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Elite Para athletes report a high incidence of sports injuries, illnesses and other health issues. Despite this, there are few prevention programmes in Para sport, and many of the existing prevention programmes are not adapted to Para athletes. To improve the success of preventive measures, it has been suggested that sports safety work should facilitate health promotion, including athlete health education. Therefore, the overarching aim of this project is to evaluate an accessible health promotion web platform as part of a complex intervention that aims to improve knowledge of athlete health in Para sport. In this protocol, the development, future implementation and evaluation of the intervention are described. To inform the implementation and use of such interventions, it is recommended to involve end users in the development and implementation process. Therefore, a participatory design process, including athletes and the sports organisation, was used to develop an accessible health promotion web platform. To evaluate this complex intervention, a process evaluation combining quantitative evaluation assessing causal pathways with qualitative methods assessing multifaceted pathways will be used. The primary outcomes are injury/illness incidence, athlete health parameters, health literacy and user behaviour. A cohort of elite Para athletes (n=150) from Sweden and South Africa will be invited to participate. This project will be the first that aims to improve athlete health in Para sport through pragmatic and accessible health promotion. It is a boundary-crossing project that will be conducted in a real-world sport setting, including athletes with different socioeconomic backgrounds.

ObjectiveTo explore the prevalence of symptoms of mental health conditions and burnout of healthcare professionals (HCPs) working during the Tokyo 2020 Paralympic Games and the Beijing 2022 Paralympic Winter Games.MethodsIn this cross-sectional, observational study, HCPs working during the Tokyo 2020 and Beijing 2022 Paralympic Games were asked to complete an online, anonymous survey, which included demographic questions and questions regarding mental health symptoms including depression (Patient Health Questionnaire 9-item depression scale) and anxiety (Generalized Anxiety Disorder 7-item scale) as well as burnout (Maslach Burnout Inventory-Human Services Survey: depersonalisation, emotional exhaustion, personal accomplishment). Correlation coefficients (r) were calculated between demographic characteristics and mental health symptoms.ResultsIn total, 256 HCPs (of 857 HCPs; 30%) completed the surveys. Twelve and eight per cent of HCP scores fell within the moderate to severe depression and moderate to severe anxiety categories, respectively. More than 30% reported moderate to high burnout (depersonalisation: 36%; emotional exhaustion: 36%; personal accomplishment: 58%). In addition, thoughts of self-harm and/or suicidality were reported by some HCPs (8%). Weak correlations were observed between age and depression (r=−0.13, p=0.046), anxiety (r=−0.16, p=0.010) and burnout (emotional exhaustion: r=−0.14, p=0.032; personal accomplishment: r=0.27, pConclusionAlthough most HCPs reported good mental health, this study suggests that a subset of HCPs experienced symptoms of depression, anxiety, burnout or thoughts of self-harm during the Tokyo 2020 and Beijing 2022 Paralympic Games. While the generalisability of these findings outside of COVID-19 restrictions should be tested, appropriate guidance and mental health support of HCPs leading up to the Paralympic Games should be prioritised.

ObjectivesResearch evidence is commonly compiled into expert-informed consensus guidelines intended to consolidate and distribute sports medicine knowledge. Between 2003 and 2018, 27 International Olympic Committee (IOC) consensus statements were produced. This study explored the policy and practice impact of the IOC Statements on athlete health and medical team management in two economically and contextually diverse countries.MethodsA qualitative case study design was adopted. Fourteen face-to-face interviews were conducted with purposively selected interviewees, seven participants from Australia (higher economic equality) and seven from South Africa (lower economic equality), representing their national medical commissions (doctors and physiotherapists of Olympic, Paralympic and Youth teams). A framework method was used to analyse interview transcripts and identify key themes.ResultsDifferences across resource settings were found, particularly in the perceived usefulness of the IOC Statements and their accessibility. Both settings were unsure about the purpose of the IOC Statements and their intended audience. However, both valued the existence of evidence-informed guidelines. In the Australian setting, there was less reliance on the resources developed by the IOC, preferring to use locally contextualised documents that are readily available.ConclusionThe IOC Statements are valuable evidence-informed resources that support translation of knowledge into clinical sports medicine practice. However, to be fully effective, they must be perceived as useful and relevant and should reach their target audiences with ready access. This study showed different contexts require different resources, levels of support and dissemination approaches. Future development and dissemination of IOC Statements should consider the perspectives and the diversity of contexts they are intended for.

ObjectiveTo review risk factors associated with acute respiratory illness (ARill) in athletes, including non-infectious ARill and suspected or confirmed acute respiratory infections (ARinf).DesignSystematic review.Data sourcesElectronic databases: PubMed-Medline, EbscoHost and Web of Science.Eligibility criteriaOriginal research articles published between January 1990 and July 2020 in English were searched for prospective and retrospective full text studies that reported quantitative data on risk factors associated with ARill/ARinf in athletes, at any level of performance (elite/non-elite), aged 15–65 years.Results48 studies (n=19 390 athletes) were included in the study. Risk factors associated with ARill/ARinf were: increased training monotony, endurance training programmes, lack of tapering, training during winter or at altitude, international travel and vitamin D deficits. Low tear-(SIgA) and salivary-(IgA) were immune biomarkers associated with ARill/ARinf.ConclusionsModifiable training and environmental risk factors could be considered by sports coaches and athletes to reduce the risk of ARill/ARinf. Clinicians working with athletes can consider assessing and treating specific nutritional deficiencies such as vitamin D. More research regarding the role and clinical application of measuring immune biomarkers in athletes at high risk of ARill/ARinf is warranted.PROSPERO registration numberCRD42020160928.

ObjectiveTo determine the incidence of acute respiratory illness (ARill) in athletes and by method of diagnosis, anatomical classification, ages, levels of performance and seasons.DesignSystematic review and meta-analysis.Data sourcesElectronic databases: PubMed-Medline, EbscoHost and Web of Science.Eligibility criteriaOriginal research articles published between January 1990 and July 2020 in English reporting the incidence of ARill in athletes, at any level of performance (elite/non-elite), aged 15–65 years.ResultsAcross all 124 studies (n=1 28 360 athletes), the incidence of ARill, estimated by dividing the number of cases by the total number of athlete days, was 4.7 (95% CI 3.9 to 5.7) per 1000 athlete days. In studies reporting acute respiratory infections (ARinf; suspected and confirmed) the incidence was 4.9 (95% CI 4.0 to 6.0), which was similar in studies reporting undiagnosed ARill (3.7; 95% CI 2.1 to 6.7). Incidences of 5.9 (95% CI 4.8 to 7.2) and 2.8 (95% CI 1.8 to 4.5) were found for studies reporting upper ARinf and general ARinf (upper or lower), respectively. The incidence of ARinf was similar across the different methods to diagnose ARinf. A higher incidence of ARinf was found in non-elite (8.7; 95% CI 6.1 to 12.5) vs elite athletes (4.2; 95% CI 3.3 to 5.3).Summary/conclusionsThese findings suggest: (1) the incidence of ARill equates to approximately 4.7 per athlete per year; (2) the incidence of upper ARinf was significantly higher than general (upper/lower) ARinf; (3) elite athletes have a lower incidence of ARinf than non-elite athletes; (4) if pathogen identification is not available, physicians can confidently use validated questionnaires and checklists to screen athletes for suspected ARinf. For future studies, we recommend that a clear diagnosis of ARill is reported.PROSPERO registration numberCRD42020160472.

Physical activity behaviour is complex, particularly in low-resource settings, while existing behavioural models of physical activity behaviour are often linear and deterministic. The objective of this review was to (i) synthesise the wide scope of factors that affect physical activity and thereby (ii) underpin the complexity of physical activity in low-resource settings through a qualitative meta-synthesis of studies conducted among patients with cardiometabolic disease living in low-to-middle income countries (LMIC). A total of 41 studies were included from 1200 unique citations (up to 15 March 2021). Using a hybrid form of content analysis, unique factors (n = 208) that inform physical activity were identified, and, through qualitative meta-synthesis, these codes were aggregated into categories (n = 61) and synthesised findings (n = 26). An additional five findings were added through deliberation within the review team. Collectively, the 31 synthesised findings highlight the complexity of physical activity behaviour, and the connectedness between person, social context, healthcare system, and built and natural environment. Existing behavioural and ecological models are inadequate in fully understanding physical activity participation in patients with cardiometabolic disease living in LMIC. Future research, building on complexity science and systems thinking, is needed to identify key mechanisms of action applicable to the local context.

BackgroundThough rare, rugby union carries a risk for serious injuries such as acute spinal cord injuries (ASCI), which may result in permanent disability. Various studies have investigated injury mechanisms, prevention programmes and immediate medical management of these injuries. However, relatively scant attention has been placed on the player’s experience of such an injury and the importance of context.AimThe aim of this study was to explore the injury experience and its related context, as perceived by the catastrophically injured player.MethodsA qualitative approach was followed to explore the immediate, postevent injury experience. Semi-structured interviews were conducted with 48 (n=48) players who had sustained a rugby-related ASCI.ResultsFour themes were derived from the data. Participants described the context around the injury incident, which may be valuable to help understand the mechanism of injury and potentially minimise risk. Participants also described certain contributing factors to their injury, which included descriptions of foul play and aggression, unaccustomed playing positions, pressure to perform and unpreparedness. The physical experience included signs and symptoms of ASCI that is important to recognise by first aiders, fellow teammates, coaches and referees. Lastly, participants described the emotional experience which has implications for all ASCI first responders.SignificanceAll rugby stakeholders, including players, first responders, coaches and referees, may gain valuable information from the experiences of players who have sustained these injuries. This information is also relevant for rugby safety initiatives in shaping education and awareness interventions.

In 2020, the IOC proposed a universal methodology for the recording and reporting of data for injury and illness in sport. Para sport is played by individuals with impairment, and they have a unique set of considerations not captured by these recommendations. Therefore, the aim of this addendum to IOC consensus statement was to guide the Para sport researcher through the complexities and nuances that should be taken into consideration when collecting, registering, reporting and interpreting data regarding Para athlete health. To develop this translation, experts in the field of Para sports medicine and epidemiology conducted a formal consensus development process, which began in March 2020 with the formation of a consensus group that worked over eight phases, incorporating three virtual consensus meetings to finalise the translation. This translation is consistent with the IOC consensus statement, yet provides more detailed Para athlete specific definitions and recommendations on study population, specifically, diagnostic and eligible impairment categorisation and recording of adaptive equipment, and defining and classifying health problems in the context of Para sport. Additionally, recommendations and Para athlete specific examples are described with regards to injury mechanism, mode of onset, injury and illness classification, duration, capturing and reporting exposure and risk. Finally, methods and considerations are provided to cater to the varied needs of athletes with impairment with respect to data collection tools. This harmonisation will allow the science to develop and facilitate a more accurate understanding of injury and illness patterns for tailoring evidence-informed prevention programmes and enabling better planning of medical services for Para sport events.

BACKGROUND: Rugby carries a risk for serious injuries, including acute spinal cord injuries. The lifetime health consequences of these injuries may be far-reaching. PURPOSE: In this study, we aimed to describe barriers and facilitators to healthcare and rehabilitation, in individuals with rugby-related spinal cord injuries in South Africa. METHODS: This study adopted a pragmatic qualitative approach. Stratified purposive sampling was used to select interviews from players from a variety of socio-economic status and geographical areas for inclusion in this study. The final sample consisted of thirty-one (n = 31) participants. Thematic analysis was used to analyze the data. RESULTS: Participants described long-term, accessible, affordable, quality healthcare and rehabilitation as important contributors to their quality of life. Even though public healthcare is accessible from a cost point of view, quality of care, availability of rehabilitation services and factors such as affordability and availability of adequate transport remain a barrier for lower socio-economic groups. CONCLUSION: This population was unique, as the support from a dedicated organization enabled participants to overcome some barriers, highlighting the challenges of the healthcare system in maintaining the health of people with spinal cord injuries. Every effort should be made to create equitable access to healthcare and rehabilitation for persons with spinal cord injuries in South Africa.

Qualitative research is increasingly recognised as relevant and useful to uncovering and understanding\ud new and differentiated insights that move both research and practice forward. The field of athlete health\ud protection – that is, injury and illness prevention and management – is reliant on high-quality knowledge\ud of athlete and other key stakeholders’ perspectives, understanding of the complex relations within the\ud athlete health protection system, the socio-ecological context in which athletes are provided with\ud prevention and care, and how best to influence those involved in athlete health protection for better and\ud more effective outcomes. Yet, deep interrogation of these aspects is often overlooked in favour of\ud quantitatively-driven research questions. As athlete health protection research and practice matures, we\ud argue that there is a need for research that complements traditional approaches, connects researchers \ud 3\ud from different disciplines - but which also distinctly holds space for the unique insights that qualitative\ud approaches can add. The purpose of this editorial is to highlight the importance, value, and relevance of\ud qualitative research to the field of athlete health protection – in other words, why qualitative research\ud matters.

Objectives There is a paucity of research investigating mental health in Para athletes. The aim of this study was to describe mental health concerns of a representative sample of South African Para athletes. Design A descriptive, cross-sectional survey was conducted at the 2019 National Championships for athletes with impairments. Methods Mental health was measured with the Trait component of the State/Trait Anxiety Inventory (STAI-T), and the Kessler Psychological Distress Scale (K-10). Between-group differences were analysed using the Mann–Whitney U test or one-way ANOVA. Results A total of 125 athletes were included. The average score for the STAI-T was 39 (±9) units, whilst a quarter (25%) of all athletes scored ≥45. The mean K-10 questionnaire score was 20 (±6) units. K-10 scores indicated that 12 % of athletes may meet formal definitions for anxiety and/or depressive disorders (score of ≥28), while 76 % of athletes have a high level of subclinical symptoms (score of ≥16). On average, females (36 ± 9) had better STAI-T scores than males (40 ± 9; p = 0.02) and married athletes (33 ± 9) had better scores than unmarried athletes (40 ± 9; p = 0.002). K-10 scores were also significantly better in married than in unmarried athletes (p = 0.002), but there was no difference between sexes. Neither the K-10 nor STAI-T was associated with level of competition, sport code or impairment type. Conclusions The study identified a high prevalence of psychological distress and anxiety among South African Para athletes, compared to the general population. There is a need to further understand factors contributing to mental health in this population.

Most contact sports, including rugby union, carry a risk of injury. Although acute spinal cord injuries (ASCIs) in rugby are rare, the consequences of such injuries are far-reaching. Optimal management of these injuries is challenging, and a detailed understanding of the different barriers and facilitators to optimal care is needed. In this study, we aimed to describe the perception of players, regarding factors related to the optimal immediate management of a catastrophic injury in a developing country with socioeconomic and health care inequities. The most frequently reported barriers were transportation delays after injury and admission to appropriate medical facilities. Other barriers included inadequate equipment, the quality of first aid care, and barriers within the acute hospital setting. Barriers were more prevalent in rural and lower socioeconomic areas. These findings are relevant for all rugby stakeholders and may help shape education, awareness, and future policy around the immediate management of ASCIs.

Anne Frank wrote in her diary, ‘All children must look after their own upbringing. Parents can only give good advice or put them on the right paths, but the final forming of a person’s character lies in their own hands’. This quote illustrates the challenge faced by BMJ Open Sports & Exercise Medicin e (BOSEM) since its creation. Born in 2015, BOSEM was initially deemed as the ‘open access’ offspring of the British Journal of Sports Medicine . Six years later, BOSEM has published 629 manuscripts with over 900 unique authors listed. Our journal is ready to fly the nest. Now, the final forming of BOSEM’s personality lies with us, the new editorial team. Who are we, what is our personality, what makes us unique? We aim to support our community to make a difference for the general health and well-being of our patients, athletes and the world population. While this goal may not be truly unique in the sports and exercise medicine (SEM) landscape, the way we want to achieve it is. What makes us different is that BOSEM hosts clinically meaningful and impactful publications Open Access. Being true to the phrase ‘scientia potentia est’, all our content is freely available to everyone, and you can interact with BOSEM regardless of where you live and work. We take a continuous …

Supplemental material, supplemental_material_1 for When This Happens, You Want the Best Care by Marelise Badenhorst, Evert Verhagen, Mike Lambert, Willem van Mechelen and James Brown in Qualitative Health Research

Objectives Rugby-related spinal cord injuries (SCIs) are rare but life altering and traumatic events. Little is known about the long-term consequences and outcomes of players who have sustained these injuries. This study investigated current quality of life (QoL) and factors associated with QoL, among individuals with rugby-related SCI in South Africa, by using the International Classification of Functioning, Disability and Health (ICF) framework. Design Descriptive cross-sectional study. Setting Rugby-related SCI population of South Africa, as captured in the BokSmart/Chris Burger Petro Jackson Players' Fund database. Participants Ninety (n=90) of the 102 eligible players on the database agreed to participate in the study. Main outcome measure The relationship between QoL, as measured with the WHO Quality of Life questionnaire (WHOQOL-BREF) and specific independent variables (demographic information, level of independence and participation in various activities and life roles) was investigated. Variables that were significantly associated with QoL in bivariate analyses were included in multiple linear regression analyses. Results The mean score and SD of the WHOQOL-BREF was 15.1±2.3 arbitrary units. Participation (an ICF framework construct) and income were significantly associated with overall QoL (p

Objectives To compare catastrophic injury rates between the 14 South African Provincial Rugby Unions. Design A prospective, population-based study conducted among all South African Unions between 2008–2014. Methods Player numbers in each Union were obtained from South African Rugby’s 2013 Census. Catastrophic injuries were analysed from BokSmart’s serious injury database. Incidence rates with 95% Confidence Intervals were calculated. Catastrophic injuries (Acute Spinal Cord Injuries and catastrophic Traumatic Brain Injuries) within Unions were compared statistically, using a Poisson regression with Incidence Rate Ratios (IRR) and a 95% confidence level (p Results Catastrophic injury incidence rates per Union ranged from 1.8 per 100 000 players (95% CI: 0.0–6.5) to 7.9 (95% CI: 0.0–28.5) per 100 000 players per year. The highest incidence rate of permanent outcome Acute Spinal Cord Injuries was reported at 7.1 per 100 000 players (95% CI: 0.0–17.6). Compared to this Union, five (n = 5/14, 36%) of the Unions had significantly lower incidence rates of Acute Spinal Cord Injuries. Proportionately, three Unions had more Acute Spinal Cord Injuries and three other Unions had more catastrophic Traumatic Brain Injuries. Conclusions There were significant differences in the catastrophic injury incidence rates amongst the Provincial Unions in South Africa. Future studies should investigate the underlying reasons contributing to these provincial differences.

Background South Africa has 14 Provincial Rugby regions (9Unions9). Although rugby-related catastrophic injuries have been reported at 2.0 per 100 000 players per year, the comparative risk between each of these SA Unions has not yet been quantified. Understanding the difference in injury risk between Unions is important for potential intervention modifications. Objective The objective of this study was to compare the catastrophic injury incidence rates between the 14 SA Unions. Design A prospective, population-based study was conducted across all SA Unions between 2008–2014. Setting The number of verified players (males and females; under-seven age group to adult; amateur and professional) in each Union was obtained from SA Rugby9s 2013 Census. Patients (or Participants) Catastrophic injuries were analysed using BokSmart9s serious injury database. Interventions (or Assessment of Risk Factors) Union-specific injury incidence rates with 95% Confidence Intervals were calculated. Catastrophic injuries (Acute Spinal Cord Injuries (ASCI) and Traumatic Brain Injuries (TBI)) within Unions were compared statistically using a Poisson regression with Incidence Rate Ratios (IRR) and a 95% level of confidence (p Results Catastrophic injury incidence rates per Union ranged from 1.8 per 100 000 players (95% CI: 0.0 to 6.5) to 7.9 (95%CI: 0.0 to 28.5). The Union with the highest incidence rate of permanent outcome ASCIs was reported at 7.1 per 100 000 players (95% CI: 0.0 to 17.6). Compared to this Union, five (n=5/14, 36%) of the Unions had significantly lower injury incidence rates of ASCI. Conclusions Regional differences in catastrophic injury incidence rates exist in SA and interventions should be tailored accordingly. Future studies should investigate the underlying reasons contributing to these regional differences.