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Concussion guidelines need to move from only expert content to also include implementation and dissemination strategies
  1. Caroline F Finch1,
  2. Paul McCrory2,
  3. Michael T Ewing3,
  4. S John Sullivan4
  1. 1Australian Centre for Research into Sports Injury and its Prevention (ACRISP), Monash Injury Research Institute (MIRI), Monash University, Clayton, Victoria, Australia
  2. 2The Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia 
  3. 3Department of Marketing, Faculty of Business & Economics, Monash University, Caulfield, Victoria, Australia
  4. 4Centre for Physiotherapy Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand
  1. Correspondence to Prof. Caroline Finch, Australian Centre for Research into Sports Injury and its Prevention (ACRISP), Monash Injury Research Institute (MIRI), Building 70, Monash University Clayton Campus, Melbourne, Victoria 3800, Australia; caroline.finch{at}monash.edu.

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Sport-related head injuries place a significant burden on the health service delivery systems needed to treat and assess them; the sport delivery systems responsible for providing safe sporting opportunities; and personally on the individuals who sustain them. The number of head injury occurrences, the anecdotally high levels of public concern about the risk of head injury in sport and the fact that there is so much public misinformation about their assessment, management and prevention1–3 make the prevention of sport-related head injury a health priority. The most recent international consensus statement on the management of concussion in sport stated that there is a need to develop guidelines, education resources and other health promotion approaches for the prevention of head injury and its adverse outcomes across all sports with a risk of serious head injury.4 However, while there is evidence that some educational resources and guidelines have been developed, these have had varying success because they have not incorporated social marketing approaches.2 ,3 ,5

The content of concussion prevention

Three meetings have developed international consensus and furthered the evidence base about the understanding and management of concussion in sport.4 ,6 ,7 The 2001 meeting defined concussion and recommended that management strategies be based on individualised clinical and cognitive recovery assessment post-injury.7 The 2004 meeting produced a standardised concussion assessment tool (the SCAT) to help medical personnel diagnose, assess and manage concussions; the concept of a concussion ‘rehabilitation’ protocol was introduced to facilitate a step-wise graded return-to-play programme.6 In 2008,4 the SCAT was modified to include an assessment of balance and more detailed screening of brain function (the SCAT2) and a brief sideline version was developed to help identify concussions on-site (PocketSCAT2). Management of concussion in specific subpopulations (eg, children) was also considered, with agreement that these injuries should be managed more conservatively than in elite athletes.4 The published statement was intended for use by healthcare professionals and others to assist them make the correct management and return to play decisions necessary when caring for concussed athletes of any age and level of play.

Guideline dissemination and uptake

Uptake by sports medicine professionals and professional sport

The major avenue for the dissemination of these guidelines has been through published consensus statements in leading peer-review journals aimed at sports medicine professionals.8 As a result, the 2008 statement4 now forms the basis of current concussion management guidelines throughout the world. It has been adopted and/or endorsed by the professional team sports associated with the: International Olympic Committee, Australian Football League, US National Football League, US National Baseball League, US Major League Soccer, US National Basketball Association, International Ice Hockey Federation, US and Canadian National Hockey Leagues, International Rugby Board, Australian National Rugby League, UK Horse Racing Association and Federation Internationale de Football Association. Unfortunately, when sports bodies have not enforced concussion guidelines, there has been very little penetration of concussion knowledge to, and best practice by, team doctors.9

Uptake in community sport

Similar guidelines, resources and prevention programmes have also been developed by several national organisations. For example, ThinkFirst Canada produced an educational video to educate youth hockey players about concussion risk in that sport.10 In New Zealand, the Accident Compensation Commission produced concussion cards and associated materials to distribute to players and their team management.11 The US Centers for Disease Control produced the ‘Heads-up: concussion in youth sports’ resource, which includes information sheets, posters, an iPhone application and training videos. While the CDC resources are comprehensive, they did not significantly improve concussion knowledge when mailed to family physicians.12

In Australian community rugby union,13 that 78% of players with suspected concussion did not receive return-to-play advice post-concussion and all who reportedly received correct advice also failed to comply with the IRB regulation requiring a 3-week stand-down. Twenty-three percent of surveyed community rugby coaches were either unaware or unsure of the Australian Rugby Union's concussion guidelines.14 These low levels of return-to-play advice received by players post-concussion, and the high level of non-compliance with enforcement of the return-to-play regulations, suggests that there has been low uptake of concussion guidelines in community sport. The reasons for this are currently unknown and could well be many.14

Increasing the reach and adoption of concussion guidelines

The challenge remains as to how to get the correct information about concussion management to players, coaches, parents, healthcare providers, etc. If consideration of the specific needs of those end-users is not considered from the outset when developing plans for message content, format and delivery, then it is highly likely that safety efforts that rely on this will fail.15–17 Most efforts to disseminate concussion guidelines to date have been from a clinical perspective on concussion assessment and management. This has meant little or no consideration of how to recognise and address the determinants of individual safety behaviours relevant for primary prevention. Nor has there been consideration of the broader contextual/ecological factors that influence sports participants’ accessing of injury prevention information, their perceptions of its value and relevance, and their responses to disseminated messages.18 ,19

Only recently have researchers begun to consider social marketing approaches and social media channels for concussion messages, as well as the quality of concussion-related information on internet sites.2 ,3 ,20 This situation is not unique to concussion prevention, however, as there have been extremely few, theory- or evidence-informed efforts to disseminate any form of sports safety guidelines or to determine their fit and relevance to end-user groups.19 ,21 ,22

Learning from health promotion and social marketing

Health promotion experts use many approaches to deliver public health messages and they recognise that successful message dissemination is complex.19 ,23 There is a whole body of research concerned with how behavioural interventions and messages should be optimally developed, packaged, transmitted and interpreted, as well as studies comparing different modes of message delivery or dissemination.19 ,23–25 Adverse health behaviours (eg, obesity and smoking) can be spread through social networks,26 ,27 highlighting the influence that an individual's social network has on their health-related behaviour. Traditional means of disseminating messages (eg, TV, newspapers, documents posted on internet sites for download, etc.) are unable to leverage the social interactions and connections underpinning social network-induced behaviour change, focusing as they do on one-to-many mass media, rather than on interpersonal and person-to-person (P2P) communication. The recent emergence of social media provides new opportunities for activating and cost-effectively leveraging existing digital social networks to motivate behaviour change,28 including in relation to sport-related concussion.2 ,3

Social media as a message dissemination channel

The term social media describes the tools and information technology platforms (eg, Facebook, Twitter) that people use to produce, publish and share content (eg, text, video, audio and photos) online to facilitate peer-to-peer interaction. Enabled by ubiquitously accessible and scalable communication technologies, social media substantially changes how organisations, communities and individuals communicate with each other.29 Social media has transformed communication to a new level of interaction where people are increasingly controlling the nature, extent and context of their information exchanges.30 Unlike traditional methods of message dissemination, it relies on high levels of consumer engagement, involvement, co-creation and P2P propagation.31

Despite its short history, the uptake of social media has been phenomenal. With such a large user-base, social media has unprecedented potential to garner large-scale social change and action.32 Individuals are now beginning to use social media to become informed about, and to share, health-related information.32 ,33 As a consequence, social media has begun to attract attention within the general health promotion literature28 and the sports medicine literature specifically,2 ,3 as a means of disseminating information and motivating health-related behaviour change.19 ,21 It is somewhat surprising, therefore, that no prior attention has been given to the design, development, dissemination and evaluation of appropriate sport concussion messages through social media to ensure that they reach their target audiences and lead to demonstrable improvements in safety practices.

To advance the field, research is needed into both the viral (P2P) and interactive components of social media campaigns for concussion prevention, as indeed for other sports safety measures. We need to know how best to encourage social media users to interact with each other and determine whether such interaction does result in the desired concussion attitude/behaviour change. But, interaction is only one element of a social media campaign. The messages must also be disseminated to the target group, and the campaign content must be deemed by them to be both engaging and relevant.

Analysis of the viral component is needed to maximise the reach of future campaigns by focussing on how best to seed and disseminate campaign content to individuals within a social network. It is likely that a mix of strategies will be needed to foster engagement in social media campaigns and that different information presentation formats could influence a campaign's viral spread. Research into the interactive component is critical for ensuring that the campaign content is received, processed and ultimately acted on by the intended end-users. Researchers will need to focus on their engagement with the campaign content and identification of strategies for best encouraging social interactions among the intended end-users; moderating these social interactions for optimal discourse; and confirming what level of direct ‘expert’ engagement there should be in the social interactions.

There would be considerable value in future concussion guidelines being produced and marketed in ways that are fully compatible with key social media formats—including specific versions with friendly content/format that would facilitate ease of transmission via different forms of social media, messages suitable for retweeting and formats that could be easily read on smartphone screens, etc. Moreover, the development of branded messages that incorporate references to key documents, such as the formal guidelines published in sports medicine journals, should help organisations and others avoid the need to rewrite key messages for distribution in different formats. Consideration should also be given towards moving beyond print-only guideline versions and incorporating high-quality videos, for example, through YouTube content, into broader dissemination strategies.

Moving beyond content expertise

The International Concussion in Sport Group is a group of largely clinical experts with clear expertise in the content of concussion guidelines and sports medicine. Many have high-level engagement with professional sport and peak sports bodies and the adoption of the guidelines by such organisations to date reflect this. However, adoption of safety messages and practices in community sport and outside of the professional sport context is necessarily more complex, and there needs to be recognition that there are several levels of influence that must also be considered because sports safety policy and practice requires action across all levels of the sports delivery setting.34

It is well known that the availability of evidence-informed guidelines (clinical or otherwise) does not guarantee their uptake and adoption. Although the concussion guidelines have always recommended the development of education and knowledge transfer strategies, there appears to have been no coordinated effort to develop and evaluate such approaches to date. It has been stated that the International Concussion in Sport group will be responsible for improving the implementation of the guidelines.35 However, it is now clear that content experts alone cannot take sole responsibility for the dissemination and adoption of guidelines and expect this to be successful. A more realistic goal would be for the International Concussion Guideline Consensus content experts to take a lead role in advocacy for improved dissemination and adoption of their guidelines. At the same time, they should initiate and actively engage in new partnerships with others, including appropriate end-user representation, to ensure that the much-needed implementation and dissemination strategies are achievable.15–17 There would also be considerable value in bringing together researchers with experience in social marketing, behaviour change and social media use with those with direct expertise in preventing and managing concussion in sport.21 In effect, we would benefit from a clearer division of labour between content generation and content dissemination.

References

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Footnotes

  • Contributor CFF led the development of the item. Each of the co-authors contributed content and editorial input into the manuscript.

  • Funding CFF was supported by an NHMRC Principal Research Fellowship (ID: 565900) and PMc was supported by an NHMRC Practitioner Fellowship. The Australian Centre for Research into Injury in Sport and its Prevention (ACRISP) is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the International Olympic Committee (IOC). This work arose from research conducted through a Victorian Sports Injury Prevention Research Grant from the Department of Planning and Community Development, Victoria, Australia.

  • Competing interests PMc currently receives financial research support from the National Health and Medical Research Council, the University of Melbourne, Victorian Department of Planning and Community Development, Sport and Recreation Division and the Eastern Health Network. Previous competitive grant funding includes the Australian Research Council, International Rugby Board, the University of Melbourne, the University of Otago (NZ), National Hockey League (US), VicHealth, Australian Football League Research Foundation, Royal Australasian College of Surgeons and the Australian Sports Commission. He has a clinical and consulting practice in neurology and sports medicine involving individuals who have sustained concussion and TBI. He has received travel funding from the Medical Commission of the International Olympic Committee (IOC), the International Football Federation (FIFA), the American Academy of Neurology and the Jockey Club (UK). He receives book royalties from McGraw-Hill and from 2001 to 2008 was employed by the British Medical Journal Publishing Group. He has conducted clinical drug trials on antimigraine (Glaxo-Welcome; Janssen-Cliag; Novartis; Parke-Davis; Schering) and antispasticity drugs (Ipsen) through the Eastern Health Clinical Trials Unit in Melbourne. This drug trial work has not involved any financial payment to PMc directly. He received consultancy fees from Axon Sports (USA) for the development of educational material (in 2010 which was not renewed) and has received support since 2001 from CogState Inc. for research costs and the development of educational material. He is a cofounder and shareholder in two biomedical companies involved in eHealth and sports compression garment technologies and does not hold any individual shares in any company related to concussion or brain injury assessment or technology.

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