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Coach-directed education is associated with injury-prevention behaviour in players: an ecological cross-sectional study
  1. James C Brown1,2,
  2. Sugnet Gardner-Lubbe3,
  3. Michael Ian Lambert1,2,
  4. Willem van Mechelen1,2,4,
  5. Evert Verhagen1,2,4,5
  1. 1 Division of Exercise Science and Sports Medicine, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
  2. 2 Department of Public and Occupational Health EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
  3. 3 Faculty of Science, Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa
  4. 4 Amsterdam Collaboration on Health and Safety in Sports, IOC Research Centre for Prevention of Injury and Protection of Athlete Health, VUmc/AMC, Amsterdam, The Netherlands
  5. 5 Australian Centre for Research into Injury in Sport and its Prevention (ACRISP), Federation University Australia, Ballarat, Victoria, Australia
  1. Correspondence to Dr James C Brown; jamesbrown06{at}


Background/aim Rugby union (‘rugby’) presents an above-average risk of injury to participants. BokSmart is a South African nationwide intervention that aims to reduce rugby-related injuries in players. This is achieved by educating coaches and referees to improve injury behaviour of players. Thus, the aim of this study was to assess if the receipt of injury-prevention education was associated with player behaviour.

Methods Junior (n=2279) and senior (n=1642) players, who attended merit-based South African Rugby tournaments (2008–2012), completed an anonymous questionnaire. Logistic regressions investigated if player injury-prevention behaviours were associated with the receipt of education on the same topic. Additionally, players' preferred sources of education were explored through frequency and χ2 analyses.

Results Of the 16 injury-prevention behaviours, 12 (75%) were associated with receiving education on that topic. The four behaviours not associated with education were: warming-up (before training and matches), and avoiding heat and massage post injury. Of the seven possible sources of this education, the majority of players chose either coaches or physiotherapists as their preferred media. In comparison with junior players, more senior players chose physiotherapists instead of coaches for warming-up and cooling-down education.

Conclusions The results of this study support, to a large degree, the strategy of BokSmart—influence of player behaviour through coach education. However, these findings also suggest that BokSmart could target team physiotherapists in addition to coaches and referees with their safety education. Also, players might have different preferences for this education depending on their age.

  • Cohort study
  • Intervention effectiveness
  • Behaviour
  • Football

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In comparison with other popular team sports, Rugby Union (henceforth ‘rugby’) carries a relatively high risk of injury to the participant.1 As a result, there are numerous examples of injury-prevention efforts that have been introduced to the game, including protective equipment trials,2 law changes3 ,4 and nationwide injury-prevention programmes such as RugbySmart of New Zealand5 and BokSmart of South Africa.6 ,7

Based on RugbySmart's association with reduced injury rates in New Zealand, the South African Rugby Union (SA Rugby) adapted and launched BokSmart as a nationwide injury-prevention programme for rugby in South Africa in July 2009.7 BokSmart—like RugbySmart—aims to reduce injury rates by changing player behaviour through coach and referee education.5 ,7 Coaches and referees are chosen as the education intervention target due to their influence over players.5 While reduction in player injury rates8 and improvements in injury-prevention behaviours9 have also been associated with the South African version of the intervention, it is yet to be established how these improvements might have occurred.

Therefore, the aim of this study was to assess if injury-prevention behaviours were associated with coach-directed education in South African rugby players. Additionally, this study aimed to describe the players' preferred delivery sources of injury-prevention education.


Study design and population

The study design and population for this study have been described in detail in a previous volume of this journal.9 In brief, data for this cross-sectional study were collected through the BokSmart programme, which is a joint initiative between SA Rugby and the Chris Burger/Petro Jackson Player's Fund (CBPJPF). The CBPJPF is a non-profit public benefit organisation, developed to aid players who have been permanently disabled while playing rugby in South Africa. Permission to analyse these data, which are owned by SA Rugby, were obtained from the University of Cape Town Human Research Ethics Committee, with SA Rugby's permission.

Between 2008 and 2012, BokSmart annually administered a ‘knowledge, attitude and behaviour (KAB)’ questionnaire (see online supplementary appendix I) to players at an under-18 (junior) and open/adult (senior) SA Rugby tournament. Both tournaments were merit-based and attended by teams representing each of the 14 rugby unions in South Africa. Between 2008 and 2012, a total of 112 junior and 84 senior teams attended these tournaments and were asked to complete the KAB questionnaire anonymously at a pretournament meeting. Of these teams, 111 (99%) and 81 (96%) completed them in those age groups, respectively (n=2279 junior players and n=1642 senior players). No information was available for those players at the tournaments who did not attend the meeting at which the questionnaires were completed.

KAB questionnaire

The KAB questionnaire was not validated by BokSmart before use in this study, because it was developed and used by RugbySmart in New Zealand over a 10-year period.5 Thus, the questionnaire was considered sufficiently refined and tested. The players were not asked to disclose their identity when they completed the questionnaire. This was assumed to improve the integrity of answers by eliminating fear of consequential action based on their answers. Therefore, it is possible that some of the same players could be in the data set more than once if they had competed in the tournament in consecutive years. However, as these tournaments are age-based and merit-based, it is unlikely that this is the case for many players.

While it is termed a ‘KAB’ questionnaire, the majority of questions actually investigated knowledge, self-reported injury-prevention behaviour (henceforth ‘behaviour’) and whether the players had received information on primary and secondary injury-prevention practices (‘education’). All questions of the KAB questionnaire were grouped into five categories by the authors (see online supplementary appendix I), three of which were pertinent for this study: (1) demographics, (2) behaviour, and (3) education (receiving information about a particular injury-prevention aspect). The behaviour and education questions that pertain to similar injury-prevention concepts in the KAB questionnaire are outlined in table 1.

Table 1

Behaviour and education components of the Knowledge, Attitude and Behaviour (KAB) Questionnaire that refer to similar concept

Study aims

The main aim of this study was to assess if the 16 behaviours listed in table 1 were associated with their corresponding ‘education’ components as outlined in the table. Second, the players' preferred source (coach, physiotherapist, internet, etc) of this injury-prevention education was then described for the junior and senior players. Together, these study aims tested the main assumption of programmes such as BokSmart and RugbySmart that coaches are able to influence player injury-prevention behaviour through education that they deliver to their players (coach-directed education). Importantly, we were not testing whether the content of this coach-directed education was influenced by BokSmart education, but rather if coaches had the potential to influence player injury-prevention behaviour.

As these players were performing at merit-based tournaments, it is likely that they would all have physiotherapists or a person performing these more medically orientated roles within the team. Whether the persons performing this function were properly qualified physiotherapists or not is outside of the scope of this study.

A questionnaire was removed from the analyses if a respondent answered <10% of the entire questionnaire.


Logistic regressions were performed with each of the 16 injury-prevention behaviours as the dependent variable and the corresponding education component as the independent variable (table 1). Both variables were binary: correct or incorrect behaviour and did or did not receive education. Multivariate analyses indicated that the following variables could be confounding the relationship between the dependent and independent variables: age group of player (junior or senior), injury in past 12 months (yes or no) and year that survey was administered (2008–2012). Thus, these three categorical variables were also added to the logistic regression models already described and all ORs presented in this study are adjusted ORs, for the effect of these confounding variables.


Study population

The average age of junior players was 17±1 years (mean ±SD), while senior players were 25±4 years of age (table 2). A majority of players noted having sustained a rugby-related injury previously (83% and 89% in juniors and seniors, respectively).

Table 2

Junior and senior players, including average age, positions and those who had never had an injury

Education and self-reported behaviour

Players receiving education on injury management was significantly associated with all the correct injury-management behaviour (figure 1) for all the interventions that should be used—ice (adjusted OR (aOR): 1.78, 95% CI 1.36 to 2.33), compression (aOR: 1.149, 95% CI 1.21 to 1.84) and elevation (aOR: 1.40, 95% CI 1.12 to 1.75). However, players receiving education on injury management was significantly associated with the avoidance of exercise (aOR: 1.25, 95% CI 1.01 to 1.54) and alcohol (aOR: 1.78, 95% CI 1.34 to 2.36), but not massage or heat following an injury (figure 1).

Figure 1

Adjusted ORs of association between education on injury management and injury-management behaviours to use and avoid.

Players receiving education on protective equipment and cooling-down (figure 2) were more likely to wear mouthguards and cool-down at both training (mouthguard aOR: 1.17, 95% CI 1.04 to 1.31; cool-down aOR: 2.07, 95% CI 1.85 to 2.33) and matches (mouthguard aOR: 1.20, 95% CI 1.08 to 1.34; cool-down aOR: 2.29, 95% CI 2.04 to 2.58). In contrast, players receiving education on warming-up was not associated with actually warming-up at training or matches.

Figure 2

Adjusted ORs of association between education on protective gear use, warming-up and cooling-down and mouthguard (MG) use and warming-up/cooling-down behaviours.

Players receiving education on safe techniques (figure 3) were more likely to report practice safe techniques of rucking (aOR: 1.97, 95% CI 1.78 to 2.19), tackling (aOR: 1.68, 95% CI 1.52 to 1.86) and scrummaging among forwards (aOR: 2.11, 95% CI 1.79 to 2.49).

Figure 3

Adjusted ORs of association between education on use of safe techniques and the practising of safe rucking, tackling and scrumming (in forwards*).

The majority of players chose either the coach or physiotherapist (physio) as preferred sources of receiving this education in contrast to the other options—sports physician, TV, internet, club and medical insurance (figure 4). For injury management and cooling-down, the majority of junior and senior players selected the physio as their preferred source of this information. The coach was the preferred source of information for the remaining four topics: warming-up, physical conditioning, safe techniques and protective equipment. A significantly greater proportion of junior players identified the coach, as opposed to the physio, as the preferred source of this information for warming-up (p=0.005) and cooling-down (p<0.001).

Figure 4

Junior and senior players' preferred sources of injury-prevention information.


The main finding of this study was that injury-prevention education was associated with corresponding behaviours in these high-level SA Rugby players (figures 1 3). Additionally, this study found that coaches, and to a lesser extent, physiotherapists were the preferred source of this information to players (figure 4). In conjunction, these two findings are critical to the strategy of the BokSmart programme, which relies on coaches to disseminate their content.7 Moreover, these findings should be expected based on the identification as coaches as important influencers of player behaviour in rugby.5 These associations were present despite adjusting for confounders (age group of player, time since injury and year of survey), previously in this cohort.9

Thus, it was unexpected that education was not associated with these four behaviours (warming-up before training/matches and the avoidance of massage and heat following an injury). Additionally, these four behaviours are also not improving over time, in comparison with other behaviours that are, such as mouthguard use and cooling-down.9 The reason for lack of association between education and behaviour for injury management and warming-up is not clear, but it is interesting to note that the majority of players preferred to receive this education from physiotherapists, not coaches (figure 4). The BokSmart safety courses only educate coaches and referees,9 but this finding suggests that physiotherapists should also be targeted, in conjunction with coaches. With the recent promulgation of a standardised warm-up designed to reduce the risk of injury for rugby ( by BokSmart, one would assume that these results might improve in the near future.

Moreover, the finding that preferred source of information differed between age group (junior and senior players) is also important information for BokSmart implementers to consider (figure 4). The present study was unable to eliminate the possibility that this difference might simply reflect lesser resources of junior teams, which might prevent their access to physiotherapists. However, this difference could reflect the plausible explanation that the preferred source of injury-prevention education may change with age. To the authors' knowledge, the fact that injury-prevention delivery agents might be age-specific has not been previously described. It is possible that these ‘physiotherapists’ who were chosen by respondents were not qualified as such. However, this response still reveals that the person tasked with more medical-orientated functions in the rugby team (eg, strapping, warming-up, etc) is an important channel for education promulgation.


Although the questionnaire used in this study was not assessed for its reliability, it was designed and has been used previously to assess the implementation of a precursor intervention to BokSmartRugbySmart of New Zealand.5 Additionally, this questionnaire was not designed to be analysed in the way it has been in this present study—where the authors identified and compared similar constructs (education and behaviour) of a similar topic (injury prevention). This meant that important information such as the effect of time since education could not be assessed, as players were not asked when they received the injury-prevention education. Importantly, the education and behaviour constructs presented here are self-reported and thus open to bias—however, this is inherent to any questionnaire-based study.


A large proportion of injury-prevention behaviours in these high-level SA Rugby players were associated with education they had received on the topics from coaches. This association suggests that coach-driven education intervention strategies could be successful in rugby and potentially other team sports as well. However, the findings that some education was not associated with a minority of behaviours, that physiotherapists were preferred over coaches for some injury-prevention education and that the preference for education channels differed by age group should be considered by BokSmart programme implementers to optimise its overall impact. A future study should directly compare the findings of BokSmart and RugbySmart in South Africa and New Zealand, respectively, in order to understand regional differences to these interventions.

What are the findings?

  • Most rugby player injury-prevention behaviours were associated with the receipt of injury-prevention education.

  • Coaches and physiotherapists are the players' preferred sources of this injury-prevention education.

  • These findings support coach-aimed interventions for reducing injuries in rugby players.

How might it impact on clinical practice in the future?

  • Besides coaches, physiotherapists should also be targeted by nationwide interventions in future.

  • This study demonstrates the importance of testing important assumptions underlying interventions' effectiveness.


The authors would like to thank Dr Wayne Viljoen (BokSmart manager) and Mr Clint Readhead (SARU medical manager) for the collection and permission to analyse these data. Furthermore, the authors would like to thank Dr Simon Gianotti, Dr Ken Quarrie and Mr Richard Skelly for their advice, based on their involvement in the RugbySmart programmes.



  • Twitter Follow James Brown @jamesbrown06, Michael Lambert @MikeLambert01 and Evert Verhagen @Evertverhagen

  • Contributors JCB conceived and planned the analyses and wrote the article. SG-L performed the initial analyses. JCB revised the analyses after input from other authors (MIL, WVM and EV). All authors revised and checked final version of the manuscript.

  • Funding JCB received PhD funding from the SAVUSA/NRF Desmond Tutu Doctoral Programmes to complete this study. Furthermore, JCB is now a Postdoctoral Research Fellow paid by the BokSmart programme and Chris Burger/Petro Jackson Players' Fund.

  • Competing interests None declared.

  • Ethics approval Human Research Ethics Committee of the University of Cape Town.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The data that were analysed are owned by SA Rugby, but are available for sharing should SA Rugby agree.