Discussion
The current study found that parents and guardians generally held safe and encouraging attitudes and beliefs towards injury prevention strategies. Over half (55%) had completed concussion education, and parent–player responses showed fair to almost perfect agreement across injury-related statements. Many parents and guardians viewed injury risk seriously, with 42% believing injuries could cause long-term physical problems and 35% perceiving players to be at a high risk of suffering an injury (table 2). Similar findings in Australian adolescent rugby have also shown that parents, coaches and players commonly rate injury risk as high, suggesting a consistent perception across adolescent rugby.9
Most parents and guardians (51%) agreed that ‘regularly training tackle skills (could) prevent injuries in rugby’ (table 2). Given the tackle is consistently identified in the wider literature as the leading injury mechanism in adolescent female rugby,3 this represents a key target for injury prevention efforts. In contrast, when the attitudes of rugby players in South Africa towards tackle training were investigated, on average, players reported that it was more important (p=0.0001) to learn proper technique for performance improvements (4.63±0.65 on a scale of 1=not at all important to 5=very important) than for reducing their risk of injury (4.2±1.12).30 The differences in responses may stem from varying demographics and/or may be indicative of improvements made to promote player welfare and safety over performance. Additionally, 49% of parents and guardians agreed that they ‘would like their child’s team to complete a rugby-specific warm-up programme prior to every game and training session’ (table 2). Similar responses have also been reported among Canadian adolescent rugby coaches, with 52% agreeing that they would like their team to complete a rugby-specific warm-up programme.21 Most community partners indicated that they would like their team to complete a rugby-specific warm-up programme, indicating a clear appetite for their use in adolescent female rugby. This is encouraging, given that such programmes are effective injury-prevention strategies in adolescent male rugby in reducing concussion rates.5
In contrast, 11% of parents and guardians disagreed that neck muscle strengthening could prevent concussion in rugby (table 2), despite evidence suggesting such programmes may reduce concussion risk.31 This disconnect may reflect poor dissemination of injury prevention guidance32 or differing parental priorities towards injury prevention. Similarly, 17% disagreed that limiting contact in training could reduce injuries (table 2), yet research in American football showed substantial reductions (64%) in practice-related concussions when collisions were restricted.33 34 Informed by the Health Action Process Approach (HAPA), particularly outcome expectancy, which refers to an individual’s beliefs about the potential consequences of a behaviour. Outcome expectancies play an important role during the motivational phase of the HAPA model, whether an individual decides to engage with a behaviour,35 and are positively associated with intention to perform a behaviour.36 Understanding players’ engagement with injury prevention strategies requires consideration of how parents and guardians influence these decisions and shape players’ outcome expectancies. As the HAPA model highlights, outcome expectancies shape intention; therefore, if parents view certain strategies as ineffective, their child may be less likely to use them. Ultimately, there needs to be a consideration of parental beliefs and targeted interventions to improve potentially harmful parental beliefs through education and communication strategies and support the adoption of evidence-based injury prevention behaviours.
Parents’ and guardians’ understanding of protective equipment (mouthguards and scrum caps) effectiveness varied, as 11% considered mouthguards as effective, and 12% considered scrum caps as effective in preventing concussions (table 2). Although protective equipment has shown benefits in sports like ice hockey,33 rugby research indicates that neither mouthguards nor scrum caps prevent concussion.37 38 These findings suggest a need for education initiatives to address misconceptions about protective equipment. Codesigning such initiatives with community partners may enhance their relevance and impact.32 Recognising what shapes parental perceptions, such as media or manufacturer messaging, would also further support effective education.8 Notably, parents and guardians with previous rugby experience were more likely to believe that protective equipment prevents injuries and concussions (figure 2), possibly reflecting experience bias, where individuals rely on personal playing history to inform their beliefs.
The current study concluded that over half of the parents and guardians had completed some form of concussion education (55%). Of the parents and guardians who had undertaken concussion education, the majority (78%) had completed the RFU’s Headcase e-learning resource, which includes a section on ‘How to reduce the risk of getting a concussion’ covering Activate, protective equipment and tackle technique. Previous literature reported that 39% of parents and guardians of adolescent rugby players had completed a form of concussion education.39 Yet both results are lower than what has been seen in other sports; in adolescent ice hockey, 79% of parents and guardians reported having received a form of concussion education.40 While the differences may stem from the differing sports, the findings imply that lessons may be learnt and applied from different sports to understand how to promote concussion education engagement from parents and guardians of adolescent rugby players. There is also a need to understand why there is a lower engagement of parents and guardians with concussion education resources within rugby in comparison to other sports. One potential explanation includes how the RFU’s Headcase resource is not mandated for parents and guardians.
The secondary aim of the current study was to examine whether the attitudes, beliefs and behaviours of parents and guardians aligned with their child’s (the player’s) attitudes and beliefs. There was almost perfect agreement (Gwet’s AC: 0.91 (0.85 to 0.96) (table 3) between parents and guardians and the player’s response to the statement, ‘regularly training tackle skills can prevent injuries’. Within adolescent female rugby, the tackle has been identified as the most frequent mechanism of injury,3 which makes the tackle a target for injury prevention strategies. The extent to which coaches and adolescent female rugby teams focus their time on tackle training is unknown and will vary between teams, but evidently, well-informed contact training could prove to be an effective form of injury prevention. One such evidence-informed contact training resource coaches/teams could use is World Rugby’s Contact Confident resource, which aims to promote confidence, physical competence and safety during contact rugby. Though ultimately, there appears to be a general buy-in from players and parents and guardians alike that regularly training tackle skills can prevent injuries.
Limitations
Participants were recruited from a wider injury surveillance project, introducing potential selection bias, as they may have been more aware of injuries and prevention strategies than the general population. Likewise, participants may have reported more positive baseline attitudes or beliefs towards injury and prevention compared with those in the wider population. This, along with the low response rate (27%), may limit generalisability. To help improve response rates, future studies could consider launching the survey at the start of the rugby season, when engagement is typically higher. Some survey items required recalling the 2022/2023 season, creating the possibility of recall bias. Social desirability bias may also have influenced responses, although anonymity was ensured to reduce this risk. Additionally, the survey was not piloted by the research team, which may have limited the ability to identify unclear questions; however, this was mitigated by drawing on previously validated surveys.
Research/policy implications
A prominent focus for community partners moving forward is to encourage parents and guardians to engage more with concussion education initiatives. Many parents and guardians believed it was their responsibility to guide their child’s RTP yet had not completed any form of concussion education. To help facilitate greater concussion education engagement among parents and guardians, current education initiatives may need to be adapted and evaluated.
