Dugan, K., Page, R., & Keith, J. (2020). Validation of a Concussion Screening Battery for Use in Medical Settings: Predicting Centers for Disease Control Concussion Symptoms in Children and Adolescents. Archives of Clinical Neuropsychology?: The Official Journal of the National Academy of Neuropsychologists. https://doi.org/10.1093/arclin/acz041
Long, Y., Jia, C., Luo, X.-S., Sun, Y., Zuo, W., Wu, Y.-B., Wu, Y., Kaierdebieke, A., & Lin, Z. (2022). The Impact of Higher Education on Health Literacy: A Comparative Study between Urban and Rural China. Sustainability. https://doi.org/10.3390/su141912142
Mantwill, S., Allam, A., Camerini, A., & Schulz, P. (2018). Validity of Three Brief Health Literacy Screeners to Measure Functional Health Literacy – Evidence from Five Different Countries. Journal of Health Communication, 23, 153–161. https://doi.org/10.1080/10810730.2017.1417515
Miles, R., Rabin, L., Krishnan, A., Grandoit, E., & Kloskowski, K. (2020). Mental health literacy in a diverse sample of undergraduate students: demographic, psychological, and academic correlates. BMC Public Health, 20. https://doi.org/10.1186/s12889-020-09696-0
Milroy, J., Wyrick, D., Rulison, K., Sanders, L., & Mendenhall, B. (2020). Using the Integrated Behavioral Model to Determine Sport-Related Concussion Reporting Intentions Among Collegiate Athletes. The Journal of Adolescent Health?: Official Publication of the Society for Adolescent Medicine. https://doi.org/10.1016/j.jadohealth.2020.01.027
Miyashita, T. (2025). The impact of an educational intervention on college athletes’ knowledge of sports related concussions.
O’Connor, S., Geaney, D., & Beidler, E. (2020). Non-disclosure in Irish collegiate student-athletes: do concussion history, knowledge, pressure to play and gender impact concussion reporting? The Physician and Sportsmedicine, 48, 186–193. https://doi.org/10.1080/00913847.2019.1671141
Pennock, K. F., McKenzie, B., Steacy, L. M., & Mainwaring, L. (2020). Under-reporting of sport-related concussions by adolescent athletes: a systematic review. International Review of Sport and Exercise Psychology, 16, 66–92. https://doi.org/10.1080/1750984x.2020.1824243
Rawlins, M., Suggs, D., Bierema, L., Miller, L., Reifsteck, F., & Schmidt, J. (2020). Examination of collegiate student-athlete concussion reporting intentions and behavior. Journal of Clinical and Translational Research, 5, 186–196. https://doi.org/10.18053/jctres.05.2020s4.005
Rawlins, M. W., Bacon, C. W., Tomporowski, P., Gay, J., Bierema, L., & Schmidt, J. (2022). Masculinity, optimism bias, and perceived pressure from stakeholders influence on student-athlete concussion reporting intentions and behavior. Journal of American College Health, 72, 2441–2447. https://doi.org/10.1080/07448481.2022.2115300
Rawlins, M. W., Wilson, A., Bay, R., & McLeod, T. (2021). An Examination of Perceived Pressure From Stakeholders on Concussion Reporting Intentions and Behavior in Ice Hockey Athletes. Journal of Head Trauma Rehabilitation, 37, 79–88. https://doi.org/10.1097/htr.0000000000000679
Register-Mihalik, J., Marshall, S., Kay, M., Kerr, Z., Peck, K., Houston, M., Linnan, L., Hennink-Kaminski, H., Gildner, P., Svoboda, S., & Cameron, K. (2020). Perceived social norms and concussion-disclosure behaviours among first-year NCAA student-athletes: implications for concussion prevention and education. Research in Sports Medicine, 29, 1–11. https://doi.org/10.1080/15438627.2020.1719493
Schmidt, J., Weber, M., Suggs, D., Bierema, L., Miller, L., Reifsteck, F., Courson, R., Hoff, R., Dill, K., & Dunham, J. (2020). Improving Concussion Reporting across National College Athletic Association Divisions Using a Theory-Based, Data-Driven, Multimedia Concussion Education Intervention. Journal of Neurotrauma, 37, 593–599. https://doi.org/10.1089/neu.2019.6637
Stillman, A., Madigan, N., Torres, K., Swan, N., & Alexander, M. (2020). Subjective Cognitive Complaints in Concussion. Journal of Neurotrauma, 37, 305–311. https://doi.org/10.1089/neu.2018.5925
Svingos, A. (2019). Validation of a Concussion Assessment Tool. Neurology, 93. https://doi.org/10.1212/01.wnl.0000580836.31693.fa
Tavousi, M., Mohammadi, S., Sadighi, J., Zarei, F., Kermani, R., Rostami, R., & Montazeri, A. (2022). Measuring health literacy: A systematic review and bibliometric analysis of instruments from 1993 to 2021. PLoS ONE, 17. https://doi.org/10.1371/journal.pone.0271524
Tolabing, M., Co, K., & Mamangon, M. (2022). Development and validation of a functional health literacy instrument in the Philippines. International Journal of Public Health Science (IJPHS). https://doi.org/10.11591/ijphs.v11i4.21755
Urstad, K., Andersen, M., Larsen, M., Borge, C., Helseth, S., & Wahl, A. (2022). Definitions and measurement of health literacy in health and medicine research: a systematic review. BMJ Open, 12. https://doi.org/10.1136/bmjopen-2021-056294
Wallace, J., Bryant, W., Ross, M., Talley, D. D., Leonard, E., Williamson, M. M., Covassin, T., & Beidler, E. (2025). Health Literacy Among Adolescent Athletes Across Rural and Urban Communities and Evaluating Scores Aside State-Mandated Concussion Education. Journal of Athletic Training, 60 12, 881–888. https://doi.org/10.4085/1062-6050-0049.25
Wayment, H., Craig, D., Huffman, A., & Lininger, M. (2019). A Simple Field-Based Tool to Assess Concussion Symptom Reporting Behavior. American Journal of Preventive Medicine, 56 2, 323–330. https://doi.org/10.1016/j.amepre.2018.10.007
Wilmoth, K., Curcio, N., Tarkenton, T., Meredith-Duliba, T., Tan, A., Didehbani, N., Hynan, L., Miller, S., Bell, K., & Cullum, C. (2019). Utility of Brief Psychological Measures for Prediction of Prolonged Symptom Clearance in Concussed Student Athletes. Archives of Clinical Neuropsychology?: The Official Journal of the National Academy of Neuropsychologists. https://doi.org/10.1093/arclin/acz061
Wilmoth, K., Magnus, B., McCrea, M., & Nelson, L. (2020). Preliminary Validation of an Abbreviated Acute Concussion Symptom Checklist Using Item Response Theory. The American Journal of Sports Medicine, 48, 3087–3093. https://doi.org/10.1177/0363546520953440
Downloads
How to Cite
Issue
Section
License
Copyright (c) 2026 Michelle Weber Rawlins, Julia Ng, Kimberly Calvert, Kelsey Picha
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License .
You are free to:
• Share — copy and redistribute the material in any medium or format.
• Adapt — remix, transform, and build upon the material for any purpose, even commercially.
Under the following terms:
• Attribution — You must give appropriate credit to the original author(s) and Health Frontiers, provide a link to the license, and indicate if changes were made.
• ShareAlike — If you remix, transform, or build upon the material, you must distribute your contributions under the same license as the original.
