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

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.