Abstract
-
Objective
This study investigated the status and evaluated factors associated with knowledge and attitudes regarding pediatric concussions among Korean parents of children aged 6 to 18 years.
-
Methods
A cross-sectional online survey was employed to collect data from a panel of parents in Korea in 2023. To assess knowledge and attitudes regarding concussions, participants completed a validated questionnaire. The outcome variables of total knowledge score (range, 0–30) and total attitude score (range, 7–49) were categorized into tertiles. We conducted multivariable ordinal logistic regression analyses with participants and their children based on demographic information and characteristics as covariates.
-
Results
A total of 260 parents responded to the survey and demonstrated moderate concussion-related knowledge (median total score, 21; interquartile range [IQR], 18–22.5). The respondents exhibited favorable attitudes toward concussions (median total score, 39; IQR, 34–43), except the attitude of the importance of reporting concussion. Multivariable ordinal regression analysis for outcomes revealed only career of healthcare provider (adjusted odds ratio, 3.15; 95% confidence interval, 1.13–8.75) to be associated with parental concussion-related knowledge. No factors exhibited a significant association parental attitudes toward concussions.
-
Conclusion
Our results confirmed the knowledge-attitude gap regarding pediatric concussions among Korean parents. Effective strategies are warranted to improve parental knowledge and attitudes.
-
Keywords: Concussion; Knowledge; Attitude; Parents
Capsule Summary
What is already known
Parents play a crucial role in their children's recovery from concussions. It is important for emergency physicians to be aware of parental level of knowledge and attitude toward concussions to ensure proper understanding, communication, and interaction between emergency physicians and parents when discharging pediatric patients with concussions.
What is new in the current study
This study revealed modest knowledge regarding concussion among parents of children aged 6 to 18 years in Korea. Parental attitude of “the importance of reporting concussion” was not favorable in contrast to other attitude items. 을 This study revealed modest knowledge regarding concussion among parents of children aged 6 to 18 years in Korea. The respondents exhibited favorable attitudes toward concussions. Parental attitude of “the importance of reporting concussion” was not favorable in contrast to other attitude items.
INTRODUCTION
Childhood concussions represent a significant public health concern due to their high incidence and potential negative effects on quality of life (QOL) [
1]. In 2019 alone, 27.16 million new cases of traumatic brain injury (TBI) were reported globally, and the age-standardized rate per 100,000 was 346 (95% uncertainty interval, 298–401). The age-standardized rate per 100,000 people in Korea was 447 (95% uncertainty interval, 385–523), which is higher than the world average [
2]. Mild TBI, including concussion, accounts for at least 75% of all TBIs reported in the United States [
3]. Most children recover from a concussion within one month without complications. However, some pediatric patients may experience prolonged recovery or long-term complications if not appropriately managed postconcussion, resulting in interruptions in schoolwork and other daily activities.
Parents play a crucial role in their children's recovery from concussions; therefore, their knowledge of and attitudes toward concussions are fundamental. Several previous studies have reported that parental knowledge and attitudes contribute to the willingness of children to report concussions and their recovery after a concussion [
4–
6]. However, parents were often unaware of the consequences of concussions and concussion management [
7–
9]. A majority of parents failed to recognize the definition of concussion, and up to 80% were unaware how to return to activity after concussion [
10,
11]. Therefore, the US Centers for Disease Control and Prevention’s National Center for Injury Prevention and Control launched the “HEADS UP” national education initiative for parents [
12].
It is important for emergency physicians (EPs) to be aware of parental level of knowledge and attitudes toward concussions as they are the basis for communication and interaction when discharging pediatric patients with concussion. When EP advice is provided in accordance with the parental level of knowledge and attitudes toward concussion, the healing effects on their children can be maximized. In particular, communication between EPs and parents is important in areas without community education programs on concussions such as in Korea because emergency departments are one of few sources of reliable information [
13,
14].
Here, we investigated the status of knowledge and attitudes among parents of children aged 6 to 18 years because little is known about parental knowledge and attitudes toward concussion in the Korean context. In addition, we evaluated the factors associated with knowledge and attitudes regarding concussion among parents of children aged 6 to 18 years.
METHODS
Ethics statement
This study was approved by the Institutional Review Board of Hallym University Dongtan Sacred Heart Hospital (No. HDT 2022-12-013-001). All participants provided written informed consent before participating in the study.
Study design
This study was designed as a cross-sectional survey using an online self-report questionnaire (
Supplementary Materials 1,
2). This study was a secondary data analysis to measure knowledge of and attitudes regarding concussions among the general population.
The study sample was part of a larger sample collected by a public health policies research firm (GRI Research). The sample pool previously had agreed to participate in an online survey, and participants consistently met the qualification criteria. Participation was entirely voluntary, and individuals could discontinue the survey at their discretion. This study included only individuals who self-reported as parents of children aged 6 to 18 years. There were no exclusion criteria for this study. The purpose of this study was presented in a consent form before the start of the study. However, the invitation did not include specific details to avoid self-selection bias. Upon survey completion, participants received “reward points” equivalent to KRW 10,000 (approximately US $8). Duplicate participation was prevented by assigning unique identities to each panel.
Data collection and variables
The entire research team adapted the online survey tool from a previously validated questionnaire and finalized it following a pilot test [
9,
15,
16]. The website address of the finalized online questionnaire was integrated into an online survey platform and provided to the participants. In January and February 2023, 260 Korean residents (aged ≥18 years) identifying as parents of children aged 6 to 18 years were selected from a pool of samples and invited to participate. The outcomes of interest were concussion-related knowledge and attitudes. Concussion-related knowledge comprised 30 questions covering the definition, symptoms and signs, and consequences of concussion and of multiple concussions. Correct answers were awarded 1 point, resulting in scores ranging from 0 to 30 for concussion-related knowledge. Concussion-related attitudes were measured using seven items on a 7-point Likert scale, where higher scores indicated a more favorable or safer attitude, resulting in scores ranging from 7 to 49. We also collected explanatory variables of interest for parents and their children. These variables included the demographics of the responder including sex, age, and educational level. We also considered characteristics of the responder including whether they had a career as a healthcare provider, their participation in organized sports within the past year, and their experience as a sports coach. Additionally, we collected data on their children’s demographics and characteristics, including age, sex, whether they had siblings, and their participation in organized sports within the past year. Additionally, we collected information on whether respondents had visited a hospital as a patient or caregiver for a concussion during their lifetime, regardless of whether it was an emergency department or outpatient clinic.
Data were analyzed using SAS ver. 9.4 (SAS Institute Inc). Descriptive analyses of the categorical variables were conducted using frequencies and percentages. Continuous variables were examined using means and standard deviations or medians and interquartile ranges (IQRs) for variables that were not normally distributed. We compared the differences in medians between the two groups using the Wilcoxon rank sum test. Further, the P-values were based on a two-sided significance level of 0.05. We categorized the total knowledge and attitude scores into tertiles (i.e., knowledge: 0–19, 20–22, and 23–30; attitude: 1–35, 36–41, and 42–49) due to the discrete nature of the outcome measures. We selected score cutoffs that represented meaningful elevations in the outcome levels. The proportional odds assumption was tested prior to fitting the model. Multivariable ordinal logistic regression models were employed to identify the parent and child characteristics associated with knowledge and attitude regarding concussion. These models incorporated covariates of demographics and characteristics of the responders and those of their children. Adjusted odds ratio (AOR) with a 95% confidence interval (CI) was calculated, and AOR was considered significant if the 95% CI did not include 1.
RESULTS
Overall, 260 parents responded to the survey, with a female to male ratio of 1:1.5. Mean parental age was 45.3±6.0 years. Most respondents (89.2%) reported having an educational level beyond high school. Parents with sons accounted for 72.3% of the sample. Among the respondents, 69.2% had experience participating in sports activities and 22.7% had experience coaching sports. The proportion of respondents working in health care was 7.3%, and the percentage of respondents who had received concussion-related education at least once in their lifetime was 9.6%. Respondents who answered that they had visited the hospital as patients or caregivers for concussions accounted for 30.8% (
Table 1).
Table 2 summarizes the parental knowledge of concussion. Overall, parents demonstrated moderate concussion-related knowledge. The median total score was 21 (IQR, 18–22.5), which corresponds to 63.0% when converted to a percentage. When asked about the injury location of a concussion, only 60.0% of the respondents answered “brain” correctly, with incorrect answers including the skull, face, and neck. Among the questions regarding the symptoms and signs of concussion, items with a correct answer rate less than 50% were bleeding from the nose (true) 45.4%, numbness in the arms (true) 49.6%, and weakness during neck movement (false) 48.8%. Regarding the consequences of multiple concussions, the proportion of respondents who answered “one may be more likely to suffer another concussion” with the correct answer (true) was 76.9%. Regarding the consequences of multiple concussion sections, 88.5% of respondents answered true for brain damage.
Fig. 1A shows the distribution of knowledge scores among the 260 parents.
Overall, parents exhibited favorable attitudes related to concussions (
Table 3). The median total score was 39 (IQR, 34–43), which corresponds to 79.6% when converted to a percentage. However, the median attitude score for “the importance of reporting possible concussion symptoms to a healthcare professional or caregiver” was 4 of 7 (IQR, 3–5).
Fig. 1B shows the distribution of attitude scores among the 260 parents.
In the multivariable ordinal regression analysis for outcomes, except for a career as a healthcare provider (AOR, 3.146; 95% CI, 1.132–8.745), no factors were associated with parental concussion-related knowledge. None of the factors included in the study showed a significant association with parental attitudes toward concussions (
Table 4).
DISCUSSION
The primary findings of this study revealed modest knowledge and favorable attitude toward concussion among parents of children aged 6 to 18 years in Korea. Moreover, this study found no significant factors associated with parental knowledge and attitudes regarding concussions except career as a healthcare provider. These findings imply the need for increased parental knowledge and attitudes toward concussions in Korea.
Our results regarding concussion knowledge contradict those of previous studies [
17–
19]. Our results showed that parental knowledge regarding concussions was lower than that found in previous studies. A recent systematic review of parental knowledge of concussion reported that more than 90% of parents identified memory problems, disorientation, and confusion as signs or symptoms of a concussion [
15,
16]. Our results showed that the rate of correct answers regarding physical symptoms or signs was 60% to 70%. However, the reasons for these differences remain unclear. A possible explanation may be differences in social interests and educational infrastructure due to differences in the prevalence of pediatric concussions.
One notable finding of this study was that parental attitude of “the importance of reporting concussion symptoms to a medical professional” was not favorable in contrast to other attitude items. Reporting concussion symptoms is important because it is the first step toward preventing delayed recovery. Reporting symptoms will enable a child to be assessed, monitored, and treated and to ensure the required time to heal. A strategy is needed to increase parental attitudes toward concussion in Korea [
18,
19]. In the United States, the “HEADS UP” campaign was launched after identifying a low concussion reporting [
20].
Our results of factors associated with concussion knowledge and attitude contrast with those of previous studies. Previous studies showed that parental demographics (sex, age, race, socioeconomic status, etc.), child age, and education about concussion were associated with knowledge of concussions [
8]. Our results did not show an association with parental demographics, other respondent characteristics, or their children between knowledge level and attitude regarding concussions. In particular, concussion-related hospital visits did not associate with parental knowledge. Nevertheless, medical advice obtained through concussion-related hospital visits was considered a potential facilitating factor for knowledge levels and attitudes regarding concussions; the reason for this lack of association is unclear. One possible explanation for this lack of association is the ineffective delivery of information regarding concussions. A previous study demonstrated that approximately 20% of parents were confused about when to return to the emergency department after evaluation for a head injury [
21]. Furthermore, 25% of parents could not recall specific discharge advice related to concussions even though they received written discharge instructions. These results emphasize the need for further investigation to determine how best to counsel the parents of pediatric concussion patients to improve parental knowledge.
Among the multivariable analysis results of this study, one that is similar to those of previous studies is that a career as a healthcare provider positively related to parental knowledge. This association seems natural because it is likely that concussions are included in job-related education and healthcare training.
This study had several limitations. First, as this study was an online survey, it was not possible to control the ability of participants to reference external sources such as books or search engines on the Internet. Before starting the survey, we asked participants not to refer to external sources. Second, this study used the concussion knowledge and attitude measurement tool, verified for validity and reliability in previous studies, which was translated into Korean. However, verification through a cultural adaptation for Korean participants was not conducted. Instead, the Korean version of the tool was modified based on pilot test feedback conducted by content experts and was distributed to participants so that they did not feel awkward answering the questions. Third, this study had an observational bias. Therefore, we could not adjust for details of the history of hospital visit-related concussions such as the time interval between hospital visits and surveys, route of hospital visits, institutional level of the hospital, and symptoms or signs of concussion at the time of the patient’s hospital visit. According to a previous study, the symptoms and signs of concussion were not significantly associated with participant concussion-related knowledge or attitudes [
15]. Finally, this study has a limitation in terms of generalization because the participants were not randomized.
In conclusion, this study confirmed the parental knowledge-attitude gap regarding pediatric concussions in Korea. Novel strategies are warranted to improve parental knowledge and attitudes toward concussions.
NOTES
-
Conflicts of interest
The authors have no conflicts of interest to declare.
-
Funding
This work was supported by a National Research Foundation of Korea (NRF) grant, funded by the Korean Ministry of Science and ICT (No. RS-2022-00166487).
-
Author contributions
Conceptualization: KOA, DWS; Data curation: HAP, KOA; Formal analysis: KOA, DWS; Funding acquisition: HAP; Methodology: JOP, HAP; Writing–original draft: DWS; Writing–review & editing: all authors. All authors read and approved the final manuscript.
-
Data availability
Data analyzed in this study are available from the corresponding author upon reasonable request.
SUPPLEMENTARY MATERIAL
Fig. 1.Score distribution of parental concussion-related (A) knowledge and (B) attitude.
Table 1.Characteristics of study participants (n=260)
Table 1.
|
Characteristic |
No. of participants (%) |
|
Sex |
|
|
Male |
157 (60.4) |
|
Female |
103 (39.6) |
|
Age group (yr) |
|
|
<30 |
53 (20.4) |
|
30–40 |
119 (45.8) |
|
>40 |
88 (33.8) |
|
Education level |
|
|
High school |
28 (10.8) |
|
Beyond high school |
232 (89.2) |
|
Presence of sons |
|
|
No |
72 (27.7) |
|
Yes |
188 (72.3) |
|
No. of children |
|
|
1 |
102 (39.2) |
|
≥2 |
158 (60.8) |
|
Experience of sports coaching |
|
|
No |
201 (77.3) |
|
Yes |
59 (22.7) |
|
Participant of sports activitiesa)
|
|
|
No |
80 (30.8) |
|
Yes |
180 (69.2) |
|
Career of healthcare provider |
|
|
No |
241 (92.7) |
|
Yes |
19 (7.3) |
|
Received concussion education |
|
|
No |
235 (90.4) |
|
Yes |
25 (9.6) |
Table 2.Participants’ knowledge of concussion (n=260)
Table 2.
|
Concussion-related knowledge question (answer) |
No. of participants (%) |
|
Total score |
21 (18–22.5)a)
|
|
Definition of concussion |
|
|
A concussion only occurs if an person loses consciousness (false) |
234 (90.0) |
|
Injured body location of concussion (brain) |
156 (60.0) |
|
Sign and symptom |
|
|
Things smell funny (false) |
148 (56.9) |
|
Things taste funny (false) |
164 (63.1) |
|
Problems remembering things (true) |
170 (65.4) |
|
Stiffness of joints (false) |
144 (55.4) |
|
Fuzzy vision (true) |
160 (61.5) |
|
Black eye (true) |
161 (61.9) |
|
Bleeding from the ear (true) |
151 (58.1) |
|
Bleeding from the mouth (false) |
173 (66.5) |
|
Bleeding from the nose (true) |
118 (45.4) |
|
Confusion (true) |
162 (62.3) |
|
Fever (false) |
143 (55.0) |
|
Dizziness (true) |
189 (72.7) |
|
Loss of consciousness (true) |
161 (61.9) |
|
Nausea (true) |
165 (63.5) |
|
Numbness in the arms (true) |
129 (49.6) |
|
Skin rash (false) |
216 (83.1) |
|
Weakness in neck movement (false) |
127 (48.8) |
|
Chest pain (false) |
181 (69.6) |
|
Trouble understanding things (true) |
151 (58.1) |
|
Consequence of premature return to physical activities from a concussion |
|
|
No bad things can ever happen (false) |
193 (74.2) |
|
One may be more likely to get another concussion (true) |
200 (76.9) |
|
Skin rash (false) |
215 (82.7) |
|
Brain damage (false) |
213 (81.9) |
|
Consequence of suffering multiple concussions |
|
|
No bad things can ever happen (false) |
211 (81.2) |
|
One may be more likely to get another concussion (true) |
211 (81.2) |
|
Skin rash (false) |
204 (78.5) |
|
Brain damage (true) |
230 (88.5) |
|
Problems remembering things (true) |
219 (84.2) |
Table 3.Participants’ attitude toward concussion (n=260)
Table 3.
|
Concussion-related attitude |
Score (7-point Likert scale) |
|
Total score (7–49) |
39 (34–43) |
|
How serious do you think it is when a person experiences a headache and dizziness after a blow to the head or body? |
5 (4–6) |
|
How important do you think it is for a person not to participate in physical activity when experiencing signs and symptoms of a concussion? |
6 (5–7) |
|
How important do you think it is to be informed about how concussions happen? |
6 (5–6) |
|
How important do you think it is to be informed about how concussions can be prevented? |
6 (5–7) |
|
How important do you think it is to know the steps to follow if a person has a concussion? |
6 (5–7) |
|
How important is it for a person to report possible concussion symptoms to a medical professional or caregiver? |
4 (3–5) |
|
Generally, there is not sufficient education about concussion. |
5 (4–6) |
Table 4.Results of multivariable ordinal regression analysis for parental concussion-related knowledge and attitudes
Table 4.
|
Variable |
Knowledge
|
Attitude
|
|
AOR |
95% CI |
AOR |
95% CI |
|
Sex |
|
|
|
|
|
Female |
1.000 |
- |
1.000 |
- |
|
Male |
0.665 |
0.402–1.101 |
1.750 |
1.065–2.874 |
|
Age group (yr) |
|
|
|
|
|
>40 |
1.000 |
- |
1.000 |
- |
|
<30 |
0.493 |
0.242–1.007 |
0.660 |
0.328–1.327 |
|
30–40 |
0.531 |
0.305–0.924 |
0.979 |
0.568–1.685 |
|
Education level |
|
|
|
|
|
High school |
1.000 |
- |
1.000 |
- |
|
Beyond high school |
0.585 |
0.273–1.251 |
1.319 |
0.622–2.796 |
|
Presence of sons |
|
|
|
|
|
Yes |
1.000 |
- |
1.000 |
- |
|
No |
0.798 |
0.460–1.385 |
0.766 |
0.445–1.319 |
|
No. of children |
|
|
|
|
|
≥2 |
1.000 |
- |
1.000 |
- |
|
1 |
0.988 |
0.590–1.656 |
1.266 |
0.762–2.106 |
|
Experience of sports coaching |
|
|
|
|
|
Yes |
1.000 |
- |
1.000 |
- |
|
No |
1.292 |
0.721–2.316 |
1.636 |
0.922–2.905 |
|
Participant of sports activitiesa)
|
|
|
|
|
|
Yes |
1.000 |
- |
1.000 |
- |
|
No |
1.549 |
0.876–2.739 |
1.092 |
0.626–1.902 |
|
Career of healthcare provider |
|
|
|
|
|
No |
1.000 |
- |
1.000 |
- |
|
Yes |
3.146 |
1.132–8.745 |
1.295 |
0.524–3.202 |
|
Received concussion education |
|
|
|
|
|
Yes |
1.000 |
- |
1.000 |
- |
|
No |
0.700 |
0.295–1.663 |
1.266 |
0.554–2.895 |
|
Concussion-related hospital visit |
|
|
|
|
|
Yes |
1.000 |
- |
1.000 |
- |
|
No |
0.820 |
0.478–1.407 |
0.620 |
0.365–1.053 |
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