Community-Level Inequalities in Concussion Education of Youth Football Coaches

  • Emily Kroshus
    Address correspondence to: Emily Kroshus, ScD, MPH, Department of Pediatrics, University of Washington, 2001 8th Avenue, Suite 400, Seattle WA 98121
    Department of Pediatrics, University of Washington, Seattle, Washington

    Seattle Children’s Research Institute, Center for Child Health, Behavior and Development, Seattle, Washington

    Harborview Injury Prevention and Research Center, Seattle, Washington
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  • Zachary Y. Kerr
    Department of Exercise and Sport Science, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina
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  • Joseph G.L. Lee
    Department of Health Education and Promotion, College of Health and Human Performance, East Carolina University, Greenville, North Carolina
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Published:February 10, 2017DOI:


      USA Football has made the Heads Up Football (HUF) concussion education program available for coaches of youth football players. Existing evidence about the effectiveness of the HUF coach education program is equivocal. For HUF and other programs, there is growing concern that even effective interventions can increase inequalities if there is different uptake or impact by SES or other demographic factors. Understanding how adoption is patterned along these lines is important for understanding equity issues in youth football. This study tested the hypothesis that there will be lower adoption of HUF among coaches of youth football players in lower-SES communities.


      The authors conducted a cross-sectional study of the association between community-level characteristics and number of USA Football youth league coaches who have completed HUF. Data were collected in 2014 and analyzed in 2015–2016.


      Implementation of the HUF program was patterned by community-level socioeconomic characteristics. Leagues located in communities with a higher percentage of families with children aged <18 years living below the poverty line and a smaller percentage of non-Hispanic white residents tended to have leagues with smaller percentages of HUF-certified coaches.


      As interventions are developed that reduce the risks of youth football, it is important to consider not just the effectiveness of these interventions, but also whether they reduce or exacerbate health inequities. These results suggest that relying on voluntary adoption of coach education may result in inequitable implementation. Further study is required to identify and remedy organizational and contextual barriers to implementation of coach education in youth sport.
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