Introduction

The dangers of concussion are becoming better-known within academia, and therefore it is necessary for this wealth of knowledge to be transferred to and applied in real life (i.e., sport activities). Rugby has been found to have the highest prevalence of concussions both in match play and training [1] when compared with other contact sports such as Association Football, Ice Hockey, and American Football. This is measured in Athletic Exposures (AE) which is defined as one athlete participating in one game or training session with the incidence rate shown as x per 1,000 AEs. Research has found Men’s Rugby to have an estimated incidence rate of 12/1000 AEs in matches and 2.8/1000 AEs in training [2]. By comparison, Association Football players are found to have an incidence rate of 0.08/1000 AEs [3]. Although descriptive, these findings indicate that Rugby players may be at an increased risk of sustaining sport-related concussion and the negative consequences associated such as poorer mental health [4–6], impaired cognition [7,8], and increased risk for neurodegenerative diseases [9,10].

Despite the well-documented negative consequences associated with concussion, many Rugby players continue to play their sport, where concussion is common, and therefore placing themselves at risk of experiencing these negative outcomes. This could be indicative of poor knowledge and therefore poor attitudes towards concussion. For example, previous work has found that just 50.8% of Rugby players that had reported having had a concussion did so during the match or training session in which it occurred [11]. The most common reasons for non-reporting were not considering it a serious injury, not knowing that it was concussion at the time, and wanting to continue participating. These findings have been found previously in Irish professional Rugby Union players [12]. Unfortunately, this poor concussion knowledge often translates into poor concussion attitude, as 61% of Miller et al.’s [11] sample did not adhere to recommended return-to-play protocols after their most recent concussion sustained in Rugby.

It could be that Rugby players continue to play with suspected concussion so that they are perceived as “head strong”. Colleagues have shown how players often downplay, deny, or conceal their concussion symptoms and play on, so they can present themselves as having a high level of commitment to their teammates and to their sport [13]. This has been reported in Men’s and Women’s Super League players where 20% of respondents stated that they did not report concussion symptoms during the 2020 and 2021 seasons [14]. 35% of the time this was due to concerns regarding team selection, where just under a quarter of the time (24%) this was due to feelings of not wanting to let the team down. These reasons are also found to be the main two motives for continued participation in the Australian National Rugby League [15] and in amateur Rugby in the United Kingdom [16]. Therefore, it could be that there is a culture where amateur Rugby players, despite their competitive status, often prioritise sporting values rather than health-related ones, rewarding serious risk taking [13]. This mentality can increase the chances of continued participation with a suspected concussion which can exacerbate symptomology [17]. Therefore, creating a team culture of reporting concussion symptoms is vital [18].

Concussion attitudes and knowledge base is variable within Rugby players with evidence that players possess safe [19] and unsafe [20] concussion attitudes. Viljoen et al. [21] also found poor knowledge in amateur Rugby players that may lead to poor attitudes and behaviour regarding concussion. Kraak et al. [19] assessed Western Province Rugby Union Super League players in South Africa using the Rosenbaum Concussion Knowledge and Attitude Survey (RoCKAS) [22]. Participants in this study answered 67% of the Concussion Knowledge Index (CKI) questions correctly, and 62% of the Concussion Attitude Index (CAI) questions correctly with 65–70% considered a moderate level of knowledge of and attitude towards concussion [21,23]. Salmon et al. [24] also found that adolescent Rugby players in New Zealand and their coaches answered 69% and 74% of the CKI questions correctly, respectively. Coaches responded significantly better than adolescent players in this study, with the authors suggesting this was likely due to coaches being required to attend an annual RugbySmart course in New Zealand.

However, the use of RoCKAS is questioned for poor reliability [25] which is probably due to limiting participants’ responses as they are restricted to predetermined questions and answers [26]. AlHashmi and Matthews [26] consider surveys a poor method of capturing complex human behaviour, such as attitudes towards and knowledge of concussion, suggesting that these can shift and change. Surveys only capture a snapshot of these and therefore it could be why we see variance in concussion knowledge and attitudes using RoCKAS. Van Vuuren et al. [20] report that players demonstrated the lowest knowledge of concussion and least safe attitudes towards concussion compared with medical staff and referees.

Aspers and Corte [27] define qualitative research as “…an iterative process in which improved understanding to the scientific community is achieved by making new significant distinctions resulting from getting closer to the phenomenon studied.” Qualitative research allows in depth insights into complex human phenomena, attitudes, perspectives, and behaviours. In contrast to quantitative research, the nuances which underpin lived experiences are illuminated within qualitative research. Such lived experiences are central to impactful educational research which is invested in the hows and the whys which are not represented easily by numbers [28]. According to Allen et al. [29] qualitative public health research can provide profound understandings of beliefs and behaviours which can feed into problem solving public health messages.

For example, Seguin and Culver [30] collected qualitative data across a two-year period that included two interviews, five focus groups, 24 member reflections, and 31 informal discussions that uncovered a unique understanding of lived experience through Bronfenbrenner’s Ecological Systems Theory [31]. They concluded that, i) microsystem – athletic identity, ii) mesosystem - (dis)trust in relationships, iii) exosystem – concussion protocols, iv) macrosystem – sport culture, v) chronosystem – timing related to major events and recovery. This work can be credited for providing a unique perspective regarding the lived experience of concussion in sport albeit not explicitly specific to Rugby, however Rugby players were included. In addition, Daly et al. [32] interviewed 23 retired professional Rugby players and identified that the players did not fully understand the consequences of concussion because it was normalised within the game. Dismissive language was commonplace which supports previous research of not reporting concussion due to not considering it a serious injury [11,12]. Therefore, a qualitative approach via interviews to explore the knowledge and attitudes of Rugby players towards concussion is optimal and can uncover nuance that RoCKAS may be unable to.

In summary, the literature using RoCKAS [22] to assess the knowledge and attitudes of concussion in Rugby players is inconsistent, and qualitative approaches can provide profound understandings into lived experience [29]. Therefore, qualitative interviews should be conducted to investigate this lived experience. The notion that Rugby players understand the risk of concussion yet continue to place themselves at risk of sustaining one is of particular interest. Therefore, this study aimed to interview amateur Rugby players to investigate their attitudes and knowledge of concussion in their sport and provide indications as to how we can best support players.

Method

Participants

Nine amateur Rugby players (7 Male, 2 Female) were included in the sample, all of whom were English (Age, M = 24.67, SD = 5.15). All players had sustained a minimum of three concussions during their playing careers. Amateur status was defined by the sportspeople themselves and therefore is operationalised as self-identification being an amateur Rugby player. Further information regarding concussion profiling and participant characteristics are presented in Tables 1 and 2, respectively. Participants were recruited via advertisements on social media platforms such as X and LinkedIn as well as word of mouth. All participants took part in semi-structured interviews designed to investigate their attitudes and knowledge towards concussion in Rugby. Interviews were conducted between January 2021 and March 2022.

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Table 1. Concussion Profiles.

https://doi.org/10.1371/journal.pone.0325368.t001

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Table 2. Participant Characteristics.

https://doi.org/10.1371/journal.pone.0325368.t002

Findings

Discussion

This study attempted to explore the knowledge and attitudes of concussion in amateur Rugby. This has been deemed necessary due to the wide-ranging knowledge bases [41] and positive and negative attitudes towards concussion in Rugby [19–21]. Many Rugby players report that they have good attitudes and appropriate knowledge of concussion, yet this seems contradictory. For one to state that they are aware of potential neurodegenerative diseases and to choose to continue participating in Rugby is indicative of the difficulty of changing health-related behaviour [42]. Kelly and Barker [42] argue that there are six common errors when discussing health-related behaviour change, i) It’s just common sense, ii) It’s about getting the message across, iii) Knowledge and information drive behaviour, iv) People act rationally, v) People act irrationally, vi) It is possible to predict accurately, and these six errors may be evident when conveying and interpreting the risks associated with concussion in Rugby. For example, Tadmor et al. [14] provide support for the fifth common error that Kelly and Barker [42] propose in that people behave irrationally in their response to concussion in Rugby. They found that 11% of their sample of 422 Men’s and Women’s Rugby League players would dissuade family members’ children from playing Rugby League but continue to do so themselves. This behaviour is illogical as it places the health of others above one’s own, as well as demonstrating an understanding of the risks associated with concussion, and actively opting to ignore them. Therefore, this study aimed to investigate and uncover the reasons as to why Rugby players continue to play their sport, despite the well-reported potential negative consequences.

From our data analysis, we developed two themes, poor duty of care and lack of education. It is unsurprising to find that there is a poor duty of care found within amateur Rugby given this has been a topic of discussion for some time [43,44]. One reason for this may be a bystander effect whereby the presence of several people in an injury situation, such as concussion, may lead to a reduction in an individual stepping in to help [45]. Salmon et al. [46] identified 30 distinct responsibilities related to concussion management in amateur Rugby and that there was a distinct lack of clarity regarding personnel accountable for each. Therefore, role confusion could aid in explaining poor duty of care from non-players in amateur Rugby.

Additionally, retired professional Rugby Union players across Ireland, England, Scotland, and Australia report that they believe owners of Rugby clubs should have a duty of care towards their players during retirement as well as during their playing careers [47]. In a way, as this is a topic of discussion, these sentiments demonstrate that former professional Rugby players feel as though they were not supported when playing and in retirement. While unreasonable, the motive for professional Rugby clubs to distance themselves from former players that then go on to develop negative outcomes associated with concussion is understandable. At the time of writing, Rugby is under scrutiny regarding the negative consequences of concussion and governing bodies are currently under litigation in the United Kingdom [48]. World Rugby annually provide grant funding for player welfare research, but it is unclear how many awards are made, the cost of these awards, and how much money goes towards concussion research [49]. This makes it difficult to understand whether governing bodies are supporting players in retirement appropriately as is reported by Daly et al. [47].

With that said, it may be that there is a role confusion as to who is responsible for supporting retired Rugby players the same way there is for who supports the injured player in that moment. For example, World Rugby may suggest it is the responsibility of the Rugby Football Union (RFU), who may say the opposite or point towards different charities for support. Ultimately, this lack of clarity can result in Rugby players not being appropriately supported directly after a concussion, or when suffering the consequences years later in retirement.

This is where the second theme of lack of education emerges. It is unlikely that anyone involved in a Rugby match, at any competitive level would like to see a player injured, particularly a brain injury. Therefore, our interpretation of why we see a poor duty of care from teammates, parents, coaches, and referees, is due to a lack of education on concussion. This behaviour is indicative of poor knowledge of concussion, rather than the alternative that they are willingly turning a blind eye to potential significant brain injury of their teammate, child, or player they are coaching or officiating.

This lack of education and poor knowledge of concussion is consistent with the literature. Kearney and See [50] found that in their sample of 255 English youth players aged 11–17, that 61 reported having had a concussion, a prevalence of 24%. Of those 61, only 7 (11%) of them followed return to play protocol, with some not adhering to it at all. In fairness, players also did show some good knowledge of concussion with 80% correctly identifying that a concussion does not have to result from a hit to the head, and 91% correctly identifying that those that have sustained a concussion in the past are not less likely to have another. Despite this positive knowledge, this does not always transfer to positive attitude, as we see that 36% reported that they would continue playing despite hitting their head and 30% agreed that they had a responsibility to continue playing with concussion symptoms. Unfortunately, 24% reported that their parents would encourage them to continue playing in a Rugby match after hitting their head, indicative of external pressures influencing this decision.

Our study builds on these findings from Kearney and See [50] supporting the narrative that Rugby players often continue with concussion symptoms and that this is in-part due to a poor duty of care from non-players. The Coaches’ code of conduct set out by World Rugby [51] states that coaches are “...responsible for maximising benefits and minimising risks to players” and that they “...should attain a high level of competence through qualifications and a commitment to ongoing training that ensures safe, current, and correct practice.” World Rugby [52] also state that “Match officials ensure the players’ safety and ensure that the players follow the principles of the Game. Match officials might need to stop the game to ensure player safety.” The interview transcripts in this study highlight that both coaches and referees have failed in their responsibilities set out by World Rugby which we deem to be due to a lack of education. This is concerning given that there is evidence that medical staff and referees in South Africa demonstrate highest concussion knowledge and safest attitudes compared to players [20]. However, these findings may only be representative of South African medical staff and referees as it may be that training and discussion towards concussion in South Africa exceeds that of what is available in the United Kingdom. For example, South African referees can exercise a Blue Card which removes players with suspected concussion from the match [53]. This has also been implemented in Australia [54], Canada [55], and New Zealand [56] whereas this has not yet been implemented in the United Kingdom. As this is not present in the United Kingdom, there could be increased pressure on continuing participation rather than having this decision taken away from the player due to being shown a Blue Card by the referee.

As we have discussed in previous work [6], quite often the reluctance towards concussion information is due to the lack of a clear message. Players sometimes oppose the message that concussion is a significant public health issue as there can be no causal link established, and that any research shows an association, or a possibility of developing negative post-concussion outcomes. However, Nowinski et al. [57] have suggested that a causal relationship between repetitive head impacts and chronic traumatic encephalopathy can be established when evaluating relevant studies using Bradford Hill criteria. These findings have also been supported by establishing that sustaining a concussion exposes sportspeople to a 57 times greater risk of developing meaningful depressive symptoms [6]. This type of work may be useful in changing the knowledge and attitudes of non-players in order to promote a healthier sense of duty of care towards Rugby players.

The simple message that Walker et al. [6] provide is in comparison to the comprehensive guidance currently distributed by World Rugby and the RFU. World Rugby provide a ten-page concussion guidance document [58] that outlines what concussion is, symptomology, and the correct return-to-play protocol for adults and children. The RFU has its own Headcase programme [59] that aims to increase the understanding and provide information on concussion. These documents are accessible to Rugby clubs in England and around the world but whether players and non-players actively engage with them is unknown. The findings of the present study would suggest that these documents are rarely accessed by amateur Rugby players in the United Kingdom. This guidance might create the illusion that World Rugby are dedicated to concussion prevention within their sport, but there is a case to be made of actions speaking louder than words. In 2023, France hosted the Rugby World Cup and French captain Antoine Dupont was substituted after a head collision in a Pool match against Namibia. Although Dupont did not play in France’s final Pool match against Italy, he did start their Quarter-Final match against South Africa. This came despite media attention that Dupont was still suffering from concussion symptoms.

While World Rugby state in their concussion guidance that “if in doubt, sit them out” and that “any player with a concussion or suspected concussion should be immediately and permanently removed from training or play” allowing Dupont to compete in a Quarter-Final of a World Cup, sends the opposite message. This is an example where World Rugby have ignored their own guidance and supports critique of using the “if in doubt, sit them out” slogan on its own as it provides governing bodies in sport the chance to create the illusion that ongoing efforts are being made regarding concussion prevention and deflects criticism from their sports [60]. This decision also opposes multiple components of the Health Belief Model [61] which has been found to be significantly related to positive concussion reporting intentions [62]. If the world governing body of Rugby are contradictory in their concussion behaviour and duty of care towards players, this could reduce the perceived susceptibility of concussion for Rugby players of any competitive level. They may feel less vulnerable to the disease as they observe one of the best players in the world bounce back to competing in a World Cup Quarter-Final and feel encouraged to emulate this behaviour. The perceived severity of concussion may also be reduced which in-turn could hinder the cue to action and discouraging behaviour change. It is also important to note that World Rugby have not represented concussion in their sport fairly in the past and have in-fact previously downplayed and denied the long-term risks [63]. This undermines the possibility for anyone to be educated appropriately on concussion in Rugby. If players and non-players in Rugby are going to protect those with concussion, it must start from the top as at present the actions of World Rugby demotes key components of the Health Belief Model which have been found to be associated with positive concussion attitudes [62].

Limitations

Although other studies that have investigated this area have obtained larger samples [13,26], qualitative research is less concerned with sample sizes than typical quantitative approaches. Instead, the depth and richness of the Rugby players’ experiences of concussion were of interest here. This was successfully explored, as all nine participants had sustained over three concussions with one having sustained an estimated twenty. All players admitted to continuing playing with concussion symptoms as well as seeing others do the same. Over half had sustained concussion before adulthood. Therefore, the sample are well-qualified to share their lived experiences of concussion, and the findings here are valuable.

Our recruitment strategy, however, should be noted. We recruited participants using advertisements across the university as well as with social media posts, and therefore the data may suffer from self-selection bias. The findings that we have obtained may reflect individuals that have had the worst experiences post-concussion. Many sustain concussion and show no symptoms [64], and therefore these players may have less motivation to take part in a study attempting to understand concussion in amateur Rugby like the present study. By contrast, those that have dealt with more negative experiences post-concussion are perhaps more likely to take part to help others and that could explain the current findings. We would argue that even if this is the case, there is value in examining the worst experiences of concussion satisfying the ontological view of the researchers. These nine amateur Rugby players highlight the negative consequences of concussion in their sport and their contributions can promote positive concussion attitudes and knowledge.

The reader should also be aware that these interviews were retrospective, self-reported accounts. As Table 2. illustrates, the experiences that were being recalled ranged from less than a year to seven years before the interview took place. However, the interviews captured data from various viewpoints, not just their own. Questions were asked regarding observing others sustaining concussion, as well as their thoughts regarding how others would perceive a certain situation, such as their coaches or their teammates. Therefore, although the concussion they sustained may have been some time prior to interview, valuable information was still captured regarding their attitudes and knowledge of concussion regardless of this event.

Additionally, participants all competed in amateur Rugby in the United Kingdom, limiting these findings to just this demographic of players. This is considerably different to the way concussion in the amateur Rugby game is reported and managed in other popular Rugby playing nations such as Australia, Canada, New Zealand and South Africa where referees can use a Blue Card to remove a player from the game that is suspected to have sustained a concussion [53–56]. Therefore, the findings of the present study can only be applied to nations where the Blue Card system is not in use as it reduces the possibility of continued participation for the player.

Conclusion and future directions

In conclusion, this study provides a deeper understanding of the variable attitudes and knowledge base of amateur Rugby players towards concussion in the United Kingdom. A poor duty of care coupled with a lack of education promotes poor attitudes and knowledge of concussion that we see in amateur Rugby players. This in-turn leads to continued participation with suspected concussion which is dangerous [17]. We therefore conclude that our sample of amateur Rugby players in the United Kingdom represent a cohort that may not be appropriately educated on the risks of concussion and not suitably cared for by non-players. Improving education of players and non-players in amateur Rugby could enhance the duty of care towards players as well as improving the chances of players making an informed decision on their participation. Finally, Rugby governing bodies like World Rugby and the RFU must set the example regarding duty of care. At present, there are instances where the two fail in their duty of care of current and former players which needs improvement if this is to be observed in the amateur game.