Journal of Science and Medicine in Sport 23 (2020) 898–901

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Journal of Science and Medicine in Sport

journal homepage: www.elsevier.com/locate/jsams

Editorial

Athlete health protection: Why qualitative research matters

The past 30 years of athlete health protection – namely, injury the work of QRSMed members around magnifying the athlete voice,
and illness prevention and management - has largely been success- exploring the circumstances under which elite athletes may hide
ful in answering the research questions that our field has, up until their pain, and uncovering the complexity of preventing and man-
now, sought to investigate. Interventions have proven efficacious aging injuries. Finally, we reflect on what the implications might
in a wide range of areas and populations, and the field has moved be for the research-to-practice gap.
to optimise effectiveness in recent years. Despite this success, it is If we truly believe that the athlete is in fact the main focus of ath-
widely acknowledged that athlete health protection still has several lete health protection, it stands to reason that their experiences and
challenges to address. perceptions should shape and inform the way we develop our ath-
These challenges include bridging the gap between research lete health protection strategies. Information about their beliefs,
and practice in a number of key ways, including for example: the perceptions, behaviour, preferences, and experiences can and do
inclusion of the athlete voice, and the implementation of health shape and improve healthcare decisions after all.4 Badenhorst and
protection strategies. In response to these challenges, recogni- colleagues5,6 reported on the experiences of South African rugby
tion of the complexity of athlete health protection has recently players who sustained spinal cord injuries on the field. The players
emerged and qualitative research methods have been advocated as in this study described the symptoms they experienced and how
one important approach that can provide new understandings and they tried to make sense of what was happening and importantly,
lead to better practical outcomes.1,2,3 This is because qualitative how they verbalised what they were feeling to fellow team-mates
research provides insight into athlete and other stakeholder per- or coaches. For example, several players experienced propriocep-
spectives, can improve clinical and implementation understanding tive disturbances, but did not understand what was happening
and outcomes, and may help us to consider the athlete experience to their bodies. Many players had never considered a spinal cord
in our health protection work. There is, in this way, a real need injury to be a possibility while playing rugby, nor what they would
for research that complements existing approaches and connects experience if it happened. Players described the factors they con-
researchers from different disciplines, and which also distinctly sidered to contribute to their injury, including descriptions of foul
holds space for the unique insights that qualitative approaches can play, which included illegal tackles (both by themselves and others)
add to current knowledge. In this way, qualitative research can and unsanctioned aggression with the intention to harm. For some
explore and incorporate dimensions that are not currently repre- participants, the pressure to perform meant winning at any cost,
sented in the literature, for better and more influential outcomes. leading to increased risk-taking behaviour. This research showed
In September 2019, we founded the Qualitative Research in that it is important for fellow team-mates, coaches and referees
Sports Medicine (QRSMed) special interest group. Our aim is to to be aware of the signs and symptoms of spinal cord injury, as
identify and champion strategies required to facilitate, support, - especially in amateur games and communities that have fewer
and incentivise qualitative research in athlete health protection. resources and less medical support (which is often the case in
The purpose of this editorial is, as a first step, to highlight why South Africa) - they are often the first to respond to an injured
qualitative research matters to athlete health protection. player.
Uncovering these complex layers of behaviour is key when con-
sidering preventative strategies.7 Optimal injury management may
1. Qualitative research in athlete health protection: key be influenced by various factors present at the time of injury and
examples these factors need to be understood in their respective contexts.8
‘Context’, in this sense, often plays a determining role in the way the
Encouragingly, high-quality and clinically/methodologically- injury management process unfolds. This is mirrored in work from
relevant examples of qualitative research are emerging in our field. Fagher and colleagues,9 who showed through qualitative research
These have revealed new, innovative, and helpful findings related that the perception of injuries and possibilities to prevent them
to athlete health protection. Whilst we recognise the importance may vary between and across athlete populations. In their research,
of quantitative approaches as being fundamental to some research Paralympic athletesṕerceptions and experiences of injury preven-
and practice questions, we also advocate that other decisions tion differed significantly from their able bodied peers due to the
are more usefully informed by qualitative (and mixed-method) already existing impairment. Consequently, these qualitative find-
approaches. To show this, we highlight qualitative exemplars from ings assisted researchers in specifically tailoring injury prevention
https://doi.org/10.1016/j.jsams.2020.06.020
1440-2440/© 2020 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
 Editorial / Journal of Science and Medicine in Sport 23 (2020) 898–901 899

programmes that are underpinned by the athletesówn perceptions sible to ‘drill below the surface’ to a more nuanced understanding
and possibilities.9 Similarly, the experiences of players reported of these complex interactions.
in the spinal cord injury study discussed above have been utilised A key example of where qualitative research may provide
by BokSmart,10 South Africa’s national rugby safety programme, in important additional information is the implementation stage of
their mandatory biennial courses to educate coaches and referees health protection strategies and guidelines, and in particular the
in the early recognition of these injuries. In this way, qualitative question “are contemporary findings and clinical recommenda-
research in athlete health protection is already proving impactful tions reaching the target audience, the athletes themselves?”
in athlete health protection policy and practice. In a recent work on sports-related concussion (SRC), despite an
A second example of qualitative research leading to differenti- evolving body of literature and scientific consensus on the topic,
ated insights is in the exploration of the circumstances under which ski racers’ understanding of SRC and its management revealed
elite athletes may hide their pain and injuries, and what the impli- to be strongly limited.24 Major shortfalls were related to: 1) ath-
cations might be for practice. Qualitative research here shows that letes’ grasp of the precise definition of SRC, 2) athletes’ awareness
elite athletes tend to ignore new physical complaints or delay seek- of the connection between SRC and affective symptoms, and 3)
ing care until it is too late. They also tend to return to training and athletes’ understanding of the reasoning behind graduated return-
competition too early after recovery.11 Concealing pain in order to to-play protocols. These three gaps may lead to the under-reporting
participate in competitions has been shown to be very common in of symptoms and premature return-to-play following SRC. These
elite sports,12–14 and one of the main reasons for this risky behavior findings, derived from qualitative research, have clear implications
is the so-called ‘culture of risk’ in these settings.15 for the implementation of athlete health protection measures.
To analyse the culture of risk by applying qualitative approaches Similarly, a recent qualitative study examined champion run-
thus seems particularly appropriate. The typical elite sports culture ners’ strategies to stay well and sustain their performance.25 It
is characterised by a collective tacit understanding that training and was found that these excelling athletes were characterized by
competing in pain is an expected part of elite sports.13 At the same their constant attention to symptoms of ill health and not let-
time, athletes perceive the willingness to return to competitions ting environmental strain interfere with adjustment of sports load.
after injuries and illnesses as early as possible as a precondition Many top-level runners originate from global regions where formal
for success.11 This research showed that some athletes are com- education programs and health insurance plans are poorly reg-
pletely aware of the health risks that go along with competing while ulated and supported, and this qualitative research showed that
being hurt, and are willing to accept the consequences. Yet that bio-psychosocial models including empowerment at individual and
others may not reflect upon the harmful nature of this behavior. systems levels should be considered when health and preventive
The research and practice questions related to this problem thus services are planned for professional runners. As Greenhalgh and
require a highly sensitive and investigative approach for gathering colleagues26 [pi563] write: “Qualitative studies help us understand
information about athlete perceptions and behaviors directly. In why promising clinical interventions do not always work in the real
this way, qualitative approaches are useful in assisting and identi- world, how patients experience care and the surrounding world,
fying the dynamics of being socialised into the culture of risk.16,17 and how practitioners think.” Further, qualitative research can help
In this way, qualitative approaches are useful in capturing details us better understand the complex relations within athlete health
about sensitive topics, hidden emotions, and confusing bodily expe- protection as a complex system, including the socio-ecological con-
riences during such biopsychosocial transitions.18 text in which athletes seek and receive care, and how best to
Qualitative research thus makes it possible to reveal harmful influence those involved in athlete health protection for better and
interaction patterns between athletes on the one hand, and train- more effective outcomes.
ers, clinicians and the broader sociocultural context of sport on the These examples show that, by applying qualitative methods, we
other.19 For example, athletes are expected to cope with stress- can gain an in-depth understanding of different contexts, and learn
ors without mentioning any complaints. As the performance level from insights that may shape future interventions.8 In this way,
increases, the more athletes are expected to show stoic invul- qualitative research can assist all stakeholders (including athletes,
nerability and ‘steeliness’. Ignoring and trivialising pain becomes governing bodies, coaches, and clinicians), to be more responsive
a standard behaviour, and athletes learn to inhibit their pain to the needs of athletes themselves, thereby putting sports in a
perception.20 This pain inhibition works because young athletes better position to provide optimal care resulting in better protec-
often transfer the control of their individual well-being onto the tion against injury and illness.5 By examining the complexities of
coach.21 Athletes accept that the coach decides whether training athlete perceptions and experience, qualitative methods may offer
loads or pain are too much for competition or training. Since the substantive improvements to a one-size fits all approach for athlete
coaches perceive themselves as to be guided by objective ‘load health protection.
standards’, and assume that they know the athletes and their com-
plaints, they tend to underestimate the athletes’ willingness to
ignore and conceal pain and injuries.18 Consequently, training load 2. A call to action: more and better qualitative research
and the actual resilience of the young athletes do not necessarily
coincide. Similar patterns are observable regarding the medical care With the turn towards the importance of centering the athlete
provided in elite sports. Medical care itself may not recognise or as key stakeholder - and their inclusion in research and practice
address the acceptance of the highly risky willingness to ‘compete decisions – qualitative research has never been more relevant or
hurt’.21 In the case of pain and injury, athletes expect their med- timely. Qualitative research has the inbuilt mandate to place the
ical staff to prioritise fitness for training or the next competition. stakeholder (often the athlete themself) front and center in both
Actions of medical staff are therefore often characterised by the formulating the research question as well as the analysis. Truly
logic of “repairing “instead of healing. In the case of pain and injury, athlete-centred approaches, as we have shown in our exemplars,
medical staff then often prioritise a “quick fix” instead of healing, will require that we embrace and incorporate the ‘multiple truths’
not infrequently due to real or perceived pressure. In this sense, and ‘social facts’ of our research and practice.27 This includes recog-
ethical dilemmas and power struggles characterise interactions in nising and integrating the perspectives of athletes, members of
the context of the treatment of injuries and pain.22,23 However, their multidisciplinary coaching, and clinical care teams, and others
ethical dilemmas and power struggles are not easily quantified. involved in athlete health protection.8 In this way, athlete health
Rather, what is needed is qualitative research that makes it pos- protection is now confronted with different kinds of questions that
900 Editorial / Journal of Science and Medicine in Sport 23 (2020) 898–901

require methodological pluralism and pluralist perspectives – with 22. Malcolm D, Safai P. Introduction: the social science of sports medicine, In: The
a specific focus on high-quality qualitative research - for better and Social Organization of Sports Medicine. Routledge, 2012.
23. Waddington I. 11 Ethical problems in the medical management of sports injuries,
more relevant outcomes.2 In: Pain and injury in sport: social and ethical analysis. Routledge, 2006.
By ensuring a seat at the table for qualitative research, we 24. Maxwell N, Redhead L, Verhagen EALM et al. Ski racers’ understanding of sports-
hold space for more clinically-relevant knowledge building, the related concussion and its management: are contemporary findings and clinical
recommendations reaching the target audience, the racers themselves? Br J
advancement of excellence in our field, and, ultimately, ensuring Sports Med 2020. Online First DOI bjsports-2019-101544.
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to, valuable for, and relevant to, the big picture of athlete health
26. Greenhalgh T, Annandale E, Ashcroft R et al. An open letter to The BMJ editors
protection. The time for high quality qualitative work has come, on qualitative research. BMJ 2016; 352:i563.
and as the Qualitative Research in Sports Medicine special interest 27. Atkinson ACP. Qualitative analysis: issues of theory and method. SAGE 1997.
group, we are eager to lead the way.
Sheree Bekker ∗
Conflict of interests Qualitative Research Centre, Department for Health,
University of Bath, UK
The authors have nothing to declare. Caroline Bolling
Amsterdam Collaboration on Health and Safety in
Acknowledgements Sports, Department of Public and Occupational
Health, Amsterdam UMC, Vrije Universiteit
The authors would like to acknowledge the Qualitative Research Amsterdam, Amsterdam Movement Sciences, The
in Sports Medicine (QRSMed) special interest group. Netherlands

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 Editorial / Journal of Science and Medicine in Sport 23 (2020) 898–901 901

Stephen Mumford Jörg Spörri

Department of Philosophy, Durhum University, UK Sports Medical Research Group, Department of
Orthopaedics, Balgrist University Hospital, University
Montassar Tabben
of Zurich, Switzerland
Aspetar Orthopedic and Sports Medicine Hospital,
Qatar Femke van Nassau
Evert ALM Verhagen
Ansgar Thiel
Amsterdam Collaboration on Health and Safety in
Institute of Sport Science, Eberhard Karls University
Sports, Department of Public and Occupational
Tübingen, Germany
Health, Amsterdam UMC, Vrije Universiteit
Toomas Timpka Amsterdam, Amsterdam Movement Sciences, The
Unit of Physiotherapy, Department of Health, Netherlands
Medicine and Caring Sciences, Linköping University,
∗ Correspondingauthor.
Sweden
E-mail address: s.bekker@bath.ac.uk (S. Bekker)
Joanna Thurston
Department of Rehabilitation and Sport Sciences,
18 June 2020
Bournemouth University, UK
Available online 3 July 2020
Linda K Truong
Department of Physical Therapy, Faculty of Medicine,
University of British Columbia, Canada