The National Football League and Center for Disease Control and Prevention’s Public Service Announcement on Concussions:Missing the Mark– Jenna Carter

Introduction

According to the Centers for Disease Control and Prevention, an estimated 1.7 million traumatic brain, TBIs, of mild to moderate severity, most of which can be classified as concussions, (i.e., conditions of temporary altered mental status as a result of head trauma), occur in the United States each year. And, an estimated 135,000 sports related TBIs are treated in the emergency, among children five to eighteen years old. (1) Now, imagine if this happened to an athlete during a game or competition and they returned to that contest the same day without proper care? That has been the reality in many sports, but specifically in the National Football League until the end of 2009, when pressure was being placed on NFL commissioner, Roger Gooddell, by the House Judiciary Committee for their lack of action when it comes to head injuries to their players. In fact, during their hearing in October, the NFL’s concussion methods, or lack thereof, were being analogized to those of the tobacco industry’s methods when it came to tobacco causing cancer a few decades ago, by Representative Linda Sanchez (D-California). (2, 3) This hearing was called for following an internal study, announced by the NFL, which showed that NFL players who had suffered from head injuries are more susceptible to higher rates of dementia and cognitive decline than the rest of the population. (3) The NFL had been ultimately accused of ignoring the research linked to long term health problems caused by head injuries suffered by their players, but that is a different argument in itself. The news of this hearing arguably sent waves through the sport of football.

In an effort to combat the problem and finally take head injuries suffered by players seriously, the NFL, with the assistance of their newly formed “mild traumatic brain injury” committee, has come up with some proposed changes in its approach to make the sport safer. One effort was creating a public service announcement put together by both the NFL and the Centers for Disease Control and Prevention, released in December. (4,5,6) (You Tube) The intent was to debut this 30-second PSA during a Thursday night NFL game on the NFL Network and continue airing it during the commercial breaks of specific NFL games until the end of the 2009 season, including the Super Bowl (5).

There are several arguments that can be made as to why this effort will not be successful in its attempt to shed light on the issue of head injuries in sports due to several reasons. It is not persuasive, lacks the facts, and created a message of forceful change.

1.PSA frames message about concussions negatively and takes freedom to choose away

According to the Ad Council, who is a leading creator of PSAs in the United States, the most critical aspect of creating awareness in advertising is to “mobilize” the public and “make lasting positive social change”. (7) In this case, the NFL totally missed the mark. The PSA sounds like it should be an advertisement for a horror film, not a public health announcement. There is a man who speaks in a chilling voice about the problem of concussions and says, “Concussions and head injuries must be taken seriously”. He then states, “If you’re a player, protect yourself and your teammates. If you think you’re hurt, don’t hide it, report it, and take time to recover. If you’re a coach or parent, know concussion symptoms and warning signs and never let an athlete return to play before a health professional says it’s ok. Help take head injuries out of play.” At that point, it is mentioned that the CDC should be contacted for more information. (3) In addition to the terrifying voice, the music being played in the background could be associated with a horror movie soundtrack, such as “Jaws”.

To frame a message so that it has characteristics of persuasion, it is necessary for a message to grab the audience’s attention and it must be easy to understand so there is a sense that the audience would “get it”. The content must also be relevant to the receiver of the message and give them reason to think or talk about it. (8) It can certainly be argued that this message may have grabbed hold of some of its audience, but not enough to keep their attention.

In 1986, the elaboration likelihood model, which was outlined by Richard Petty and John Cacioppo, proposed that there are two routes a message can take to change a person’s attitude or behavior, the central route and the peripheral route. The central route requires careful scrutiny of an argument presented in a message that appeases to people who enjoy thinking through the logic of statements. (8) In other words, the message needs to be presented by a source that is credible and forms a compelling logical argument. The peripheral route focuses on the overall feeling that one would get from the message, rather than thinking critically. For example, the basis of this would be whether or not the character in the message is likeable or having a catchy slogan. (8) Obviously, the CDC is a very credible source and it was smart for the NFL to partner with them in this message. However, there is nothing likeable about how the message is delivered and doesn’t even offer a reasonable argument. In addition, this short announcement doesn’t offer any motivation or reason to support it’s plead. Why should the athlete report that they’re hurt? What is going to happen to them? What are the warning signs that a player needs to be treated by a health care professional? There is no information given that cites the dangers of concussions or any possible long-term effects. The implication of the announcement is clear, that concussions and brain injuries need to be taken seriously, but there is no evidence that gives viewers a reason to buy into the message and therefore, know which symptoms to report. (5)

Another point to add to this argument lies in Psychological Reactance Theory, where a person is not going to change just because they are told to do so. By approaching it in this way, the target audience may feel threatened that are losing their freedom to choose (“you must take concussions and head injuries seriously”) and in turn, try to find a way to restore that freedom. . (9) A large part of the target audience are teenagers and they like to rebel. This is a large reason why many anti-smoking campaigns were not successful, which will be covered later. (10) Also, with the message lacking support to back up the claim that symptoms must be reported and lacking attractiveness to the advertisement, there would be no reason for anyone in the target audience to follow through.

2. Assumes that the athlete, parent, or coach will do the research by putting owness on them rather than giving the facts in a compelling way

Not once during the PSA, did it mention what the symptoms of a concussion or head injury are, nor does it advice potential consequences of not reporting this type of injury. Ultimately, this advertisement imposes the work of doing research on its audience by stating they should go to the CDC for more information. It is clear that the athlete, parent, and coach must know or find out what the symptoms of a head injury are and then take responsibility for reporting it and lastly, taking the necessary precautions. Based on Social Marketing, there is a related principal, which is to take complete responsibility for the customer’s (i.e. athlete, parent, coach) satisfaction with the product and to not take for granted that they will have the ability, knowledge, and skills to put that product to use. In this case, the product would be the dangers of concussion and head injuries. (11) This would have been a tremendous opportunity for the NFL to make clear as to why they are sending the message and it’s importance in order to compel their audience to take action.

It also poses another dangerous problem in that; there may be a lack of communication between the athlete, parent, and a coach. It is very possible that an athlete may believe that his or her parent/guardian will do the research and educate them on the issue or for the parent/guardian to guess the same about the coach’s responsibility. In essence, there is a lack of clear direction that could potentially continue the risk of an athlete going forward. There should be a separate targeted message to all three populations.

Furthermore, here is nothing stated about the health consequences of not reporting a head injury, such as cognitive decline, Chronic Traumatic Encephalopathy (CTE), or Second Impact Syndrome. Research has shown that the most cognitive impairments following a concussion are related to visual motor reaction time and information processing, memory, and attention. (12) CTE is a degenerative brain disease that is caused by head trauma and is neuropathologically related to Alzheimer’s disease. According to research from the Center for the Study of Traumatic Encephalopathy at Boston University School of Medicine, this had been a disease only linked to boxers, but more recently, in other athletes. (13) Lastly, Second Impact Syndrome is a condition that occurs from a second and recurring concussion, which causes vascular congestion and increased intracranial pressure, and can be very difficult, if not, impossible to control, and potentially be fatal. This is more likely to occur if there isn’t complete recovery from a previous concussion. (12)

If the NFL justly wants to be the leader on this issue, it should at the very least, disclose the facts, symptoms, precautions and risks of concussions in the actually PSA, rather than asking the players, parents, and coaches to do their own research.

3. Assumes the athlete will report symptoms of a head injury Football is a well known “hitting” sport and it seems the harder the hit, the tougher the play or player, and the more entertaining the sport. Football has a persona that you must be tough to play and because of that stigma and perception, athletes will most likely never divulge that they are hurt. This is the most obvious critique of NFL’s approach to get the message out about the importance of concussions and head injuries. Children who grown up playing sports are always taught to “suck it up and play” so why would this change now? In fact within the NFL itself, nearly one-fifth of the one hundred sixty players surveyed by The Associated Press from November 2-15 replied that they have hidden or played down the effects of a concussion. This survey was done to assess what the players are really revealing in association with the NFL’s new concussion policy that was launched in December stating that a player may return to game play if they don’t have persistent symptoms after passing a neurological exam. (14) While this policy has it’s own challenges (i.e. players not wanting to get sidelined, fear of losing their job/position ranking and not getting paid, etc…), the PSA assumes the same for younger athletes as well.

To persuade athletes, parents, and coaches to change this engrained belief, and genuinely accept the message, there needs to be a connection to the audience or someone they can relate to. There is nothing for the target audience to connect with and in turn, urge individuals to genuinely accept the message and be persuaded to change this learned principal. To do this, the NFL must be keyed into the mindset of their target audience. (8) And attitudes such as Hines Ward from the Pittsburgh Steelers, when his teammate, Ben Roethlisberger had to sit out a game due to his recent concussion, when he said “I could see some players or teammates questioning, like, ‘It’s just a concussion. I’ve played with a concussion before.’ It’s almost like a 50-50 toss-up in the locker room. Should he play? Shouldn’t he play? It’s really hard to say. I’ve been out there dinged up. The following week, got right back out there”. is a great example of that stigma. (15)

The Proposed Intervention

In order to effectively prevent long-term health problems for athletes due to traumatic head injuries, players need to feel that they have the freedom to make decisions that will affect their lives. In the same sense, the parents and coaches need to have the correct information about signs, symptoms, and warning signs of concussions and what proper treatment needs to be given to the injured athlete so they can assist with proving education. As mentioned earlier, it is important that the message be relatable to the target audience, framed in a positive way so that it’s persuasive, and needs to be compelling to captures their attention. While the risks of concussion need to be known, it is important to portray the message of having the freedom to choose whether or not the consequence is worth it to the athlete. This can be done using an effective media campaign.

1.Message needs to be delivered to a more specific target audience to grab their attention in a compelling way

The “truth” campaign, that was launched in the year 2000 developed into one of the most successful and effective anti-smoking campaigns in U.S. history. Ads such as displaying 1,200 body bags laid out on the street, which covered two city blocks, as visual evidence as to how many people tobacco kills everyday was extremely eye catching. And, it was this sort of campaign message that inspired teenagers, the intended target audience, not to smoke. (10) It can be argued that the NFL is moving down the same road as tobacco industry giant Phillip Morris, when they made a failed attempt to release their own set of ads around the same time as the “truth” campaign. They’re slogan, “Think. Don’t Smoke.” was not so successful at changing the behaviors of teens. It portrayed a message of taking away a teenager’s freedom to choose. In fact, according to research published in the American Journal of Public Health in 2002, teens that were exposed to “truth” commercials were sixty six percent less inclined to smoke than those who saw the “Think. Don’t Smoke.” advertisements, which interestingly enough, had the opposite effect on a teen, who were more inclined to smoke by thirty six percent. (16)

To make this media campaign more effective, the target audience would need to be divided into three separate groups; athletes, parents, and coaches. Successful social marketing campaigns, similar to the media campaign used in Oklahoma County to combat one of their greatest public health problems, Syphilis, focused on delivering a specific message to a specific part of the population to change a specific behavior. Another approach using Social Marketing, allows the message and strategy to actually come from the target audience, increasing the effectiveness of the message instead of an expert view, who may have opinions and knowledge about the matter at hand, but are not actually part of the population that is affected. (17)

Formative research needs to be done to find out what makes each of the target audiences tick. This helps those planning a campaign produce messages that ring with the audience it is attempting to change their behavior. (10) One of the reasons why the “truth” campaign was so successful was due to the research done by those spearheading the campaign in order to directly relate to teens. They found that teenagers were looking for the facts and then wanted to be left to make their own decision. What they also learned in the investigation process was that a youth’s reasoning for tobacco use had nothing to do with making rational decisions, but rather everything to do with emotion. (10)

2. Encourage athletes, parents, and coaches to do more research based on evidence shown in the media campaign

Supporting what can happen from too many concussions or not taking proper care when they occur may be very powerful, so much that it would prompt additional research by the specified target audience. For example, a prevailing story is that of former San Francisco 49ers linesman George Visger. He now lives his life and has been for more than 20 years, using hundreds of small yellow notebooks. This is because of dementia, a condition he has acquired as a result of too many concussions, and he is forced to write down everything he does in a given day so he doesn’t forget. By him delivering the message that this is what his life has become and stating that he believes he had hundreds, maybe even thousands, of concussions from Pop Warner football all the way through his professional football career, there is no denying this would be an impactful message. (18) A case like George’s and showing his family and what they are left to cope with, could be targeted toward the parents to show how the potential of suffering from the consequences of repeated head trauma to their loved one.

For coaches, using a former NFL player who has suffered from concussions during his career and had a story about how a coach intervened or in some cases failed in this action, could serve as a strong spokesperson in targeting them, and compel them to be more involved in doing the same. Kurt Warner, the former St. Louis Rams, and most recently Arizona Cardinals quarterback, just retired from the NFL and is known for suffering from sustaining concussions. During a recent interview, he was quoted as saying; “I can tell you I wrestled with it when I was going down to that room to talk to them (before the game), saying, ‘Do I not want to tell them everything so I can play?’ But I had to go, ‘What are you thinking? This is bigger than that.’ The easy thing to do is play. The hard thing is to make that decision where you feel like you could be hurting your team, but you don’t know whether you’re putting yourself at risk or not.” (15) This is an important part of his story because most likely, this kind of thought goes through the mind of a player and it’s important that a coach keep that in mind. It may just be easier for a coach to step in and tell the athlete they are not allowed to return to play until cleared by a health professional.

Specific to children and teens, said Lisa Unsworth, the executive vice president of the Boston-based ad agency who is responsible for a separate state government sponsored anti-drug ad campaign, “Kids think they will live forever. Talking about a disease you may get when you’re 50 or 60 isn’t a compelling motivator.” (18) So, if this is true, then the evidence needs to be seen in a young athlete, someone like John Doe, whose name his parents asked to remain anonymous, was a multi-sport athlete, who suffered from multiple concussions and died at the age of 18. His brain was donated to the Center for the Study of Traumatic Encephalopathy (CSTE) at Boston University, who collects and studies the brain and spinal cord tissue of deceased athletes to gather more information and evidence on the effects of trauma to the human nervous system. John Doe, the youngest brain at the CSTE Brain Bank, was already showing signs of CTE, which was defined earlier. (19) This may motivate children and teens to re-think they’re attitude that they are invisible to this type of hazard.

3. In order to encourage athletes to report symptoms, the culture needs to change

This is where the NFL can set the bar and make the most impact. They can serve as the role model for not just college, high school, and Pop Warner football, but all of sports to achieve a trickling down effect. Fortunately, they are now really taking the issue seriously. In December, Roger Gooddell sent a memo to all NFL teams informing them of a new concussion policy where, if a player has symptoms of amnesia, poor balance and an abnormal neurological examination; they are required to be removed from a game. A player can return to the field with symptoms of dizziness and headache, but only if they are not “persistent”. Formerly, players could return to a game or practice once their symptoms subsided, assuming they actually reported it. (20) Most recently, the NFL formed a new “mild traumatic brain injury” committee and Roger Goodell hired two new chairman for this panel, Dr. H. Hunt Batjer, the chairman of neurological surgery at Northwestern Memorial Hospital in Evanston, Ill., and Dr. Richard G. Ellenbogen, the chief of neurological surgery at Harborview Medical Center in Seattle. Unlike the previous chairmen, who were paid by the NFL, which consequently, was considered a conflict of interest, the NFL, except for costs associated, will not pay these two doctors. (4) Other changes that are being looked at for future policies are banning helmet-to-helmet hits on ball carriers, roster exemptions for a player suffering from a concussion, stricter guidelines for practice that would limit the amount of hits, new helmet design, and a possible removal of the three point stance in the line of scrimmage. (20,21)

Instilling change is not easy and takes time. Being persistent and planning for a long time frame is necessary. If you consider the lessons learned from some of the cardiovascular risk reduction programs, it may take up to ten years for an effective distribution of new policies and ideas to produce social change that is measurable. (11)

Conclusion

While the NFL is taking other measures to make the game of football safer and implementing new policies for when a player is injured, they have a crucial opportunity to be the leader and send a clear and successful message to those athletes in any sport. They seem to be taking a positive step in the right direction and acting as the future role model to combat the traumatic brain injury problem. They just need to do a better job of delivering that message to instill change across the sports world.

References

1. “Traumatic Brain Injury” Centers for Disease Control and Prevention accessed from http://www.cdc.gov/TraumaticBrainInjury/index.html
2. “Conveyers Plans Hearings on NFL Player Injuries” US House of Representatives Committee on the Judiciary (2009) Accessed from http://judiciary.house.gov/news/040908.html
3. Daneil Kain “NFL’s Work on Concussions Far From Over” National Football Post, (1/4/2010) Accessed from http://www.nationalfootballpost.com/print.html&post=NFLs-work-on-concussions-far-from-over
4. Alan Schwarz “N.F.L. Picks New Chairmen for Panel on Concussions” New York Times, (3/17/2010) Accessed from www.nytimes.com/2010/03/17/sports/17concussions.html
5. National Football League and Centers for Disease Control and Prevention Head Injuries PSA You Tube Accessed from http://www.youtube.com/watch?v=NhgIfWl40m4
6. Christopher Wanjek “NFL Tries to Get Serious on Concussions” Fox News (12/15/2009) Accessed from http://www.foxnews.com/story/0,2933,580268,00.html?sPage=fnc/health/neurology
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12. Brain Injury in Sports Brain Injury Resource Center Accessed from http://www.headinjury.com/sports.html
13. Terry Zeigler Chronic Traumatic Encephalopathy: Possible Consequence of Recurrent Concussions, (June 2009) Accessed from http://sportsinjuries.suite101.com/article.cfm/chronic_traumatic_encephalopathy
14. Associated Press NFL changes return-to-play rules ESPN, (2009) Accessed from http://sports.espn.go.com/espn/news/story?id=4707604
15. Chris Nowinski Written Testimony Before Committee on the Judiciary United States House of Representatives Hearing on “Legal Issues Relating to Football Head Injuries, Part II”, (January 2010) Accessed from http://judiciary.house.gov/hearings/pdf/Parrish100104.pdf
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18. Stephanie Smith Ex-NFL players feel concussions’ long-lasting damage CNN, (2010) Accessed from http://www.cnn.com/2010/HEALTH/02/05/concussions.visger.football/index.html
19. Center for the Study of Traumatic Encephalopathy at Boston University Accessed from http://www.bu.edu/cste
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