Abstract
Background and aims
Within adolescent female rugby union, various effective injury prevention strategies are available to players to mitigate injury. However, little is known regarding the players’ attitudes, beliefs and behaviours towards those strategies, as well as injuries. The primary aim of the study was to investigate the attitudes, beliefs, behaviours and injury-reporting behaviours of adolescent female rugby players regarding injury and injury prevention strategies. The secondary aim was to examine associations between individual factors (eg, player demographics) and injury-reporting behaviours.
Methods
Participants completed an online cross-sectional survey and were recruited from under-16 and under-18 rugby teams in schools/colleges, clubs and developing player pathway programmes in England.
Results
1062 players were contacted to participate, 424 responded and 422 met the eligibility criteria; 79 participants had incomplete responses. 14% of players had not previously reported a suspected concussion to a coach/medical staff member, and 37% of players had previously not reported sustaining one or more musculoskeletal (MSK) injuries to a coach/medical staff member. Factors cited for non-disclosure of concussion and MSK injuries included not wanting to miss rugby sessions (43% and 39%) and not knowing that symptom(s) were related to an injury (11% and 17%). Players held positive attitudes, beliefs and behaviours towards injury and injury prevention, but their understanding of the effectiveness of protective equipment varied.
Conclusion
This study provides a greater understanding of adolescent female rugby players’ attitudes, beliefs and behaviours towards injury and injury prevention and aids in the development of effective injury prevention initiatives.
Keywords: Rugby, Injury, Prevention, Concussion
WHAT IS ALREADY KNOWN ON THIS TOPIC
To implement effective injury prevention strategies, it is crucial to consider the context in which strategies are being implemented. This includes the attitudes, beliefs and behaviours of the players, who are the end-users of injury prevention strategies and can often act as barriers and/or facilitators of implementation.
Currently, little is known about the attitudes, beliefs and behaviours of adolescent female rugby players regarding injury, injury prevention and injury-reporting behaviours.
WHAT THIS STUDY ADDS
14% of players had previously not reported a suspected concussion to a coach/medical staff member, and 37% had previously not reported a musculoskeletal (MSK) injury. Factors cited by players for not reporting their suspected concussions and MSK injuries to coaches/medical staff members included not wanting to miss rugby sessions and not knowing symptom(s) were related to an injury.
Players held positive attitudes, beliefs and behaviours towards injury and injury prevention strategies.
The understanding of protective equipment effectiveness varied, as some players considered mouthguards and scrum caps effective in preventing concussions.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
This study highlights the need for targeted educational initiatives to enhance players’ knowledge of injury symptoms and injury prevention strategies, as well as to improve the culture surrounding injury reporting behaviours.
The study’s findings provide current and future injury prevention strategies with an understanding of players’ attitudes, beliefs and behaviours, which in turn can help to tailor injury prevention strategies specific to adolescent female rugby players.
Introduction
Injuries and concussions are more common within adolescent rugby union (hereafter rugby) than in non-contact sports due to the contact within rugby.1 In adolescent female rugby, injury incidence rates (IRs) are as high as 93.7 injuries/1000 match hours (95% CIs: 78.6 to 111.7).2 Concussion IRs are as high as 37.5/1000 match hours (CI: 26.8 to 52.3),2 higher than those reported in some adolescent male rugby studies (57.9/1000 match hours, 95% CI: 45.4 to 73.8).3 Sustaining either a concussion or musculoskeletal (MSK) injury may lead to acute and/or long-term symptoms and outcomes; symptoms for either concussions and/or MSK injuries may include pain,4 while outcomes include temporary removal from physical activity.5 Long-term consequences of a concussion or MSK injury could include reduced levels of physical activity,6 while an MSK injury may result in osteoarthritis.7 8
Various injury prevention strategies have been made available to rugby players to mitigate injuries, including neuromuscular training (NMT) warm-up programmes,9 player protective equipment,10 law and policy changes11 (eg, reducing the tackle height in community rugby12) and educational initiatives.13 However, to optimise the effectiveness of injury prevention strategies so that they are more readily adopted, players’ attitudes, beliefs and behaviours towards injury and injury prevention strategies should be considered.14 Understanding the context in which injury prevention strategies are used is critical to aid in their implementation.15 Arguably, there is a need for injury prevention strategies to be implemented within adolescent female rugby, due to high injury IRs.2
Historically, research on players’ attitudes, beliefs and behaviours across various sports has focused on concussions.13 14 A recent study reported that female rugby players in the UK demonstrated good knowledge of concussion symptoms, but that 41% of players admitted to not disclosing a suspected concussion.16 Though factors related to player non-disclosure of a suspected concussion were not reported.16 Within community rugby league, 43% of players (≥18) disclosed having not previously reported a suspected concussion, citing ‘not wanting to be ruled out of a match’ (25%) as the main factor for non-disclosure.17 These findings are concerning as players may be putting themselves at an increased risk of prolonged recovery and worsening of concussion symptoms.18
Despite a few studies focusing on non-concussive injuries and prevention of MSK injury, non-disclosure of suspected MSK injuries among adolescent athletes has been reported as high as 77%.19 While 73% of female rugby players reported having ‘failed to report a non-concussive injury to keep playing’.16 MSK injuries pose acute and/or long-term issues4 5; thus, it is concerning that MSK injury non-disclosure is as high as 77%.19 Furthermore, adolescent rugby players reported that ‘there is much less clarity around MSK injuries: specifically, awareness and knowledge of the severity of injury, management and return to play strategy’.20 Therefore, this illustrates how guidance around MSK injuries may not be available for players, and there is a need to consider players’ understanding of all types of injury when developing injury prevention resources. When attitudes towards injury and injury prevention were investigated amongst adolescent male rugby players (ages 14–19), 39.3% of players agreed that injuries were preventable.21 Additionally, players demonstrated poor attitudes and motivations towards injury prevention strategies, a clear barrier to prevention strategy implementation.
Given the absence of adolescent female rugby players’ views and behaviours towards injury and injury prevention in previous literature, the primary aim of this study was to identify attitudes, beliefs and behaviours of adolescent female rugby players towards injuries and injury prevention strategies, as well as the reporting behaviours of players towards concussions and MSK injuries. The secondary aim was to examine individual factors (eg, age, playing level, position, years played) and their association with players’ injury-reporting behaviours.
Methods
Design
An online cross-sectional survey (March–August 2024) was used to understand the attitudes, beliefs and behaviours of adolescent female rugby players in England. Players were recruited from a larger cohort study (‘Injury Prevention in Female Youth Rugby Union: a Multisite International Study’). During the 2023–2024 rugby season, 1062 participants were invited via email/text to complete the survey at home or during in-person sessions at the end of the season. This survey was anonymised to encourage full disclosure without fear of any selection repercussions. Invited players (U16/U18) participated in multiple settings, including school and college, community clubs, regional (Developing Player Pathway and Centre of Excellence) and national (England age-grade or equivalent) teams. Informed consent was obtained for players ≥18 years old, and informed assent and consent from a parent/guardian were collected for players <18 years old before completing the survey. The survey was administered, and results were reported in line with the recommendations from the Checklist for Reporting of Survey Studies.22
Survey tool design, development and validation
The online survey was based on previous surveys examining participants’ attitudes, beliefs and behaviours towards injury and injury prevention strategies.1923,25 Players were invited to complete the survey through a bespoke online portal, SHREDConcussion (https://shred.concussions.co.uk), where both parent/guardian consent and player assent were captured and stored. This participant-facing platform was connected to REDCap,26 27 where the data were stored securely for analysis purposes. The survey consisted of five sections: (a) players’ demographics; (b) players’ attitudes and beliefs towards injuries; (c) players’ attitudes, understanding and behaviour towards injury prevention strategies; (d) concussion reporting during the previous rugby season, factors for non-reporting of concussions and concussion symptom reporting and (e) MSK injury reporting during the previous rugby season and factors for non-reporting of MSK injuries (see online supplemental Appendix A). MSK injuries were defined within the survey as ‘any injuries to the muscles, tendons, ligaments, cartilage and/or bones. They can include, but are not limited to, sprains, strains, dislocations, tears, ruptures and fractures’. Responses were captured through multiple-choice options, yes/no responses, 7-point Likert scales (1: strongly disagree to 7: strongly agree), and open-text responses. Before recruitment, the survey was face-validated by a group of nine experienced clinicians, practitioners and researchers to assess its clarity and relevance. It was deemed unnecessary to pilot the current survey as it was based on previously validated surveys used within adolescent sports such as rugby and football. The time constraints of data collection further supported this decision.
Patient and public involvement statement
The target population for the current study was not consulted regarding the study design, survey or burden of participation. However, those involved in reviewing the survey had extensive experience working in and with various rugby settings.
Data analysis
For all data analyses, STATA BE V.17 was used. Player demographics (section a) were presented as frequencies and proportions, except for age, which was presented as mean and SD. Responses to sections b, c, d and e were described as frequencies and proportions with 95% CIs. Open-ended responses were either left as ‘other’ response, added to an already defined and relevant option or a new response was created. Bivariate logistic regression was used to examine associations between injury reporting (yes/no) for both concussion and MSK injuries and predictor variables, including age, position, playing experience, playing level, playing age group, protective equipment usage and concussion education. Multicollinearity was assessed between these variables using variance inflation factors. An exploratory multivariable logistic regression analysis was undertaken, including all predictor outcomes. Confounding was assessed for each variable within the model, while interaction terms were also included to assess the potential for effect measure modification. Statistical significance was reported for p values <0.05, along with effect sizes and CIs.
Results
424 participants engaged with the survey, and 422 (40% response rate) met the eligibility criteria (2 players no longer played rugby) (table 1). There were 79 players with incomplete answers to questions, but they were not excluded from the data set.
Table 1. Player demographics.
| Player demographics | |
|---|---|
| Number of participants | 422 |
| Age (years) | |
| Mean | 15.7 |
| SD | 1.1 |
| Playing age group | n (%) |
| U16 | 294 (70) |
| U18 | 128 (30) |
| Rugby playing experience | n (%) |
| 1 or less years | 22 (5) |
| 2–4 years | 171 (40) |
| 5–7 years | 104 (25) |
| 8–10 years | 94 (22) |
| 11–13 years | 28 (7) |
| 14+ years | 3 (1) |
| Playing position | n (%) |
| Forwards | 232 (55) |
| Backs | 185 (44) |
| Missing | 5 (1) |
| Level of play | n (%) |
| School/college/club | 63 (15) |
| Regional | 337 (80) |
| National | 22 (5) |
Attitudes and beliefs towards injury/injury prevention strategies
Most players (55%) ‘agreed’ that it is possible to prevent some rugby injuries (table 2). 49% of players ‘agreed’ that regularly training their tackle skills could prevent injuries, and 35% of players ‘agreed’ that lowering the legal height of the tackle to below the base of the sternum could prevent injuries in rugby (table 3). Over half of players (52%) ‘agreed’ that a NMT warm-up, such as Rugby Football Union’s (RFU) Activate warm-up, could prevent rugby injuries (https://www.englandrugby.com/run/player-welfare/activate) (table 3).
Table 2. Heat map of players’ percentage responses to statements regarding rugby injuries with 95% CI.
| Statements | Strongly disagree | Disagree | Slightly disagree | Neither | Slightly agree | Agree | Strongly agree | Missing |
|---|---|---|---|---|---|---|---|---|
| Injuries are not a problem in rugby | 34% (29–38) | 38% (33–43) | 14% (11–18) | 5% (3–7) | 2% (1–4) | 4% (2–6) | 2% (0–3) | 1% (0–2) |
| Rugby injuries can shorten a player's rugby career | 4% (2–5) | 1% (0–2) | 2% (1–4) | 3% (1–5) | 11% (8–13) | 50% (44–54) | 29% (24–33) | 1% (0–2) |
| Rugby injuries can lead to physical problems later in life | 3% (1–4) | 0% (0–1) | 2% (0–3) | 5% (2–6) | 19% (15–23) | 49% (44–54) | 21% (17– 25) | 1% (0–2) |
| Rugby injuries have a negative impact on team performance | 3% (1–5) | 8% (5–10) | 12% (8–15) | 21% (17–24) | 26% (21–30) | 25% (21–29) | 5% (3–7) | 1% (0–3) |
| Rugby injuries have a negative impact on a player's quality of life | 2% (0–3) | 8% (5–11) | 9% (6–11) | 23% (18–26) | 29% (24–33) | 21% (17–25) | 8% (5–10) | 1% (0–2) |
| Rugby players are at high risk of suffering an injury | 2% (1–4) | 3% (1–4) | 4% (2–6) | 12% (8–15) | 27% (22–31) | 38% (33–42) | 13% (10 16) | 1% (0–1) |
| I expect to sustain a rugby injury sometime during the season | 3% (1–4) | 6% (4–8) | 5% (3–8) | 20% (16–23) | 21% (17–25) | 27% (23–31) | 17% (13–20) | 1% (0–2) |
| It is possible to prevent some rugby injuries | 1% (0–2) | 1% (0–2) | 2% (1–4) | 3% (1–5) | 16% (12–19) | 55% (49–59) | 21% (17–25) | 1% (0–1) |
Table 3. Heat map of players’ percentage responses to statements regarding rugby injury prevention strategies and use of protective equipment with 95% CI.
| Statements | Strongly disagree | Disagree | Slightly disagree | Neither | Slightly agree | Agree | Strongly agree | Missing |
|---|---|---|---|---|---|---|---|---|
| Static stretching can prevent rugby injuries | 1% (0–3) |
3% (1–4) |
7% (5–9) |
11% (8–14) |
29% (24–33) |
41% (36–45) | 7% (5–10) |
0% (0–1) |
| Balance exercises can prevent rugby injuries | 1% (0–2) |
3% (1–4) |
5% (3–7) |
22% (18–26) |
29% (24–33) |
33% (28–37) | 7% (4–9) |
1% (0–2) |
| Controlled jumping/landing exercises can prevent rugby injuries | 2% (0–3) |
1% (0–2) |
4% (2–6) |
11% (8–14) |
23% (19–27) |
48% (42–52) | 11% (8–13) |
1% (0–2) |
| A warm-up/run can prevent rugby injuries | 2% (0–3) |
2% (0–3) |
5% (2–6) |
10% (7–12) |
31% (26–35) |
40% (35–44) | 11% (8–14) |
1% (0–2) |
| Change of direction exercises can prevent rugby injuries | 1% (0–3) |
1% (0–3) |
4% (2–6) |
9% (6–12) |
23% (18–27) |
48% (42–52) | 13% (9–16) |
1% (0–2) |
| Cooldown jog/run can prevent rugby injuries | 1% (0–2) |
2% (0–3) |
4% (2–6) |
13% (10–16) |
25% (20–29) |
42% (37–46) | 13% (10–16) |
1% (0–2) |
| Resisted shoulder exercises can prevent shoulder injuries in rugby | 1% (0–2) |
0% (0–1) |
2% (0–3) |
4% (2–6) |
24% (20–28) |
54% (49–58) | 14% (10–17) |
1% (0–2) |
| Neck muscle strengthening can prevent concussion in rugby | 5% (3–7) |
4% (2–6) |
5% (3–7) |
8% (6–11) |
20% (16–24) |
41% (35–45) | 16% (12–19) |
1% (0–3) |
| Trunk (core) strengthening exercises can prevent rugby injuries | 1% (0–2) |
1% (0–3) |
4% (2–6) |
19% (15–23) |
30% (25–34) |
36% (31–40) | 8% (6–11) |
1% (0–2) |
| A neuromuscular training warm-up, such as the RFU's activate warm-up, can prevent rugby injuries | 0% (0–1) |
1% (0–1) |
2% (0–3) |
11% (8–13) |
20% (16–23) |
52% (46–56) | 14% (10–17) |
1% (0–2) |
| I would like my team to complete a rugby-specific warm-up programme before every game and training session this season | ~ | 0% (0–1) |
2% (0–3) |
12% (9–15) |
19% (15–23) |
41% (36–46) | 24% (20–28) |
1% (0–2) |
| Regularly training my tackle skills can prevent injuries | ~ | 1% (0–2) |
1% (0–3) |
4% (2–5) |
14% (11–17) |
49% (44–53) | 29% (24–33) |
2% (0–3) |
| Lowering the legal height of the tackle to below the base of the sternum can prevent injuries in rugby | 3% (1–5) |
6% (4–8) |
7% (5–9) |
13% (10–16) |
24% (19–28) |
35% (30–40) | 10% (7–13) |
1% (0–2) |
| Limiting contact sessions in training can prevent injuries in rugby | 7% (4–9) |
15% (12–18) |
14% (10–17) |
18% (14–21) |
21% (17–25) |
19% (15–22) | 5% (3–8) |
1% (0–2) |
| Wearing a scrum cap can prevent injuries in rugby | 6% (4–8) |
14% (10–17) |
10% (7–13) |
21% (17–25) |
28% (24–32) |
15% (12–18) | 5% (2–6) |
1% (0–2) |
| Wearing a scrum cap can prevent concussion injuries | 9% (6–12) |
17% (13–20) |
10% (7–12) |
16% (12–19) |
24% (20–28) |
19% (15–22) | 4% (2–6) |
1% (0–2) |
| Wearing a mouthguard can prevent injuries in rugby | 1% (0–2) |
1% (0–2) |
1% (0–2) |
3% (1–4) |
13% (10–16) |
42% (37–47) | 38% (33–42) |
1% (0–3) |
| Wearing a mouthguard can prevent concussion injuries | 9% (7–12) |
19% (16–24) |
10% (7–13) |
23% (19–27) |
17% (13–21) |
12% (9–16) |
6% (4 – 8) |
1% (0–2) |
| Statements | In matches | In training | In matches and training | Never | Missing | |||
| Do you wear a scrum cap? | 18% (14–21) |
0% (0–1) | 5% (3–8) |
76% (71–79) |
2% (0–1) |
|||
| Do you wear a mouthguard? | 17% (13–20) |
0% (~) | 80% (76–83) |
2% (0–3) |
1% (0–2) |
|||
| Statement | Yes | No | ||||||
| Do you feel you could tackle harder while wearing a scrum cap? | 70% (58–79) | 30% (20–41) | ||||||
~indicates no response.
RFU, Rugby Football Union.
Understanding and behaviours towards injury/injury prevention strategies
80% of players reported wearing a mouthguard during both matches and training sessions (table 3). Understanding of the effectiveness of mouthguards in preventing injuries in rugby varied; as 12% ‘agreed’ that a mouthguard could prevent concussion injuries, while 19% of players ‘disagreed’ (table 3). Few players (18%) reported wearing a scrum cap (protective headgear) in matches, and 70% of those who wore a scrum cap consequently felt they could tackle harder (table 3).
Most players (n=213, 51%) stated that they had not completed any form of concussion education (including symptoms and potential consequences). While concussion education was available, but not mandatory, those who had received concussion education commonly cited having engaged with the RFU’s Headcase resource (n=69, 16%).
Injury reporting behaviours
14% of players reported not disclosing a concussion/concussion symptom(s) to a coach/medical professional, and 37% of players reported not disclosing an MSK injury to a coach/medical professional (figure 1). Factors attributed to non-reporting of a concussion or MSK injury included ‘Not want(ing) to be ruled out of the game/training (39% and 43%) and ‘not thinking that symptom(s) were related to an injury’ (11% and 17%) (figure 2).
Figure 1. Percentage responses of players’ answers to the questions ‘Had they suffered a suspected concussion or MSK injury in the past year (2022/2023) and not reported it to a member of their coaching team/medical staff member?’. MSK, musculoskeletal.
Figure 2. Players’ percentage responses to the question, ‘For what reason have you not reported a concussion or MSK injury to your coach/clinical professional in the previous year (2022/2023)?’. MSK, musculoskeletal.
Factors associated with concussion and MSK injury reporting
No bivariate associations were found between concussion reporting (yes/no) and playing level, playing age group, use of protective equipment or playing position (table 4). However, after adjusting for other covariates, an association was found between playing experience and concussion reporting (OR: 0.88, 95% CI: 0.79 to 0.99, p=0.02). MSK injury reporting behaviours (outcome variable) were not associated with any predictor variables (table 4).
Table 4. Univariable and multivariable analysis results for factors associated with non-reporting of concussion and MSK injury.
| Covariate | Concussion reporting | MSK reporting | ||
|---|---|---|---|---|
| Univariable OR (95% CI) | Multivariable OR (95% CI) | Univariable OR (95% CI) | Multivariable OR (95% CI) | |
| Players’ demographics | ||||
| Age | 1.12 (0.88 to 1.42) | 1.07 (0.71 to 1.61) | 0.91 (0.76 to 1.09) | 0.79 (0.58 to 1.06) |
| Position | 1.00 (0.90 to 1.11) | 1.01 (0.91 to 1.13) | 0.95 (0.88 to 1.02) | 0.95 (0.88 to 1.03) |
| U16 | 0.82 (0.45 to 1.48) | 0.89 (0.32 to 2.44) | 0.93 (0.60 to 1.44) | 0.55 (0.27 to 1.12) |
| U18 | 1.21 (0.67 to 2.17) | (omitted due to collinearity) | 0.76 (0.57 to 1.01) | (omitted due to collinearity) |
| Playing experience | 0.91 (0.83 to 1.00) | 0.88 (0.79 to 0.98) | 0.98 (0.92 to 1.04) | 0.99 (0.93 to 1.06) |
| School/college/club | 1.08 (0.88 to 1.42) | 1.14 (0.19 to 6.6) | 1.09 (0.62 to 1.91) | 1.00 (0.32 to 3.08) |
| Regional | 1.07 (0.53 to 2.17) | 1.37 (0.26 to 7.18) | 0.88 (0.54 to 1.45) | 0.91 (0.33 to 2.51) |
| National | 0.59 (0.13 to 2.61) | (omitted due to collinearity) | 1.16 (0.48 to 2.78) | (omitted due to collinearity) |
| Protective equipment use | ||||
| Mouthguard | 1.55 (0.95 to 2.53) | 1.59 (0.93 to 2.70) | 0.61 (0.30 to 1.24) | 0.62 (0.30 to 1.27) |
| Scrum cap (protective headgear) | 0.95 (0.77 to 1.18) | 0.89 (0.71 to 1.14) | 0.91 (0.78 to 1.07) | 0.94 (0.80 to 1.11) |
| Concussion education | ||||
| Have you ever received concussion education | 0.88 (0.50 to 1.54) | 1.06 (0.58 to 1.92) | – | – |
Concussion reporting: yes/no to previously having not reported a concussion, and MSK reporting: yes/no to previously having not reported an MSK injury.
Mouthguard and scrum cap (protective headgear): yes/no to wearing a mouthguard and scrum cap (protective headgear).
Bold font indicates a significant difference.
MSK, muskuloskeletal.
Discussion
Overall, players’ attitudes and beliefs towards injury prevention strategies were favourable, and they viewed injuries as being preventable. While some players lacked understanding regarding protective equipment effectiveness, 17% ‘slightly agreed’ that wearing a mouthguard could prevent concussion injuries. Likewise, injury reporting behaviours also varied, as 14% and 37% of players reported that they had previously not disclosed a concussion or MSK injury, respectively. There were no associations between individual factors (player demographics) and injury-reporting behaviours, except for playing experience and concussion reporting.
Generally, players reported safe and encouraging attitudes and beliefs towards injuries and prevention, as 55% of players believed that ‘some rugby injuries were preventable’ (table 2). Similarly, in an English adolescent male rugby cohort, 45% of players believed that some rugby injuries were preventable. Potential explanations for why adolescent female rugby players hold such positive attitudes and beliefs could include team social norms, the influence of peers, parents/guardians and coaches, as well as the high profile of rugby injuries within the media.28 Most players ‘agreed’ (38%) and ‘slightly agreed’ (27%) that ‘rugby players have a high risk of suffering an injury’, which may explain why most players held favourable attitudes towards injury prevention, as players wish to decrease their perceived risk of injury (table 2). 27% of players ‘agreed’ and 21% ‘slightly agreed’ that they ‘expected(ed) to sustain a rugby injury sometime during the season’ (table 2), emphasising how adolescent female rugby players perceived themselves at a high risk of injury. The finding is unsurprising as the previous literature has identified that adolescent female rugby players have a high injury and concussion IR.1
Most players (52%) ‘agreed’ that the RFU’s Activate warm-up could prevent injuries, and 41% ‘agreed’ that they would like their team to complete a rugby-specific warm-up programme before sessions (table 3). These results are promising as they indicate positive attitudes towards NMT warm-ups. Moreover, these results may illustrate how adolescent rugby players’ attitudes and knowledge of NMT have improved; previously, within adolescent male rugby, 13% of players were aware of Activate, and 41% of players ‘neither agreed nor disagreed’ that ‘Activate reduces (their) injury risk (during the) season.29 However, the contrast in results may be attributed to the differences in sex and/or the survey questions. Additionally, most participants in the current study played at a regional level, where they may have been exposed to Activate to a greater extent than at the community rugby level.
Although scrum caps have not previously been reported to be protective of head injury,30 31 many players ‘slightly agreed’ that wearing scrum caps could prevent injuries (28%) and concussions (24%). Reasons for this disconnect may be due to research being slow to filter down to grassroots players, indicating that improvements to knowledge translation to players may be needed.32 Alternatively, some players may potentially be gaining their understanding of injury prevention strategies from various key partners who hold misconceptions regarding injury prevention strategies. Thus, improving research dissemination to all end-users (including coaches, parents/guardians, etc) is critical to reduce misconceptions. Furthermore, of the players who reported wearing a scrum cap, 70% reported that they ‘felt (they) could tackle harder while wearing a scrum cap’. This potentially indicates that players who wear a scrum cap may change their behaviour and tackle harder, as they perceive their risk of injury to be lower when wearing a scrum cap,31 which aligns with the risk compensation theory.33 This theory dictates that those players wearing a scrum cap may view their level of risk as being lower and, thus, change their behaviour.34 However, whether players are tackling harder and whether there is an increased risk of sustaining an injury has yet to be explored.
Nearly half (47%) of players had received a form of concussion education, with 16% having completed the RFU’s Headcase concussion education (https://www.englandrugby.com/run/player-welfare/headcase). Previous literature has also reported that 16% of adolescent female rugby players had completed Headcase as a concussion education initiative.35 Though it was encouraging to see that nearly half of adolescent female rugby players are engaged with some form of concussion education, further research should be undertaken to establish potential facilitators and barriers to concussion education. For example, a study in New Zealand found that concussion education initiatives lacked relatable role models and ‘real’ content.13 Understanding the context in which concussion education initiatives are being implemented and how players view them may help facilitate changes needed to increase completion.
With just over half of players reporting no previous concussion education, it is unsurprising that 14% reported not disclosing a concussion previously (figure 1). The non-disclosure of concussions is concerning as players may be participating while concussed, bringing with it an inherent risk of further serious injury.36 Concussions are already difficult to detect and diagnose,18 but in this population, concussion detection is even more difficult due to limited/no access to clinicians’ pitch-side.37 Although there is a collective responsibility for coaches, referees and spectators to watch out for signs of concussion, team staff often rely on players disclosing concussions and symptoms. Compared with other rugby cohorts, where concussion non-disclosure rates are as high as 43% and 41%,16 17 adolescent female rugby players reported lower non-disclosure rates.
A novel aspect of the current study was to also investigate the non-disclosure of MSK injuries. 37% of players did not disclose an MSK injury during the rugby season (figure 1), with similar reasons for non-disclosure as concussion (figure 2). Evidently, not only does there need to be more education initiatives focused on concussion and MSK injuries and their symptoms, but also a potential culture shift to allow players to feel as though they can take their time in recovery and not fear being absent. However, before initiatives are implemented to facilitate a potential culture shift, further research should be conducted to gain a deeper understanding of why players may feel fearful of being absent from rugby sessions. The association between playing experience and concussion reporting (table 4) revealed that players with more years of playing experience had a lower odds of reporting a concussion (OR: 0.88, 95% CI: 0.79 to 0.99, p=0.02). This indicates that players with more experience should be a target for educational initiatives and behavioural changes14 to improve concussion reporting behaviours.
Limitations
Limitations of the current study included the potential issues of reporting bias, such as social desirability bias and recall bias. To mitigate this bias, players were assured that their survey responses would remain confidential and that no individual responses would be shared with coaches or parents/guardians. Additionally, due to player recruitment from a wider surveillance project, there is the potential for selection bias. This may have meant that players held more positive baseline attitudes or beliefs towards injury and prevention compared with those in the wider population. Although the sample of this wider study was representative of multiple levels of participation across adolescent female rugby in England, it must be acknowledged that this may not reflect all players’ beliefs, attitudes and injury disclosure, which may affect the study’s generalisability. The survey was also not piloted by the current research group, which may have resulted in a limited ability to pre-empt misunderstanding of questions by participants. To overcome this limitation, the survey used previously validated surveys that were used in adolescent sports, such as rugby and football.
Research/policy implications
The study’s results emphasise the need for targeted educational initiatives which improve players’ knowledge of injury symptoms and injury prevention strategies. Furthermore, understanding the extent of injury non-reporting allows key community partners to increase their suspicions when potentially injured players may be attempting to conceal an injury. There is potential to have individuals act as ‘spotters’ at games/training to help identify players who may have had an injury but not disclosed it to a coach/medical professional. Likewise, referees could also act as ‘spotters’, through the ‘blue card’ initiative, where referees who have undergone specific training to identify concussion symptoms can issue players they have suspected of having sustained a concussion a ‘blue card’, meaning they are removed from play.38 Finally, the current study may be used as a reference point for future studies to establish whether improvements have been made to injury disclosure.
Conclusion
Within adolescent female rugby, players demonstrated positive attitudes, beliefs and behaviours towards injury and injury prevention. Generally, players (55%) believed ‘some rugby injuries were preventable’, while their understanding of protective equipment effectiveness varied. A key finding was that 14% of players had not previously reported a suspected concussion to a coach/medical staff member, and 37% of players had previously not reported sustaining one or more MSK injuries to a coach/medical staff member. Developing a greater understanding of adolescent female rugby players’ attitudes, beliefs and behaviours towards injury and injury prevention will support the development, implementation and evaluation of effective injury prevention initiatives.
Supplementary material
Acknowledgements
The authors would like to thank all the players who voluntarily participated in the study, as well as the coaches and team managers who helped facilitate the study.
Footnotes
Funding: This study was funded by World Rugby (grant number: G-2104-02800).
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient consent for publication: Not applicable.
Ethics approval: This study involves human participants and was approved. Ethical approval was obtained from the University of Bath Research Ethics Approval Committee for Health (EP 22 073). Participants gave informed consent to participate in the study before taking part.
Data availability free text: All data relevant to the study are included within the article or supplementary information.
Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Data availability statement
No data are available.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
No data are available.