Downloaded from http://journals.lww.com/jphmp by BhDMf5ePHKbH4TTImqenVE5wmW8EcRnjTit/5KGRbXPFlJyyQK9RnlJg6W8VmphA on 03/14/2020 Research Full Report Putting Policy Into Practice: School-Level Compliance With and Implementation of State Concussion Laws Lindsay Sullivan, PhD, MA; Hosea H. Harvey, PhD, JD; Gary A. Smith, MD, DrPH; Jingzhen Yang, PhD, MPH ABSTRACT Context: Each year, approximately 2 million US children 18 years or younger sustain a concussion, a type of mild traumatic brain injury (TBI). Concussions can have detrimental effects on physical, cognitive, emotional, or sleep health. Policy: Between 2009 and 2014, all 50 US states and Washington, District of Columbia, enacted state concussion laws aimed to increase awareness about concussion and reduce the prevalence and severity of this injury. Most state laws include the following core tenets: (1) immediate removal from play after an actual or suspected concussion; (2) medical clearance before an athlete can return to play (RTP); and (3) concussion education for athletes, parents, and coaches. Implementation: State concussion laws allow for substantial interpretation at the school level, resulting in considerable variation in the content of school written concussion policies and the level of implementation of state law requirements at the school level. Evaluation: We assessed the degree of high school written concussion policy compliance with the respective state law and examined the relationship between concussion policy compliance and school-level implementation of concussion laws. Seventy-one school of fcials completed a semistructured telephone interview and submitted their school’s written concus- sion policy. Of the 71 policies analyzed, most complied with the removal-from-play, RTP, and concussion education tenets (90.1%, 97.2%, and 76.1%, respectively). The majority of participants reported that their school implemented the removal- from-play (91.5%), RTP (93.0%), and concussion education (80.6%) tenets well or very well. No signifcant relationships were found between researcher-rated school policy compliance and school-reported implementation of state law require- ments at the school level. Discussion: Our fndings suggest that most participating schools complied with their state concussion law and imple- mented law requirements well or very well. Future studies should identify facilitators and barriers to the implementation of state concussion laws at the school level. KEY WORDS: compliance, concussion, concussion laws, high schools, implementation C oncussion, a type of mild traumatic brain in- jury (TBI) induced by biomechanical forces, often results in the temporary impairment of neurological function. 1 An estimated 1.1 million Author Affliations: Center for Injury Research and Policy, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, Ohio (Drs Sullivan, Smith, and Yang); formerly Beasley School of Law, Temple University, Philadelphia, Pennsylvania (Dr Harvey); and Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio (Drs Smith and Yang). This work was supported by the Robert Wood Johnson Foundation grant no. 30822. The authors thank High School Reporting Information Online (RIO) and the athletic directors and athletic trainers who participated in this study. This study would not have been possible without you. The authors declare that they have no conficts of interest. Correspondence: Jingzhen Yang, PhD, MPH, Center for Injury Research and Policy, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, RBIII-WB5403, Columbus, OH 43205 (Ginger.Yang@nationwidechildrens.org). Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/PHH.0000000000001128 to 1.9 million sports- and recreational-related con- cussions occur in US children 18 years or younger each year. 2 Concussions may present with a wide ar- ray of signs and symptoms including impairments in cognitive, behavioral, physical, emotional, or sleep health. 1,3,4 An untreated or improperly managed con- cussion can lead to intensifed symptoms, prolonged recovery, as well as subsequent and more severe injury. 5-8 Evidence also suggests that concussion can lead to long-term health consequences such as de- creased cognitive function, increased rates of depres- sion, and dementia. 7,9 Given the morbidity associated with concussion, a national conversation has commenced regarding what can be done to increase concussion awareness and reduce the prevalence and severity of this in- jury, especially among young athletes. One approach to combat this public health issue is the passage of youth sports concussion laws. In 2009, Washing- ton State enacted the nation’s frst statewide law re- garding concussion safety (ie, the Lystedt law). 10,11 Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. S84 www.JPHMP.com March/April 2020 • Volume 26, Number 2 Supp