Communication Plan – Rowan’s Law: A New Approach to Concussion Safety
Introduction
Concussions have been a part of sports of all levels and types for a long time; from amateur tennis to Olympic trampolining to professional football. Sports are in fact the most common reason for concussions among both children and adults (Rao, McFaull, Thompson and Jayaraman, 2017). Within the past ten years, rates of reported concussions have been rising in Canada (Rao et al., 2017) and unreported concussion rates are likely quite similar. Unfortunately, it is impossible to gauge how many concussions go unreported and there are many reasons as to why people do not report them. According to a study done by Donnell, Hoffman, Sarmiento and Hays (2017), just over half of young athletes actually recognize the symptoms of concussions or that they should report to a parent or coach when they believe they may have a concussion. Lack of knowledge surrounding concussions and the effects on health ultimately leads to under reporting and premature return to play (Wallace, Covassin, Nogle, Gould & Kovan, 2017). For those that actually understand what concussions entail, they may not believe them to be severe enough to quit participating in their sport (Register-Mihalik, Guskiewicz, McLeod, Linnan, Mueller and Marshall, 2013; Donnell et al., 2017). Others may in fact believe there is a certain stigma associated with reporting an injury or they may not want to let down their coaches, teammates, parents or fans (Register-Mihalik et al., 2013).
Background
This brings us to the case of Rowan Stringer, a 17-year-old rugby player from Ottawa, Ontario, who was hit in the head in a game and returned to play for her high school team without reporting her injuries. After being hit in the head for a second time in a week, she was hospitalized and later died. The cause of death was determined to be second impact syndrome, a severe swelling of the brain caused by traumatic brain injury while the brain is still healing from previous trauma (Rowan’s Law Advisory Committee, 2017). This sparked action within the amateur sport community in Ontario to develop legislation surrounding concussion safety education, removal-from-play and return-to-play protocols and lead to the creation of the Rowan’s Law Advisory Committee. The Committee is made up of many individuals such as doctors of neurosurgery, researchers in concussions, public health professionals, members of sports organizations, professional and Olympic-level athletes who have suffered many concussions and have become advocates for concussion safety, and Rowan Stringer’s father (Rowan’s Law Advisory Committee, 2017). Based on recommendations made by the Concussion in Sport Group at the 5th International Conference on Concussion in Sport in 2016 (McCrory et al., 2017), other existing research, best practices and experience, this interdisciplinary team will make recommendations to the Government of Ontario’s Ministry of Health and Long-Term Care and the Ministry of Tourism, Culture and Sport to help draft a bill that can improve concussion safety and protect youth and amateur athletes in Ontario.
Goals and Objectives
Our goal is to implement legislation for concussion safety in all amateur and school sports throughout the province of Ontario. Through training certifications, information sessions, advertising and policy changes within all the sports associations, we aim to have this implemented by June 2020. At this time, we will use surveys to determine parents’, coaches, athletes’ and other volunteers’ knowledge about concussions and safety protocols relating to concussions. This legislation will aim to improve concussion surveillance, prevention, detection, management and awareness (Rowan’s Law Advisory Committee, 2017).
Surveillance will be improved by having a more comprehensive system in place within sporting organizations, hospitals, family doctors and health clinics to report concussions. By having one place to report all concussions, which can hopefully be based on the already existing Canadian Hospitals Injury Reporting and Prevention Program or CHIRPP (Public Health Agency of Canada, 2016), which could make it easier to keep track of concussions. Unfortunately, this program is only available to select emergency departments across Canada. Since individuals are becoming more and more likely to go to family physicians or clinics rather than emergency rooms (Rao, McFaull, Thompson and Jayaraman, 2018) to seek care for their concussions, it may become a future goal of this legislation to implement a similar reporting program for concussions that can be accessed by doctors and coaches alike, which can give a more accurate number of confirmed or suspected concussions, the severity of these concussions in any given place and the sport or competition level at which they took place.
Prevention will be improved by educating athletes about the dangers of concussions, making them more likely to protect their head during a hard hit or fall. It may also help them to avoid certain dangerous situations such as continuing play without a helmet on, hitting another person head first or falling head first. Additionally, rules within the sport may be implemented or enforced more heavily such as no hits to the head, upper body, or any contact at all.
Detection will be improved by implementing baseline testing at the beginning of a season on all athletes. Baseline testing consists of psychological and cognitive testing to determine an athletes’ “normal” function level. After a suspected concussion, the tests will be repeated to determine any differences, which may indicate a concussion. If a concussion is detected through these means, it is more likely to be reported.
Management of concussions will be improved by ensuring all coaches, volunteers and even referees have concussion and concussion safety training and ensuring there is always at least one coach or volunteer with valid First Aid training located near the playing area. This will increase the likelihood of detecting and reporting a concussion, as the coaches will know what to look for in athletes who have just hit their head. Also, implementing more rigorous return-to-play policies within amateur sporting organizations in Ontario can help to manage concussions. The main policy that is to be implemented is the required medical clearance from a doctor before returning to the sport. Another tactic for return-to-play might be gradual reintroduction to training, followed by return to competition. The goal of the return-to-play policies are to avoid having an athlete return to sport too early, to lower the chances of them getting second impact syndrome, like Rowan Stringer.
Awareness will be increased by having information sessions for coaches, volunteers, parents and the athletes involved in sports. Understanding what a concussion is, what the symptoms are and how it can affect athletes are all important in preventing them and managing them. Awareness can make athletes think more about how they are playing, to avoid certain situations or be conscious of hitting their heads. It can make coaches, parents and volunteers look for any symptoms if an athlete has hit their head and use that information to protect the athlete. It can also lead to more prevention policies being put in place within the sport. Without awareness, these efforts would all be unnecessary, as it is the basis of Rowan’s Law.
Situational Analysis
Legislation surrounding concussion safety was first brought forward to Queen’s Park in 2012, however ended up not being renewed on the agenda when a new government took office (Rowan's Law Advisory Committee, 2017). Policies and legislation surrounding concussion safety have been in place with all professional hockey, basketball, baseball and football teams in North America for the last seven years at least (Cochrane, Owen, Ackerson, Hale & Gould, 2017). Additionally, such policies for amateur and youth sports are in place in all 50 states in the US and some have been in place for nearly ten years (Simon & Mitchell, 2016). Since no current legislation exists surrounding concussion safety in any Canadian provinces, Canada has certainly been a laggard in this area and it is time for change to protect all our athletes, no matter their age, sport or competition level. This lack of concussion safety policy lead to Rowan Stringer’s return to rugby while still suffering the effects of a concussion, leading to second impact syndrome and her death. Some say the system failed her, and perhaps it did, however this new law will ensure that she is the last death from second impact syndrome in organized sport in Ontario.
This Law has a very broad audience, from the organizational bodies of the amateur sports to the coaches, volunteers, parents and athletes who participate in them. As there is such a broad audience varying in age, competition level and amount of knowledge of concussions, a lot of different information will be communicated. For the organizations, there will be more formal language and policies that they must follow, and they may tailor the information to be more specific to their sport. For example, a hockey association may restrict high hits or hits of any kind for lower levels of competition. For coaches and volunteers, it would also be wise to use more formal language in official certification and education sessions. For parents and athletes, as some do not possess any knowledge of concussions, it may be best to give basic information at an elementary level and build upwards. For athletes who are a bit older and their parents, who may be more familiar with concussions and their effects, the messages can be simply how to lower risks of getting one or another one. Some messages can be specific to younger athletes below the age of 12, who are still at risk of concussion but do not understand the implications or jargon. Other messages can use influential elite-level athletes to have a more familiar face delivering the message.
STAGE OF BEHAVIOUR CHANGE
In terms of financial resources, the Government of Ontario is prepared to provide grants to all sporting organizational bodies, so they may implement education programs for all their members. Funding can also be obtained by organizations applying for grants or seeking donations from philanthropists or foundations relating to youth sports, who believe in the importance of concussion safety and education or simply who believe in protecting youth athletes. This funding can help organizations set up workshops to provide certification in concussion safety training to coaches and volunteers, workshops for parents and athletes, and other educational resources such as posters and pamphlets.
There will also be many actors helping to bring concussion safety from a recommendation to a fully implemented law, which everyone understands. These actors include the Government of Ontario’s Ministries of Health and Long-Term Care and Culture, Tourism and Sports. These Ministries as well as the Rowan’s Law Advisory Committee will be responsible for researching and drafting the law. Once it is brought through Queen’s Park to become law, the message will be disseminated through to all amateur and youth sports associations and clubs across the province, all public health units, the Ontario Physical and Health Education Association (Ophea) and the Ontario Coaches Association. The sports associations will be responsible for education sessions for parents and athletes and policy changes within the sport. The public health units and Ophea will be responsible for more education to the general public about concussions and concussion safety in sports. They will accomplish this with the help of Carve Design and Strategic Developments, which are the official graphics design and public relations firms that will provide any posters, pamphlets, informational materials, ad banners on social media, social media posts or commercials. The Ontario Coaches Association will be providing mandatory training and certification for volunteers and coaches. With the provincial and local sports associations, this will ensure anyone involved in the sport from an organizational point of view understands concussions. As previously mentioned, we also have some elite athletes interested in helping share the message about the importance of concussion safety, including Eric Lindros or Rosie McLennan. Eric was a former NHL player who has suffered from many concussions and is an advocate for concussion safety, research and education. Rosie is a current world-champion Canadian trampolinist who has also suffered major concussions, which has pushed her towards wanting to educate others about their dangers. Having people who have been where the current young athletes are is the best way of getting the message across, as they understand the wants and needs of someone participating in their respective sports. Finally, to help with the surveying of the public and the organizations, we will be using Pricewaterhouse Coopers (PwC), an objective accounting firm.
Target Audiences
A top-down approach to communication will be used in this case with coaches, volunteers, athletes and parents being the ultimate target. To reach these individuals, the Government of Ontario will provide information to organizational bodies for youth school and non-school related sports in Ontario. All provincial-level sports and coaching associations will be the initial recipients of information, such as Ontario Ringette Association (ORA), Skate Ontario, Ontario Football Alliance (OFA), Gymnastics Ontario, the Ontario Federation of School Athletics Associations (OFSAA) and the Ontario Coaches Association (OCA). These organizational bodies can use this as an opportunity to make the information sport-specific and it will then be disseminated to regional and local associations and leagues such as Nepean Ringette Association, Ilderton Skating Club, Cambridge Minor Football Association, Richmond Hill Gymnastics Club and the Northern Ontario Secondary School Athletics (NOSSA) and Nipissing District Athletics (NDA). Through these organizations, there will be mandatory training and certification sessions for coaches and volunteers. Additionally, there will be information sessions and advertisement campaigns that will target parents and athletes with varying levels of knowledge of concussions and of all ages.
As many young athletes do not even know about concussions, their symptoms or their risks (Register-Mihalik et al., 2013) they are the most important people to inform on the topic, as they will be the ones most likely to suffer from them. Parents also identify concussions and hits to the head as the injuries that concern them most when their children participate in sports (Rieger, Lewandowski, Potts, Potter & Chin, 2018). General knowledge about concussions is also rather varied between parents (Rieger et al., 2018), making detection inconsistent and putting some athletes more at risk than others. Lack of understanding of concussions, detection and management are what lead to dangerous situations such as Rowan’s. It is the responsibility of sports organizations, coaches and volunteers to protect all their athletes from further injuries, no matter theirs or their parents’ level of knowledge relating to concussions. By having everyone involved in sports well educated on the topic of concussions, ideally, there will be a downward trend in these injuries in youth athletes province-wide. Ontario hopes to exemplify good concussion safety education, mitigation and management to the rest of the country, so all Canadians will one day be protected.
Key Messages
The importance of Rowan’s Law is to educate the public on concussions, the effects concussions can have on athletes of all ages and how to protect athletes from suffering major mental and physical effects relating to concussions. The majority of sport-related concussions are a form of mild brain trauma and in some cases, there may be more severe hits may lead more severe brain trauma (McCrory et al., 2017). According to the American Association of Neurological Surgeons ([AANS], 2018), concussions are defined as an “alteration of normal brain function due to trauma, causing confusion, dizziness, issues with memory, muscle function and overall cognitive functions” (AANS, 2018). Only suffering from one concussion is not necessarily dangerous, depending on the severity, however a second trauma soon after the first could cause permanent brain damage or death, no matter how severe (AANS, 2018). This condition is known as second impact syndrome and it is the condition which lead to the death of 17-year-old Rowan Stringer in 2013 (Rowan’s Law Advisory Committee, 2017).
Action Plan
For this communication plan, we plan to implement a law surrounding concussion safety in amateur and youth sports in Ontario named Rowan’s Law for Concussion Safety. To develop this legislation, it must first be researched and developed into a proper bill by the Ministries of Tourism, Culture & Sport and Health & Long-Term Care to be presented at Queen’s Park by December 2018. Ideally, this bill will pass through legislation by June 2019. By the end of Summer 2019, we intend to have a full budgetary review completed for the implementation, as well plans for how to the Act will be presented to the public and who will be responsible for what parts of the implantation. By December 2019, we intend on having a design firm and a public relations firm design and implement a complete media and advertising campaign with the goal of educate the public about the new law, concussions and concussion safety. These will come in the form of commercials, radio ads, ad banners on social media, social media campaigns, posters in public places and sports and recreation areas targeted towards parents and athletes (See Appendix A). By this time, there should be policies being put in place surrounding concussion safety within all amateur and school sports associations across Ontario, in accordance with Rowan’s Law for Concussion Safety. By January 2020, there should be mandatory education sessions and certifications for various volunteers and coaches involved in the sports, followed by sessions for athletes and their parents. These sessions will be put on by certified individuals on concussion education and cover topics such as how to identify a concussion and symptoms, what to do when an athlete gets a concussion, safe return-to-play policies and procedures and the risks of concussions and returning to a sport too early. These will continue through the end of the 2019/2020 sporting season into the 2020/2021 season. By the end of the 2021 sporting season, around June 2021, there will be surveys (see Appendix B) about concussions and concussion safety for sporting associations, coaches, parents and athletes to determine if these sessions and media campaigns have had any positive impact.
In the following RACI chart, responsibilities for all steps of implementation are outlined, as well as what actors are ultimately accountable for all steps and who will be consulted and informed along the way.
Evaluation Strategies
To measure the impact of Rowan’s Law for Concussion Safety, surveys surrounding concussions and concussion safety (see Appendix A) will take place by the end of the 2021 sporting season, around June 2021. An objective third party accounting firm will gather the results and provide figures on the impacts the Law has made on the public province-wide. These surveys will have questions be given to sporting organizations, coaches, volunteers, parents and athletes across Ontario about concussion surveillance, prevention, detection, management and awareness. The goal of these surveys is to ensure there have been improvements in these five areas at all levels throughout the province, since the Law has taken effect.
Conclusion
The Province of Ontario hopes to be at the forefront of concussion safety in Canada and to align ourselves with the recommendations made at the 5th International Conference on Concussion in Sport. As the country itself is lagging in such regulations in amateur and youth sports, it is time to make a change to ensure no athlete is left behind or put at risk. By enacting Rowan’s Law, it will ensure that the resources are always there for concussion education and safety within all sporting organizations at all levels.