Date of Award


Document Type

Campus Access Dissertation

Degree Name

Doctor of Philosophy (PhD)



First Advisor

Laura L. Hayman

Second Advisor

Sarah J. Miano

Third Advisor

Teri Aronowitz


Objective: The major purpose of this cross-sectional, descriptive, and explanatory survey research was to assess key school personnel’s perceptions of barriers to and facilitators of implementation of the Massachusetts (MA) policy on youth sport-related mild traumatic brain injury (mTBI) to guide, inform, and increase awareness of implementation of this policy.

Background: Mild TBI is a serious public health concern. A legislative act aimed at educating those directly involved in interscholastic youth sports on the potential severity of mTBIs was established in MA on August 19, 2010. This act establishes and mandates that key personnel in all MA public schools and all other schools under the MA Interscholastic Athletic Association (MIAA) umbrella attend a head injury safety-training program. The policy also requires that any athlete with a suspected or actual TBI be removed from play immediately, not to return until given written consent from an authorized healthcare provider (a licensed physician, nurse practitioner, physician assistant, neuropsychologist, or athletic trainer).

Methods: An investigator-designed survey was completed by key personnel at all MA public schools and those private schools that are members of the MIAA using a web-based survey (hosted by Survey Monkey). Quantitative data was analyzed using descriptive statistics. Three open-ended survey questions were analyzed using qualitative thematic content analysis.

Results: Respondents (N=171) reported perceived facilitators and barriers to implementation of the MA policy on youth sport related mTBI. The web-based survey methodology and the indirect access to the schools’ key personnel likely contributed to the low response rate (<32% of all schools contacted) for this study. Key school personnel were largely aware (93.59%, N=146) of the MA policy on youth sport-related mTBI, and similarly most respondents (92.31%, N=144) reported being aware of the DPH regulations established to enforce the policy. Most respondents (83.09%, N=113) reported that they believe their colleagues are aware of the policy, and 78.67%, N=107 believed that coaches are compliant with the policy. A smaller majority of respondents (66.17%, N=90) believed athletes are compliant with the policy, and roughly half of the respondents (55.14%, N=75) believe parents also comply with the policy. Themes that emerged from the open ended questions included a perceived need for increased communication and education from the MA DPH to school personnel, coaches, athletes, parents, and healthcare providers, a belief that the reporting requirements are complex and burdensome and would benefit from simplification and clarification, as well as a call for improved technology to standardize the data collection and storage.

Conclusions: Access to training courses online and availability of handouts and other materials provided by regulatory agencies, as well as internal standardized processes and teamwork within each individual institution were perceived by respondents as facilitators to implementation of this policy. Perceived barriers to implementation of the policy were the lack of compliance from parents and students, a burdensome volume of required documentation, and healthcare provider inconsistency in diagnosis and recommendations.

Implications: The results of this study can be used to inform future research as it revealed concern regarding the complexity of the regulations, the burden of the requirements, and the lack of utilization of technology. A larger sample size and a methodology allowing for direct access to key school personnel would improve generalizability and transferability of findings.


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