A large international study of female Rugby Union athletes has demonstrated that 50% of players have reported a contact breast injury (CBI), exercise-induced breast pain (EIBP) or both. Despite the potential adverse health and performance implications of these occurrences, knowledge and awareness of CBI or EIBP in the female Rugby Union game is lacking. Therefore, this study aimed to develop and assess an interactive female-tailored education intervention (EI) addressing this gap.
The EI, based on current literature, included videos and multiple-choice questions and was delivered to 61 female Rugby Union players and 7 support staff across various playing levels. Pre- and post-intervention knowledge and awareness were analysed using paired t-tests, and post-EI semi-structured questions explored potential future behaviour change.
Awareness of potential future health complications, measured via 5-point Likert-scale, significantly increased for both players and support staff. Players showed the largest effect size (d = 2.30) and a mean difference (MD) of 2.78 (95% confidence interval (CI): 2.47, 3.10), support staff demonstrated a similarly strong effect (d = 2.44, MD = 2.71; 95% CI: 1.69, 3.74). Over 98% of players noted that their future behaviour around CBI and EIBP had been positively influenced by the EI, including increased likeliness to report such.
This work is pioneering in its development and assessment of a sport-specific EI on the underrepresented topic of breast health in women’s Rugby Union. The findings indicate a void of knowledge and awareness around the topic, but reveal high receptiveness and potential future behavioural change amongst participants.
Introduction
Rugby Union (hereafter Rugby) has reported a 28% rise in female player registrations since 2017, which has led to female players now accounting for a quarter of the total Rugby playing population worldwide (worldrugby.org, 2025). This global growth of female participation in sport more generally (de Borja et al., 2022) is supported through initiatives aiming to create equality in key areas such as resource allocation and access to facilities and coaches (“Gender Equality in Sport”, 2023), and equity, providing resources and opportunities tailored to individual needs and circumstances to achieve equal outcomes. This extends to issues particular and unique to the female athlete, including breast health issues such as exercise-induced breast pain (EIBP) and contact breast injury (CBI). CBI is caused by direct impact to the breast (Greydanus and Patel, 2002; Obourn et al., 2021), while EIBP often originates from excessive movement during sport (Brisbine et al., 2020b; Brown et al., 2014; Burbage and Cameron, 2017; McGhee and Steele, 2020).
Female Rugby players are exposed to a notable risk of a CBI, EIBP or both during their career (Bibby et al., 2025c; Brisbine et al., 2020a). However, reporting of these breast health issues is remarkably low in Rugby (Bibby et al., 2025b; Brisbine et al., 2020a) and other female team and contact/combat sports (Brisbine et al., 2019; De Jager et al., 2024; King et al., 2024; Smith et al., 2022a, b; 2018; Wakefield-Scurr et al., 2023). Consequently, the recording of these breast health issues by support staff is limited (Bibby et al., 2024; De Jager et al., 2024; King et al., 2024). Furthermore, a limited number of studies have investigated the prevalence of CBIs and EIBP. Reported CBI prevalence revealed that over half of Rugby players sustained multiple injuries (Dang et al., 2025); 35.7% of French basketball players reported three or more (Smith et al., 2022a), and 62.5% of U.S. water polo players experienced six or more injuries during their careers (Smith et al., 2022b). The prevalence of EIBP has been reported at 40% amongst female horse riders (Burbage and Cameron, 2017) and 32% in female runners (Brown et al., 2014). Both CBI and EIBP can have adverse impacts on performance, such as the inability to run comfortably, or the hesitancy to engage in tackle events (Bibby et al., 2025a; Brisbine et al., 2019, 2020b). Additionally, both CBI and EIBP may present potential future health complications. Excessive breast movement during dynamic sport can lead to EIBP, which may be associated with mechanical strain on breast support structures, particularly the Cooper’s ligaments and overlying skin (Haake and Scurr, 2010; Norris et al., 2020), as well as frictional injuries such as skin damage from repetitive rubbing against ill-fitting sportswear, protective equipment or skin-on-skin contact (McGhee and Steele, 2023; Scurr et al., 2010). In cases of inadequate anatomical protection of the breast against high-energy impacts, CBI may cause damage to tissues including lobules, ducts and alveoli, further increasing the likelihood of contusions and haematomas (Holschen, 2004; McGhee and Steele, 2023). Resulting fat necrosis can falsely be identified as cancerous tissue during breast screening, leading to unnecessary distress in athletes (Wakefield-Scurr et al., 2024). Despite these potential short and longer-term complications, this is an issue that receives minimal attention in the literature (Bibby et al., 2025a, b).
Raising awareness and increasing knowledge around breast health in all stakeholders, including players, support staff and management involved in Rugby, has been identified as one of the most consequential and important steps moving forward (Bibby et al., 2025a, b; Wakefield-Scurr et al., 2024). Education interventions (EIs) are an established method in sporting environments, and have been used previously to enhance knowledge and awareness around topics such as concussion (Miyashita et al., 2013; Salmon et al., 2024), nutrition (Foo et al., 2021; Tam et al., 2019) and the female athlete triad (Bergstein et al., 2024). EIs pertaining to breast health and breast issues in young equestrians (Cameron et al., 2024) and adolescent girls (Omrani et al., 2020) showed significant positive pre- and post-intervention changes in topic knowledge and awareness. Both studies further indicate that participants felt more comfortable talking about breast health in general after the EI.
For the development of a complex intervention such as an EI, it is essential to first identify existing evidence, develop a theoretical understanding of the intended mechanism of change, and model potential processes and outcomes. Altogether, this ensures that the intervention is grounded in prior research, theory-informed, and sufficiently refined to be expected to have a meaningful impact (Craig et al., 2008). Interventions further have the potential to be effective and influence behaviour change when addressing the underlying conditions required for behaviour to occur – namely, capability, opportunity and motivation (Michie et al., 2011). Including all stakeholders involved within the environment in which the intervention is intended to be implemented can further be considered as a vital component for increased impact (Byrne, 2019). Therefore, the aim of this study was the development and assessment of an interactive EI to enhance breast health knowledge and awareness of all stakeholders involved in women’s Rugby in Ireland. It was hypothesised that (1) baseline levels of knowledge and awareness of breast health issues would be low across all stakeholder groups and (2) the EI would significantly improve knowledge and awareness, positively influencing intended future behaviours related to the reporting, recording and management of breast health issues.
Methods
Participants
Active adult (≥18) female Rugby players and support staff (coaches, strength and conditioning (S&C) and medical support staff such as physiotherapists, athletic therapists or team doctors) were invited to participate in an online EI, embedded within a webinar on breast health in Rugby. Informed consent was provided electronically by all participants, who took part voluntarily and were informed of their right to withdraw from the study at any time without consequence, in line with the approved procedures of the local university’s research ethics committee. Players and support staff from amateur, provincial and national-level Rugby in Ireland were included in this study. Amateur clubs playing at levels such as provincial Division 1 or the All-Ireland League (AIL) are the foundational level of Women’s club Rugby in Ireland. Provincial women’s Rugby then provides a higher-level competitive platform for players across the four provinces (Munster, Ulster, Leinster and Connacht). Each province selects players from amateur clubs within its region, typically choosing some of the most talented individuals, including those who may be under consideration for national selection. The authors’ network was utilised for the recruitment of participants.
Design
A within-subject, pre-post design to assess the impact of an interactive EI on breast health issues in women’s Rugby was employed. Participants completed pre- and post-surveys immediately before and after the EI. No control group was included as the primary aim of the study was exploratory and focused on assessing the immediate impact and feasibility of the EI within a real-world setting without considering maturation (Marsden and Torgerson, 2012). This study received ethics approval from the faulty research ethics committee (2025_03_09_EHS) and all participants gave informed written consent.
Development of the educational intervention (EI)
The development of the EI, which consisted of educational videos and interactive multiple-choice questions (MCQs), took place between September 2024 and March 2025. Due to the paucity of assessed EIs focusing on CBI, the development of the EI was guided by previous research utilising EIs to enhance knowledge and awareness of breast health, including EIBP, among young equestrians (Cameron et al., 2024) and adolescent girls (Omrani et al., 2020). Additionally, based on previous research on breast health, including both EIBP and CBI, specifically in Rugby, indicating limited knowledge and awareness of the topic among female athletes and stakeholders overall, the following topics were included (Bibby et al., 2025b): (1) definition and explanation of breast pain and injury; (2) implications for performance; (3) prevention strategies and (4) potential future health complications and the necessity to report breast pain and injury. Depending on the topic, appropriate educators (e.g. medical doctor or physiotherapist) were identified to present topic content via an educational video. The educators were chosen for their broad clinical experience within and beyond rugby, as well as their profile in the game in some instances. They supplemented evidence-based scripts about breast health as curated by the research team, with their own professional experience. Any pre-existing breast-specific education was therefore unnecessary. The Irish Rugby Football Union (IRFU) supported professional recording of the educational videos, facilities and the educators. Video duration ranged between 18 and 49 s. Each educational video was followed by an interactive, relevant and self-assessed MCQ for content reinforcement (Fox, 1983). The development was further directed by the Universal Design for Learning guidelines to accommodate the diverse needs, abilities, and preferences of all learners (Rogers-Shaw et al., 2018). The EI was designed to support multiple means of representation, engagement, and action and expression. Videos and accompanying subtitles addressed diverse sensory and cognitive processing needs, while the dynamic format helped sustain learners’ interest and motivation. Additionally, the inclusion of MCQs offers an interactive method for learners and promoted active learner participation and provided opportunities for formative assessment. Videos and MCQs were piloted internally and externally prior to data collection to ensure evidence-based content and fit to the demands of the cohort of interest. Internally, this piloting was carried out by two male and two female researchers with expertise in sport science, physiotherapy, biomechanics, S&C, teaching and actively playing Rugby. Externally, the piloting consisted of three females and one male with expertise in sports medicine, physiotherapy, actively playing Rugby, and communication. The gathered feedback addressed video script content, clarity, appropriateness and length and the selection of suitable MCQs. Feedback included some wording changes, alteration and inclusion of MCQ answer options, target group-specific terminology and shortening of script length. Topic order and detailed overview of profession and sex of the educator, video script and MCQ content can be seen in Table 1.
Educational video and multiple-choice question content
| Order and topic | Profession of educator | Sex of educator | Video script | Multiple-choice question | Answering options (correct answer(s) marked with *) |
|---|---|---|---|---|---|
| (1) Definition and explanation of breast pain and injury | Medical manager of the Irish domestic Rugby game | Female | “As part of the Irish Rugby Injury Surveillance Project, we asked over 500 female players from across the globe, about their experience of breast pain or injury. And we found that over 50% of players suffered from breast pain or injury while playing Rugby. While these issues may be common, they are rarely reported. We know that injuries are a risk of playing any sport and can impact our performance and health. However, if we don’t talk about these injuries then we can’t get the right treatment or learn how to reduce the risk of injury. There are two main types of breast health issues we’re talking about. The first is exercise-induced breast pain due to running or jumping. The second is a contact injury to the breast, due to being tackled or falling onto the ground or ball. Both issues can impact on your performance and participation in Rugby” | How many female Rugby Union players have had either a contact breast injury or exercise-induced breast pain during their career? (1 correct answer) | A: 15% B: >50%* C: 35% D: 20% |
| (2) Implications for performance | Active female national Rugby player | Female | “Performing at your best is difficult if you are carrying an injury or are in pain. Breast pain and injury can affect how you perform in both matches and training. Studies show that players are less likely to engage in contact activities, such as the tackle, or may limit running and jumping activities in training because of breast pain or injury | What impact does breast pain or injury have on performance? (2 correct answers) | A: Reluctant to engage in the tackle* B: Difficulty kicking the ball C: Limit running or jumping activities* D: Difficulty changing direction |
| It is important to report injuries to our breasts, the same way we would to any other part of our body. Talking about our breasts can be a sensitive topic but that shouldn’t stop us getting the right help that we need. Finding someone, whether it’s your team medical professional, a coach, a teammate or a friend, who you feel comfortable talking to is the first step in learning how to reduce your risk and help improve your rugby performance and enjoyment” | |||||
| (3) Prevention strategies | Physiotherapist | Female | “The first step to reducing breast pain is to make sure you are wearing a good supportive sports bra. Breasts can move up to 15 cm if not properly supported while running or jumping and this can cause pain or discomfort. One way to reduce breast pain is to reduce this movement, by getting a properly fitted sports bra. Guidance on the different types of sports bras and how to make sure they fit correctly is on the Irish Rugby website | Wearing a well-fitted sports bra can reduce excessive breast movement during sport. (True or False) | A: False B: True* |
| Breast padding might help to reduce impacts to the breast and prevent the risk of breast injury. Breast padding should be comfortable, smooth with rounded edges and not restrict your movement. It does not replace the need for a sports bra. There is ongoing research into the benefits and use of breast padding and you should check out the World Rugby website to make sure that any breast padding you wear meets their current guidelines” | |||||
| (4) Potential future health complications and the necessity to report breast pain and injury | Medical doctor | Male | “There is no link between breast injury and cancer. In some cases breast pain or injury can damage some of the structures in the breast, such as ligaments, blood vessels or even milk ducts. This can result in swelling or scar tissue in the breast. Sometimes the fatty tissue of the breast can be damaged resulting in a lump. This lump is called fat necrosis, and while it is a non-cancerous lump, you should still seek advice from a medical professional to rule out any more serious problems. Reporting breast pain or injury to a medical professional is the first step in getting advice, appropriate treatment or onward referral if needed” | What are the potential consequences of a breast injury? (select all that apply) | A: Fat necrosis* B: Scar tissue* C: Breast cancer D: Inflammation* |
| (5) Summary | Medical manager of the Irish domestic Rugby game | Female | “While breast pain and injury occur in sport, these issues often go unreported and can have short- or long-term impact on players’ performance and welfare. Starting the conversation and becoming breast aware is the first step in developing evidence-informed strategies to enhance player welfare and performance across all levels of the women’s game” | aN/A | N/A |
| Order and topic | Profession of educator | Sex of educator | Video script | Multiple-choice question | Answering options (correct answer(s) marked with *) |
|---|---|---|---|---|---|
| (1) Definition and explanation of breast pain and injury | Medical manager of the Irish domestic Rugby game | Female | “As part of the Irish Rugby Injury Surveillance Project, we asked over 500 female players from across the globe, about their experience of breast pain or injury. And we found that over 50% of players suffered from breast pain or injury while playing Rugby. While these issues may be common, they are rarely reported. We know that injuries are a risk of playing any sport and can impact our performance and health. However, if we don’t talk about these injuries then we can’t get the right treatment or learn how to reduce the risk of injury. There are two main types of breast health issues we’re talking about. The first is exercise-induced breast pain due to running or jumping. The second is a contact injury to the breast, due to being tackled or falling onto the ground or ball. Both issues can impact on your performance and participation in Rugby” | How many female Rugby Union players have had either a contact breast injury or exercise-induced breast pain during their career? (1 correct answer) | A: 15% B: >50%* C: 35% D: 20% |
| (2) Implications for performance | Active female national Rugby player | Female | “Performing at your best is difficult if you are carrying an injury or are in pain. Breast pain and injury can affect how you perform in both matches and training. Studies show that players are less likely to engage in contact activities, such as the tackle, or may limit running and jumping activities in training because of breast pain or injury | What impact does breast pain or injury have on performance? (2 correct answers) | A: Reluctant to engage in the tackle* B: Difficulty kicking the ball C: Limit running or jumping activities* D: Difficulty changing direction |
| It is important to report injuries to our breasts, the same way we would to any other part of our body. Talking about our breasts can be a sensitive topic but that shouldn’t stop us getting the right help that we need. Finding someone, whether it’s your team medical professional, a coach, a teammate or a friend, who you feel comfortable talking to is the first step in learning how to reduce your risk and help improve your rugby performance and enjoyment” | |||||
| (3) Prevention strategies | Physiotherapist | Female | “The first step to reducing breast pain is to make sure you are wearing a good supportive sports bra. Breasts can move up to 15 cm if not properly supported while running or jumping and this can cause pain or discomfort. One way to reduce breast pain is to reduce this movement, by getting a properly fitted sports bra. Guidance on the different types of sports bras and how to make sure they fit correctly is on the Irish Rugby website | Wearing a well-fitted sports bra can reduce excessive breast movement during sport. (True or False) | A: False B: True* |
| Breast padding might help to reduce impacts to the breast and prevent the risk of breast injury. Breast padding should be comfortable, smooth with rounded edges and not restrict your movement. It does not replace the need for a sports bra. There is ongoing research into the benefits and use of breast padding and you should check out the World Rugby website to make sure that any breast padding you wear meets their current guidelines” | |||||
| (4) Potential future health complications and the necessity to report breast pain and injury | Medical doctor | Male | “There is no link between breast injury and cancer. In some cases breast pain or injury can damage some of the structures in the breast, such as ligaments, blood vessels or even milk ducts. This can result in swelling or scar tissue in the breast. Sometimes the fatty tissue of the breast can be damaged resulting in a lump. This lump is called fat necrosis, and while it is a non-cancerous lump, you should still seek advice from a medical professional to rule out any more serious problems. Reporting breast pain or injury to a medical professional is the first step in getting advice, appropriate treatment or onward referral if needed” | What are the potential consequences of a breast injury? (select all that apply) | A: Fat necrosis* B: Scar tissue* C: Breast cancer D: Inflammation* |
| (5) Summary | Medical manager of the Irish domestic Rugby game | Female | “While breast pain and injury occur in sport, these issues often go unreported and can have short- or long-term impact on players’ performance and welfare. Starting the conversation and becoming breast aware is the first step in developing evidence-informed strategies to enhance player welfare and performance across all levels of the women’s game” | aN/A | N/A |
Not available (N/A)
Pre- and post-EI surveys
Qualtrics (Qualtrics, Provo, UT) was used for the data collection of the pre-and post-EI surveys, which were carried out between March and April 2025. This data collection aimed to assess the change in knowledge and awareness around breast health pre- and post-EI. Pre- and post-EI surveys involved participants rating their knowledge, awareness and perceived importance of various breast health issues such as CBI and EIBP, and their likeliness to report or record breast pain or injury. Answers were recorded on a 5-point Likert-scale, e.g. 1 = very unlikely, very unaware or very unknowledgeable, 5 = very likely, very aware or very unknowledgeable. The pre-EI survey additionally collected demographic information on age, sex, profession (female player, S&C, medical support staff or coach), level of play/work (amateur, provincial or national) and years involved in the previously selected profession. Participant data were pseudonymised to allow pre- and post-EI surveys to be matched. In addition to re-rating their knowledge and awareness, the post-EI survey also included standalone questions. These questions assessed participants’ perceived enhancement (or otherwise) of knowledge and awareness of breast health issues and potential future behaviour change around the topic as a result of completing the EI. These questions consisted of multiple choice, 10-point numeric rating scale (NRS) and semi-structured questions. Internally the piloting of the pre- and post was carried out by two male and two female researchers with expertise in sport science, physiotherapy, biomechanics, S&C, teaching and statistics. External piloting was carried out by two females and one male with expertise in physiotherapy, S&C, coaching and playing Rugby. Feedback was given on the clarity, appropriateness, and length of the survey questions. This feedback led to the addition of several pre-and post-EI questions to generate a more comprehensive picture of the impact the EI had on the participants’ awareness, knowledge and potential future behaviour change. The surveys were designed to take no longer than 8 min to complete.
Delivery
For the delivery of the EI and the pre- and post-survey, all components were embedded into a webinar presented via Microsoft (MS) Teams. No other educational content, bar the educational video and MCQ content presented in Table 1, was delivered. Previous work interviewing stakeholders involved in Rugby identified a webinar as one of the preferred education outlets with regard to breast health issues (Bibby et al., 2025b). To avoid influencing participants during the intervention, the opportunity to ask questions was only provided after the post-EI survey. The webinar structure was further piloted externally by two females and one male with expertise in physiotherapy, S&C, coaching and playing Rugby. Feedback consisted of advice regarding the overall webinar structure and flow and led to the inclusion of quick response (QR) codes for easy survey access. To further limit any bias due to recall memory, the post-survey was placed immediately after the EI. The full structure of the webinar can be seen in Figure 1.
The illustration shows a table with six rows and three columns. The first row presents the column headers as: Row 1: Column 1: Timeline; Column 2: Component; Column 3: Content. The timeline column shows different times written inside a circle. The second column shows the components in a rectangle with a gradient of blue from top to bottom, with the right edge of each rectangle merging with a right-facing arrowhead. The third column shows bullet points. The complete table is as follows: Row 2: Timeline: 2 minutes; Component: Introduction; Content: Explanation of the study aims and webinar structure. Row 3: Timeline: Greater than or equal to 8 minutes; Component: Pre-survey; Content: Participation in the pre-E I survey immediately before the E I including giving informed consent. Row 4: Timeline: Greater than or equal to 6 minutes; Component: E I Left superscript a; Content: Presentation of the E I videos each followed by the assigned M C Q left superscript b; Verbal guidance through the E I without additional input. Row 5: Timeline: Greater than or equal to 8 minutes; Component: Post-survey; Content: Participation in the post-EI survey immediately after the E I. Row 6: Timeline: As needed; Component: Questions; Content: Offering the participants the opportunity to ask questions.Webinar structure. aEducation intervention (EI), bMultiple choice question (MCQ). Source(s): Authors’ own work
The illustration shows a table with six rows and three columns. The first row presents the column headers as: Row 1: Column 1: Timeline; Column 2: Component; Column 3: Content. The timeline column shows different times written inside a circle. The second column shows the components in a rectangle with a gradient of blue from top to bottom, with the right edge of each rectangle merging with a right-facing arrowhead. The third column shows bullet points. The complete table is as follows: Row 2: Timeline: 2 minutes; Component: Introduction; Content: Explanation of the study aims and webinar structure. Row 3: Timeline: Greater than or equal to 8 minutes; Component: Pre-survey; Content: Participation in the pre-E I survey immediately before the E I including giving informed consent. Row 4: Timeline: Greater than or equal to 6 minutes; Component: E I Left superscript a; Content: Presentation of the E I videos each followed by the assigned M C Q left superscript b; Verbal guidance through the E I without additional input. Row 5: Timeline: Greater than or equal to 8 minutes; Component: Post-survey; Content: Participation in the post-EI survey immediately after the E I. Row 6: Timeline: As needed; Component: Questions; Content: Offering the participants the opportunity to ask questions.Webinar structure. aEducation intervention (EI), bMultiple choice question (MCQ). Source(s): Authors’ own work
Statistical analysis
Participant characteristics, pre- and post-responses were summarised as number (percentage) for categorical data and mean (SD) or median (IQR) for numeric data, as appropriate. Numeric data were assessed for skewness through the visual inspection of histograms and Q-Q plots. The pre- and post-intervention scores were not normally distributed and were summarised as median and interquartile range (IQR = 25th percentile, 75th percentile). Difference scores (post – pre) were found to be normally distributed and analysed using the paired t-test. Mean differences and associated 95% confidence intervals and Cohen’s d effect size are reported. Cohen’s d effect size was based on the following thresholds: <0.3, small; 0.3–0.5, moderate and >0.5, strong (Cohen, 1992). Statistical analyses were undertaken using IBM SPSS (Version 30.0) with a 5% level of significance used throughout. The 10-step content analysis guideline developed by White and Marsh (2006) was utilised to analyse the semi-structured questions and was further supported by the deductive analysis approach displayed by Elo and Kyngäs (2008).
Results
Over the course of 11 days, seven EI webinars were held, with the duration of webinars ranging between 24:00 and 30:00 min. In total, there were 68 participants, of which 61 were active female players (age in years 21.3 ± 4.6; years active as players 8.7 ± 4.1), and seven support staff, three males and four females, of whom three were coaches, one physiotherapist, one team manager and two S&C (age in years 39.4 ± 11.6; years active in selected role 6.7 ± 6.1). The distribution across the different levels of play was: Amateur: 23 players and two support staff; provincial: Four players and one support staff, and national: 34 players and four support staff. The majority of the participants (67.6%) rated their overall pre-EI knowledge and awareness around breast health issues as somewhat or very unknowledgeable (Tables 2 and 3). Further, over half of the participants (54.4%) responded that their current Rugby environment would not encourage them to report or record breast pain or injury. The main reasons given were that the topic is not being spoken about (44.1%), a lack of education/awareness around the topic (29.4%), and topic sensitivity in general (14.7%). Two players further alluded to only having access to male staff, which contributed to their lack of awareness and education and added to topic sensitivity in general. Less than a third (32%) of all participants had previously been exposed to other breast health education, such as other webinars, websites or information sheets.
Players pre- and post-education intervention changes recorded on a 5-point Likert-scale
| Question | Pre-median (aIQR) | Post-median (IQR) | Mean difference (95% bCI) | p-value | Choen’s d |
|---|---|---|---|---|---|
| How would you rate your knowledge around breast health issues in Rugby? | 2 (1,3) | 4 (4,4) | 1.85 (1.54,2.17) | <0.001 | 1.51 |
| How would you rate your knowledge around prevention strategies for breast pain or injury in Rugby | 1 (1,2) | 4 (4,5) | 2.23 (1.87,2.59) | <0.001 | 1.58 |
| How aware are you of the occurrence of contact breast injuries amongst female rugby players during their career? | 2 (1,2) | 4 (4,5) | 2.11 (1.78,2.45) | <0.001 | 1.62 |
| How aware are you of the occurrence of exercise-induced breast pain amongst female rugby players during their career? | 1 (1,2) | 4 (4,5) | 2.36 (2.03,2.69) | <0.001 | 1.85 |
| How aware are you of potential future health complications such as fat necrosis, hematoma or cooper ligament strains? | 1 (1,1) | 4 (4,5) | 2.78 (2.47,3.10) | <0.001 | 2.30 |
| How aware are you of implications on performance such as the inability to run comfortably or the hesitancy to engage in tackle events? | 2 (1,3) | 4 (4,5) | 2.05 (1.70,2.40) | <0.001 | 1.48 |
| How likely would you be to report breast health issues? | 2 (1,3) | 4 (4,5) | 1.33 (0.96,1.70) | <0.001 | 0.92 |
| How important do you think general breast health education is? | 5 (4,5) | 5 (5,5) | 0.31 (0.08,0.54) | 0.005 | 0.34 |
| How important do you think it is for female players to report breast health issues? | 5 (4,5) | 5 (5,5) | 0.15 (−0.12,0.42) | 0.141 | 0.14 |
| How important do you think it is for support staff to record breast health issues? | 5 (4,5) | 5 (5,5) | 0.18 (−0.07,0.43) | 0.073 | 0.18 |
| How comfortable would you be reporting breast pain or injury in general and to members of the backroom staff? | 3 (2,4) | 4 (3,4) | 0.57 (0.32,0.83) | <0.001 | 0.58 |
| How comfortable would you be to report breast pain or injury in general and to members of the backroom staff – medical support staff? | 4 (3,4) | 4 (4,5) | 0.53 (0.28,0.75) | <0.001 | 0.59 |
| How comfortable would you be to report breast pain or injury in general and to members of the backroom staff – strength and conditioning coach? | 3 (2,4) | 3 (3,4) | 0.61 (0.35,0.86) | <0.001 | 0.61 |
| How comfortable would you be to report breast pain or injury in general and to members of the backroom staff – Rugby coach? | 2 (2,3) | 3 (2,4) | 0.64 (0.41,0.87) | <0.001 | 0.71 |
| Question | Pre-median (aIQR) | Post-median (IQR) | Mean difference (95% bCI) | p-value | Choen’s d |
|---|---|---|---|---|---|
| How would you rate your knowledge around breast health issues in Rugby? | 2 (1,3) | 4 (4,4) | 1.85 (1.54,2.17) | <0.001 | 1.51 |
| How would you rate your knowledge around prevention strategies for breast pain or injury in Rugby | 1 (1,2) | 4 (4,5) | 2.23 (1.87,2.59) | <0.001 | 1.58 |
| How aware are you of the occurrence of contact breast injuries amongst female rugby players during their career? | 2 (1,2) | 4 (4,5) | 2.11 (1.78,2.45) | <0.001 | 1.62 |
| How aware are you of the occurrence of exercise-induced breast pain amongst female rugby players during their career? | 1 (1,2) | 4 (4,5) | 2.36 (2.03,2.69) | <0.001 | 1.85 |
| How aware are you of potential future health complications such as fat necrosis, hematoma or cooper ligament strains? | 1 (1,1) | 4 (4,5) | 2.78 (2.47,3.10) | <0.001 | 2.30 |
| How aware are you of implications on performance such as the inability to run comfortably or the hesitancy to engage in tackle events? | 2 (1,3) | 4 (4,5) | 2.05 (1.70,2.40) | <0.001 | 1.48 |
| How likely would you be to report breast health issues? | 2 (1,3) | 4 (4,5) | 1.33 (0.96,1.70) | <0.001 | 0.92 |
| How important do you think general breast health education is? | 5 (4,5) | 5 (5,5) | 0.31 (0.08,0.54) | 0.005 | 0.34 |
| How important do you think it is for female players to report breast health issues? | 5 (4,5) | 5 (5,5) | 0.15 (−0.12,0.42) | 0.141 | 0.14 |
| How important do you think it is for support staff to record breast health issues? | 5 (4,5) | 5 (5,5) | 0.18 (−0.07,0.43) | 0.073 | 0.18 |
| How comfortable would you be reporting breast pain or injury in general and to members of the backroom staff? | 3 (2,4) | 4 (3,4) | 0.57 (0.32,0.83) | <0.001 | 0.58 |
| How comfortable would you be to report breast pain or injury in general and to members of the backroom staff – medical support staff? | 4 (3,4) | 4 (4,5) | 0.53 (0.28,0.75) | <0.001 | 0.59 |
| How comfortable would you be to report breast pain or injury in general and to members of the backroom staff – strength and conditioning coach? | 3 (2,4) | 3 (3,4) | 0.61 (0.35,0.86) | <0.001 | 0.61 |
| How comfortable would you be to report breast pain or injury in general and to members of the backroom staff – Rugby coach? | 2 (2,3) | 3 (2,4) | 0.64 (0.41,0.87) | <0.001 | 0.71 |
Interquartile range (IQR)
Confidence interval (CI)
Support staffs pre- and post-education intervention changes recorded on a 5-point Likert-scale
| Question | Pre-median (aIQR) | Post-median (IQR) | Mean difference (95% bCI) | p-value | Choen’s d |
|---|---|---|---|---|---|
| How would you rate your knowledge around breast health issues in Rugby? | 3 (2,3) | 4 (3,4) | 1.14 (0.15,2.13) | 0.015 | 1.07 |
| How would you rate your knowledge around prevention strategies for breast pain or injury in Rugby | 2 (1,3) | 4 (3,5) | 1.86 (0.73,2.98) | 0.003 | 1.53 |
| How aware are you of the occurrence of contact breast injuries amongst female rugby players during their career? | 1 (1,4) | 4 (4,5) | 2.43 (1.03,3.83) | 0.003 | 1.60 |
| How aware are you of the occurrence of exercise-induced breast pain amongst female rugby players during their career? | 1 (1,4) | 4 (4,5) | 2.29 (1.01,3.56) | 0.002 | 1.66 |
| How aware are you of potential future health complications such as fat necrosis, hematoma or cooper ligament strains? | 1 (1,2) | 5 (3,5) | 2.71 (1.69,3.74) | <0.001 | 2.44 |
| How aware are you of implications on performance such as the inability to run comfortably or the hesitancy to engage in tackle events? | 4 (2,4) | 5 (4,5) | 1.57 (0.17,2.97) | 0.017 | 1.04 |
| How likely would you be to record breast health issues? | 5 (4,5) | 5 (5,5) | 0.71 (−0.67,2.10) | 0.127 | 0.47 |
| How important do you think general breast health education is? | 5 (5,5) | 5 (5,5) | 0.28 (−0.41,0.98) | 0.178 | 0.38 |
| How important do you think it is for female players to report breast health issues? | 5 (5,5) | 5 (5,5) | *cN/A | N/A | N/A |
| How important do you think it is for support staff to record breast health issues? | 5 (5,5) | 5 (5,5) | N/A | N/A | N/A |
| How comfortable would you be with recording breast pain or injury in general if reported to you by a player? | 5 (5,5) | 5 (5,5) | N/A | N/A | N/A |
| Question | Pre-median (aIQR) | Post-median (IQR) | Mean difference (95% bCI) | p-value | Choen’s d |
|---|---|---|---|---|---|
| How would you rate your knowledge around breast health issues in Rugby? | 3 (2,3) | 4 (3,4) | 1.14 (0.15,2.13) | 0.015 | 1.07 |
| How would you rate your knowledge around prevention strategies for breast pain or injury in Rugby | 2 (1,3) | 4 (3,5) | 1.86 (0.73,2.98) | 0.003 | 1.53 |
| How aware are you of the occurrence of contact breast injuries amongst female rugby players during their career? | 1 (1,4) | 4 (4,5) | 2.43 (1.03,3.83) | 0.003 | 1.60 |
| How aware are you of the occurrence of exercise-induced breast pain amongst female rugby players during their career? | 1 (1,4) | 4 (4,5) | 2.29 (1.01,3.56) | 0.002 | 1.66 |
| How aware are you of potential future health complications such as fat necrosis, hematoma or cooper ligament strains? | 1 (1,2) | 5 (3,5) | 2.71 (1.69,3.74) | <0.001 | 2.44 |
| How aware are you of implications on performance such as the inability to run comfortably or the hesitancy to engage in tackle events? | 4 (2,4) | 5 (4,5) | 1.57 (0.17,2.97) | 0.017 | 1.04 |
| How likely would you be to record breast health issues? | 5 (4,5) | 5 (5,5) | 0.71 (−0.67,2.10) | 0.127 | 0.47 |
| How important do you think general breast health education is? | 5 (5,5) | 5 (5,5) | 0.28 (−0.41,0.98) | 0.178 | 0.38 |
| How important do you think it is for female players to report breast health issues? | 5 (5,5) | 5 (5,5) | *cN/A | N/A | N/A |
| How important do you think it is for support staff to record breast health issues? | 5 (5,5) | 5 (5,5) | N/A | N/A | N/A |
| How comfortable would you be with recording breast pain or injury in general if reported to you by a player? | 5 (5,5) | 5 (5,5) | N/A | N/A | N/A |
Interquartile range (IQR)
Confidence interval (CI)
Not available (N/A), *The correlation and t could not be computed as the standard error of the difference was 0
Post-EI findings
A significant change in 12 out of 14 questions answered by the players was recorded. The players’ positive shift in awareness of potential future health complications presented the largest effect size (d = 2.30) and change in mean difference (MD = 2.78 (95% CI: 2.47, 3.10)). This was closely followed by the positive change in awareness of the occurrence of both breast pain (d = 1.85, MD = 2.36 (95% CI: 2.03, 2.69)) and injury (d = 1.62, MD = 2.11 (95% CI: 1.78, 2.59)). For the two questions that did not record a significant change, the recorded pre median and IQR were close to the upper limit. All results of the players’ pre- and post-EI changes can be seen in Table 2.
Amongst support staff, six out of eight questions showed significant positive change, while for those two that did not, pre-median and IQR were again found to be at the upper limit. Similar to the players pre- and post-EI changes, the support staff changes in awareness of potential future health complications (d = 2.44, MD = 2.71 (95% CI: 1.69, 3.74)), the occurrence of breast pain (d = 1.66, MD = 2.29 (95% CI: 1.01, 3.56)), and the occurrence of breast injury (d = 1.60, MD = 2.43 (95% CI: 1.03, 3.83)) were the most dominant. All the support staff pre- and post-EI changes can be seen in Table 3.
In total, 54.4% of all participants stated that the EI greatly improved their knowledge and awareness, while an additional 42.6% noted improved knowledge and awareness and 3.0% noted no improvement. The vast majority of participants chose the correct answers to the MCQs (70.6–100%).
Influence on potential future behaviour change
Of the 61 female players, 98.3% noted that their future behaviour around breast pain and injury had been positively influenced by the EI. Only one female player noted that their future behaviour would not be influenced by the EI but did not provide any reasoning for her response. For those who noted a positive influence, it ranged from increased general awareness around the topic (28.0%), increased likeliness to report breast pain or injury (24.3%), selecting a properly fitted sports bra (23.1%) and increased comfort addressing breast health issues in the first place (8.5%). Statements from respondents, some indicating multifaceted influence on their potential future change in behaviour around breast health issues, included the following;
General awareness around the topic:
I think I would be more aware that breast injury does happen and that there are various types of injury that may cause breast pain or injury. I’d consider using breast padding as outlined in the video if I felt this would be beneficial at any given time in my playing career
I think it will help to bring awareness to this issue which will hopefully make coaches more aware and make the players feel more comfortable to engage with them about any of their breast related issues
Increased likeliness to report CBI or EIBP:
Yes, I think I’ll report if I’ve any injuries to the breast more openly as I can see the repercussions now
Yes, I wouldn’t have considered reporting breast specific injuries as would have just considered being a bit sore. If the awareness is raised from the IRFU down, it makes it more open and easier to talk about
Yes, I think I’ll report if I have any injuries to the breast more openly as I can see the repercussions now
Selection of a properly fitted sports bra:
Yes, being more aware in what sports bra I’m wearing
Yes, by ensuring that I put in more attention to any pain and to ensure I’m taking preventative steps
Increased comfort addressing breast health issues:
Absolutely. I would like to think that I would be confident and comfortable enough to have those conversations and open them to others
Amongst support staff, increased general awareness was the predominant aspect influenced (55.5%). This was often mentioned in combination with the creation of a more aware and open environment (33.3%):
Yes, means players will know it’s ok to talk to us about it and know that we are aware and comfortable with the info
More comfortable discussing with players especially if the players themselves have taken part in the education piece
Education intervention component rating
When being asked which aspect of the EI had the greatest impact, 21.4% responded that the videos did, with 55% of those adding that this was due to the use of people they could relate to or knew in the videos:
Hearing it coming from one of the women’s national players helped it to be relatable
Seeing players and staff we know talking about it
Further aspects which were shown to have an impact on the participants were the initial creation of awareness and primary education (16%), pointing out potential future health complications (13%), and guidance on preventative and protective measurements (13%).
All facets of the videos and related MCQs were received positively by the participants and the average ratings on the NRS (1 = low, little or unclear 10 = high, very or clear) can be seen in Table 4.
Video and multiple-choice question rating on a 10-point numeric rating scale
| Videos | |
|---|---|
| Question | Rating |
| How useful/beneficial did you find the videos? | 8.8 ± 1.3 |
| Were the videos easy to understand (language and content)? | 9.6 ± 0.9 |
| Was the duration of the videos appropriate? | 9.9 ± 0.7 |
| aMCQs | |
| How useful/beneficial did you find the MCQs? | 8.5 ± 1.8 |
| Were the MCQs written in a way that was easy to understand? | 9.4 ± 1.3 |
| Was the placement of the MCQs (after each video) appropriate? | 9.6 ± 0.7 |
| Videos | |
|---|---|
| Question | Rating |
| How useful/beneficial did you find the videos? | 8.8 ± 1.3 |
| Were the videos easy to understand (language and content)? | 9.6 ± 0.9 |
| Was the duration of the videos appropriate? | 9.9 ± 0.7 |
| aMCQs | |
| How useful/beneficial did you find the MCQs? | 8.5 ± 1.8 |
| Were the MCQs written in a way that was easy to understand? | 9.4 ± 1.3 |
| Was the placement of the MCQs (after each video) appropriate? | 9.6 ± 0.7 |
Multiple choice question (MCQ)
Discussion
The aim of this study consisted of the development of an interactive female-tailored EI on breast health, and the assessment of the EI’s impact through analysing the participants’ pre- and post-changes of awareness, knowledge and potential influence on future behaviour. In line with our hypotheses, baseline levels of knowledge and awareness of breast health issues were low across stakeholders, and the intervention led to significant improvements. Furthermore, reported intentions to support future reporting, recording and management of breast health issues also increased, supporting the second part of our hypothesis.
As breast health education has been identified as a relevant component to increase female Rugby players’ welfare overall, this study targeted active female Rugby players and other stakeholders involved in women’s Rugby. As females still do not receive the same level of care as males do due to deep-rooted systemic issues embedded within wider societal structures, there remains an absence of female-specific health education (Wise, 2022). It is also important to note that Rugby may have entrenched gender norms and androcentric subcultural values which might limit open conversations about pain or injury (Dane et al., 2023, 2024). The current study demonstrates the effectiveness of a female-focused EI targeting breast health issues, indicating the need for more female-specific education overall. To the author’s knowledge, this study is the first of its kind to have developed and assessed a breast health EI focused on women’s Rugby.
This study showed overall limited baseline knowledge, awareness, topic comfort and likeliness to report or record breast health issues. These findings concur with current literature, which has reported the overall lack of breast health education in Rugby and elite female athletes more broadly (Bibby et al., 2025b, c; Brisbine et al., 2020b; Wakefield-Scurr et al., 2024). Other work on breast health issues amongst female athletes has further alluded to incorrectly fitted sports bras (Brisbine et al., 2020c; Burbage and Cameron, 2017) and the lack of protective equipment (Coltman et al., 2024; Smith et al., 2022b, 2018). However, there is an overall paucity of evidence in the field with limited prospective data on components such as injury incidence rate, severity, burden, injury mechanism, and other health and performance implications attributable to either CBI or EIBP (Bibby et al., 2025a; King et al., 2024; McGhee and Steele, 2023). Increased knowledge and awareness amongst players and support staff of key components such as reporting and recording practices, prospective pain and injury surveillance and management, and potential implications on performance and health are paramount in addressing the research gap, which is breast health in women’s Rugby.
The quantitative pre- and post-comparison of the developed breast health EI showed significant change in 12 out of 14 questions in player responses and six out of eight in the responses of the support staff. The significant increase in player reporting may reflect greater comfort and willingness to disclose breast health issues. This is a potentially important development given that underreporting was previously identified as a significant hurdle for optimal breast pain and injury surveillance (Bibby et al., 2025b, c; Brisbine et al., 2020a; Smith et al., 2018). Various factors influencing this recorded improvement can be noted, including increased comfort around the topic (Bibby et al., 2025b; De Jager et al., 2024) and quintessentially the creation of a more supportive and open environment (Ekegren et al., 2014). The noted increase in awareness of breast pain and injury in general for both players and support staff is fundamental to improve recording and reporting (Bibby et al., 2025b, c; Smith et al., 2022a). The effect size related to the change of awareness around potential future health complications was highest for both players (d = 2.30) and support staff (d = 2.44), indicating the largest magnitude of change. These findings can be seen as salient considering the documented limited knowledge around this facet of breast health (Bibby et al., 2025b, c; Brisbine et al., 2019; King et al., 2024; Smith et al., 2018). Our study further noted that increased awareness of potential future health repercussions may influence behaviour, making individuals potentially likely to report breast pain or injury in the first place. Behaviour is typically influenced when an individual demonstrates the capability, opportunity and motivation to engage with it (Drattell et al., 2025; Michie et al., 2011). Several results in our work showed a positive influence on these components. The results of this study indicate a growth in the psychological capability of the participants, as their understanding and awareness of breast health issues increased. Improvements in both physical and social opportunities were observed, marked by a shift towards a more open and aware environment and a decrease in the perceived sensitivity of the topic. Additionally, the increased awareness of potential future health complications related to breast health issues may contribute to reflective motivation, again potentially leading to reporting breast pain or injury in the first place. These results highlight the potential impact of the EI on the aforementioned key components identified as critical for addressing the noted gap in current literature.
Both components of the EI, including the videos and MCQ received an overall high rating (all over 8.5 on a 1–10 NRS), showing positive receptiveness to these components. Other work using videos as an EI tool in sport and health settings has shown their effectiveness amongst various ages and sexes on knowledge, attitudes and behaviour change (Cowdery et al., 2019; Cusimano et al., 2014; Hunt, 2015; Jones et al., 2022). The use of relatable educators is a known contributor to successful EIs (Bush et al., 2025). This is corroborated by the indication from participants that seeing Rugby players and other people they knew in the EI videos improved their initial education and enhanced their awareness of the topic. The MCQ results demonstrated strong participant understanding with the majority answering correctly across all questions. Accuracy was consistently high, ranging from just over 70% to full correctness, with minimal selection of incorrect options (0–14%). Amalgamated quantitative and qualitative findings demonstrated the amenability of the cohort towards more “open” attitudes and behaviour around breast health issues through the EI. These findings are congruent with health promotion literature indicating improved attitudes towards health issues through effective health EI (Naidoo and Wills, 2009).
Limitations
The absence of a follow-up assessment to evaluate knowledge retention and behaviour change over time can be seen as a limitation of this study. While the EI recorded significant pre- and immediate post-EI change, no data were collected at a later timepoint to determine whether the observed improvements were sustained and thus limits any conclusion with regard to the long-term impact of the intervention (Cusack et al., 2018). With support staff contributing 10% of this study’s participants, their participation could be described as limited, but could be seen as a normal distribution of players and support staff in women’s Rugby. Support staff participants in this study were predominantly female, which does not reflect the preponderance of male support staff in Rugby (Barrett et al., 2021; Findlay et al., 2020). Thus, it is unclear whether this EI would fully meet the needs and preferences of male support staff in the game. A further limitation is that while education and intention to report are important, they do not necessarily lead to behaviour change (Kroshus et al., 2015). Additional strategies, such as enhancing motivation, addressing physical and social capability, updating injury coding systems and fostering open dialogue, may be needed, with future prospective injury surveillance required to assess sustained changes in reporting behaviour around breast health issues (Bibby et al., 2024, 2025b).
Conclusion
This study showed that the developed EI can raise awareness and knowledge on breast health issues such as CBI and EIBP amongst active female Rugby Union players and support staff alike. The documented increase in awareness, alongside the potential development of an overall more open and supportive environment, may further facilitate the much-needed prospective surveillance of breast pain and injury, helping to establish long-term strategies that reflect the specific needs of female players. Greater engagement with the rugby community, both nationally and internationally, is essential to advancing conversations around issues of specific interest to female athletes, including but not limited to breast health. By including these often-overlooked areas, better support for female athlete performance and overall well-being, both in the short and long term, can be achieved.
