title: Disclosure and non-disclosure of concussion and concussion symptoms in athletes: review and application of the socio-ecological framework.
abstract: OBJECTIVE
  To summarize the factors associated with athletes' disclosure-and non-disclosure-of sports-related concussion and concussion symptoms within the context of the socio-ecological framework and to identify research gaps in the current literature.
  
  
  METHODS
  Searches using electronic databases identified studies written in English, published through October 2013 and addressing some aspect of disclosure of concussion and concussion symptoms. The literature search aimed to be comprehensive and inclusive of all previous contributions.
  
  
  RESULTS
  Of the 30 identified studies, most originated from the US (n = 19) and sampled athletes (n = 21) and coaches (n = 10) from high school (n = 11) and college levels (n = 9). The identified reasons for non-disclosure were organized into four levels using the socio-ecological framework: intra-personal (e.g. lack of knowledge; internal pressure; sex; concussion history; n = 20 studies); inter-personal (e.g. others' knowledge/attitudes; external pressure; external support; n = 15 studies); environment (e.g. access to concussion prevention materials; sports culture; n = 4 studies); and policy (e.g. concussion-related legislation; n = 3 studies). No study examined all four levels.
  
  
  CONCLUSIONS
  Research gaps exist concerning factors influencing athletes' disclosure of sports-related concussions and concussion symptoms. Notably, researchers have focused on intra-personal and inter-personal levels, placing less emphasis on the environment and policy levels.
authors.affiliation: Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina-Chapel Hill , Chapel Hill, NC , USA .
authors.forename: Zachary Y
authors.initials: ZY
authors.lastname: Kerr
authors.forename: Johna K
authors.initials: JK
authors.lastname: Register-Mihalik
authors.forename: Stephen W
authors.initials: SW
authors.lastname: Marshall
authors.forename: Kelly R
authors.initials: KR
authors.lastname: Evenson
authors.forename: Jason P
authors.initials: JP
authors.lastname: Mihalik
authors.forename: Kevin M
authors.initials: KM
authors.lastname: Guskiewicz
mesh_terms: D056352:Athletes; D001265:Athletic Injuries / Q000175:diagnosis*; D001924:Brain Concussion / Q000175:diagnosis*; D057189:Checklist; D007722:Health Knowledge, Attitudes, Practice; D006291:Health Policy; D006801:Humans; D012650:Self Disclosure; D057566:Self Report; D013177:Sports; D013178:Sports Medicine; D011795:Surveys and Questionnaires; D015599:Trauma Severity Indices
keywords: Policy; reporting; sports; traumatic brain injury