https://orcid.org/0000-0001-6691-6239
ABSTRACT
Athletes report poor breast/bra knowledge, breast pain, sports bras causing lacerations and chafing, negatively affecting sports performance. No bra interventions to address these issues are reported. Working with 142 UK female athletes preparing for Tokyo Olympics/Paralympics (27 sports), this multi-phase intervention assessed breast/bra knowledge, preferences, issues via surveys and breast/bra assessments. Data were used to develop two sports bras. A total of 112 athletes were prescribed one of the new bras through individual assessments. After four weeks, wear athletes completed evaluations. Pre-intervention breast/bra knowledge was low (83% ≤average), multiple breast/bra issues were reported and most athletes wore ill-fitting, loose bras, offering limited support. Post-intervention, 63% reported improved knowledge and 97% reported their prescribed bra as better than their original bra. Eighty-seven per cent reported benefitting from this intervention, with 17% reporting improved performance. This intervention effectively assessed sports bra needs, developed and implemented solutions, which improved knowledge and potentially performance for some UK athletes.
Introduction
Survey studies report that most (77%) UK adult females rate their breast/bra knowledge as average or below average (Burnett et al., Citation2015). Similarly, studies report the majority in active cohorts also have average or below average breast/bra knowledge (Brown, White, Brasher, Scurr et al., Citation2014a; McGhee et al., Citation2010). Poor bra knowledge is linked to poor bra choice and poor bra fit (McGhee et al., Citation2010). However, during sport, wearing appropriate bras is essential to restrict breast motion caused by weak intrinsic, anatomical breast support (Page & Steele, Citation1999). Sports bras restrict breast motion in two ways; compressing or encapsulating tissue. Previous research found encapsulating bras more effective at reducing breast motion than compression bras (McGhee & Steele, Citation2020).
Selecting appropriate sports bras can reduce breast pain (Scurr et al., Citation2010), reduce potential tissue damage (Sanchez et al., Citation2017), reduce embarrassment related to breast movement (Burnett et al., Citation2015), improve running mechanics (Milligan et al., Citation2015), change upper body muscle activity (Milligan et al., Citation2014), change gait parameters (White et al., Citation2009) and change breathing frequency (White et al., Citation2011). However, sports bra selection is challenging (McGhee et al., Citation2010) and elite athletes may face similar or greater challenges than general populations due to atypical anatomy, sporting demands and prolonged wear. Therefore, this presents unique opportunities for elite athlete bra education, assessment, development and prescription.
Sports bra preferences and issues are reported across active cohorts; issues include rubbing/chafing, shoulder straps digging in, straps slipping and fasteners digging in (Bowles et al., Citation2012; Brown, White, Brasher, Scurr et al., Citation2014a; Burbage & Cameron, Citation2017). However, sports bra preferences and issues are not widely understood in elite sport, including in the United Kingdom (UK). Elite female athletes in Australia reported lacerations or chafing caused by sports bras (Brisbine et al., Citation2019), negatively effecting sporting performance (Brisbine et al., Citation2020; Brown, White, Brasher, Scurr et al., Citation2014a).
Bra development based on preferences and issues within specific cohorts has been reported in limited published studies; posture bras (Jones et al., Citation2021); body armour bras (Coltman et al., Citation2022); nursing sports bras (Morris et al., Citation2017); larger-breasted sports bras (Krenzer et al., Citation2005); senior generation bras (Lim & Cho, Citation2013); and bras for older Chinese women (Zhang et al., Citation2021). These studies commonly include initial assessment, prototype development, wearer trials and outcome evaluation. Bra prescription based on individuals’ preferences and issues has also been reported to a limited extent. Sharland et al. (Citation2021) prescribed bras to breast pain patients, identifying improvements in quality of life post-intervention.
Breast/bra preferences and issues are commonly assessed through surveys. However, due to low breast/bra knowledge, surveys may not provide a full understanding of breast/bra needs. Instead, individual, semi-structured discussions and bra assessments may contribute richer data beyond survey results (Robson, Citation2011). Individual bra assessments would also enable bra size evaluation, which is known to be poorly understood (McGhee & Steele, Citation2020; McGhee et al., Citation2010).
In collaboration with English Institute of Sport (EIS) and Clover Global (bra manufacturer), working with elite female athletes within the UK High Performance System (UKHPS) preparing for the Tokyo Olympics/Paralympic, this multi-phase intervention study firstly aimed to assess breast/bra knowledge, preferences and issues via surveys and individual breast/bra assessments; using these data two sports bras were developed (phase one: pre-intervention). Aim two was to prescribe these sports bras based on athletes’ individual needs (phase two: intervention), and aim three was to evaluate outcomes of this sports bra intervention (phase three: post-intervention assessment). It was hypothesized:
H1. Utilizing feedback on breast/bra preferences and issues would enable the development of more appropriate sports bras compared to athlete’s original bra.
H2. When compared to athlete’s original bra, breast/bra issues would be reduced in the prescribed bra.
H3. Athletes would perceive an improvement in sporting performance when wearing a bra developed based on their preferences and issues compared to their original bra.
H4. Athlete’s perception of their breast/bra knowledge would improve pre to post intervention.
Methods
Study design
This study received institution ethical approval (University of Portsmouth, Faculty of Science Ethics Committee; SFEC 2019–023). This was a repeated measures intervention consisting of three phases, each with different sample sizes of elite female athletes within the UK High Performance System preparing for the Tokyo Olympics/Paralympics (). In phase one 30 athletes attended individual breast/bra assessments, with 22 completing pre-intervention surveys. Breast/bra assessments were undertaken by breast/bra specialists (researchers/trained bra fitters with >6 years experience) and bra designers from the Research and Development team, Clover Global, bra manufacturing partner for this intervention. The designers used information from phase one to develop two, non-commercial, sports bras () that attempted to address athletes’ needs. For phase two, pre-intervention surveys (n = 89) and breast/bra assessments continued (n = 112), during which athletes were prescribed one of the two new sports bras. For a minimum of four weeks, athletes wore their prescribed bras and 30 athletes completed post-intervention evaluations (phase three).
Figure 1 a. Medium support compression style; lightweight, non-padded crop top, with adjustable straps, 50 g fabric with xtra-dry nylon yarn, zoned wing, clean cut edges, wide comfortable underband, rigid adjustable front strap, racer back, optional removable cookie. b. High support encapsulation style; padded cups, adjustable straps and two adjustable back closures, 50 g fabric with xtra-dry nylon yarn, rigid front strap and top cup, perforated foam cup with birdseye lining, wing design has a continuous strap pull, back wing double hook and eye adjustment, specially developed curved hardware, wide comfortable underband.
Table 1. Study design, timeline and sample sizes.
Survey
Breast/bra knowledge, preferences and issues pre- and post-intervention were assessed using an online survey designed for this cohort (Wakefield-Scurr et al., Citation2022). The survey began with study information and consent, finishing with contact details for post-intervention surveys. The survey collected data on demographics, breast pain, bra use and preferences, [post-intervention] prescription bra feedback, and study evaluation.
Individual breast/bra assessments
Breast/bra assessments in phase one and two took place at EIS training centres across the UK. Assessments took ~15 minutes, beginning with an explanation of procedures and consent. Athlete’s current sports bra fit (White & Scurr, Citation2012) and style were assessed, in phase two bra size was also assessed in the two prescription sports bras, and assessment discussions were semi-structured to ensure consistency. Athletes were given bra advice based on their anatomy, sport, preferences, size and comfort. Encapsulating support was often recommended for more dynamic sports and larger bra sizes. Phase two athletes then chose their preferred prescription sports bra and received samples for use during training/competition (). Prior to the Olympics, athletes wear tested their prescribed bra for ≥four weeks before completing post-intervention surveys. If no response was received, weekly follow-up emails were sent for four weeks.
Table 2. Number of athletes fitted and bra style selection for each sport.
Bra development
Survey and breast/bra assessment data were combined to determine key bra performance variables, issues and preferences. Additionally, other factors were considered in the bra development: heat/humidity in the Tokyo Olympics, previous experience of appropriate sports bra features and designs, offering options across the two bras. Once data were gathered, bra development began with manufacturer testing of existing commercial bras to determine what features might address athletes’ feedback. Existing bra frameworks were used to incorporate relevant features. Two sports bras were developed: high support encapsulation and medium support compression. Many features would not be scalable or cost-effective commercially; however, this was not a consideration. Initial prototypes were developed in one size (34B), which underwent two rounds of industry standard fit testing with a fit model, wear testing and wash testing. The bras were informally tested during jumping and running using video recording. Following each test updates were made. Bras were then graded to larger sizes (34D and 38DD), fit model tested, wear tested and updated accordingly. A full-size range (32–44 underband, A-G cup) was then made in white and shipped to the testing team. The designer was present for the first 20 athlete fit-sessions.
Data analysis
Demographic data were assessed for normality using Kolmogorov–Smirnov and Shapiro–Wilk Tests (p > 0.05). Normally distributed data were compared across phase one and two using Independent T-Tests. All data demonstrated homogeneity of variance (Levene test, p > 0.05). Where data were not normally distributed (p < 0.05; ~half of variables), Mann Whitney U Tests were conducted. Phase three data were not normally distributed (p < 0.05), so pre- post-intervention data were compared within-participant using Wilcoxon Signed Ranks Tests.
Results
Phase one: initial breast/bra survey and assessment
Survey data for phase one athletes (n = 22) identified self-reported bra sizes 32–44 underband, A-G cup (). All except one athlete wore sports bras during training/competition. The majority wore compression sports bras (74%). Key performance indicators were comfort, then performance/function. Racerback shoulder straps were most popular, with adjustable straps and underband. Wide straps and maximum coverage were preferred, with most wanting nipple concealment. Underwire, padded or moulded cups, narrow, padded straps were not as important. Most athletes experienced sports bras rubbing/chafing (78%), and five of 22 reported conflicts between their sports bra and smart device (GPS tracker, etc.).
Table 3. Mean, mode, range, percentage and frequency outcomes from the pre-intervention breast and bra survey with 89 elite female British athletes that took part in phase 2 of the study (*denotes significant differences between the groups in phase one and two)
In bra assessments, most athletes wore ill-fitting bras, with loose underbands and limited support. Thirteen athletes (59%) needed bra size adjustment, the largest being 36D to 32DD. Many reported using bras provided by their sponsors, regardless of fit or appropriateness. Several reported bra discomfort in the heat, heat rash at the underband and heavy, sweaty bras when hot. Athletes felt thermal comfort was particularly important in Tokyo.
Phase one: bra development
Bra A was compression, medium support; the most popular pre-intervention style and Bra B was encapsulation, high support; less popular, but usually because athletes were unaware of this style. Encapsulation style was chosen based on previous research demonstrating superior support, particularly for larger breasted females. Given the hot/humid environment of Tokyo, the fabric used for both bras contained extra-dry nylon yarn, which was wicking, breathable and cooling with UV protection. It also utilized special knitting methods which created thin, lightweight fabric, which remained opaque. To enable a streamlined silhouette, there were minimal elastics in specific areas. Comfort was the key bra performance variable, so both bras contained minimal seaming, clean cut edges and wide underbands. Bra A had racerback straps (most popular pre-intervention) and Bra B had straighter straps (for choice). Based on feedback and for choice, Bra B had an adjustable underband, Bra A did not. Again, based on feedback, both bras incorporated shoulder straps that were adjustable and wide, plus large front panels for maximum coverage, without being visible under clothing. For nipple concealment, Bra A contained removable pads and Bra B padded cups. Both bras were designed to retrofit GPS pockets.
Phase two: breast/bra assessment and bra prescription
In phase two, 112 athletes attended individual breast/bra assessments. Again, most (73%) wore compression bras (), but following fittings in the new sports bras and advice, 36 athletes (32%) changed style, with more choosing encapsulation over compression. Fitted sizes ranged from 30 to 40 underband and A-H cup. Compared to phase one, phase two athletes displayed similar demographics but lower body mass (t = 2.106, P = 0.008) and a wider range of sports (). The prevalence of breast pain in this cohort was significantly less than phase one (U = 676.5, p = 0.003). However, for symptomatic athletes’ severity, cyclic nature, things that increased/decreased breast pain, and when breast pain occurred were similar across cohorts. Bra use in the two cohorts was similar, however, due to the different sports included in phase two, significantly fewer athletes (20%) reported smart devices conflicting with their sports bra, compared to phase one (42%) (U = 655.0, p = 0.047). Sports bra preferences were similar across phases one and two, except for nipple concealment, which was somewhat important in phase one athletes, but not at all important for phase two athletes.
Phase three: post-intervention evaluation
Post-intervention surveys were completed by 30 athletes who attended phase two breast/bra assessments and were prescribed a bra, which they wore ≥four weeks. Athletes reported wearing their prescribed bras 3 to 5 times a week (n = 14), 1 to 2 times a week (n = 13) or ≤once a week (n = 3). Ninety-seven per cent reported their prescribed sports bra as significantly better than their original bra (p < 0.001; ). Twenty-eight of the 30 athletes (93%) reported continuing to use their prescribed bra. Interestingly, when wearing their prescribed bra, no athlete reported breast pain. However, six athletes (20%) reported that their prescribed bra affected the fit or style of clothing. There was a 50% increase in athletes reporting they “never” experience rubbing/chafing and a 38% increase in athletes reporting they “never” experience shoulder straps digging in when wearing their prescribed bras compared to their original bras (). Overall the most liked feature of Bra A and B was tightness/firmness.
Figure 2. Phase three, study outcomes: a. Median athlete rating (0 = really bad and 10 = really good) for the overall function of their prescribed sports bras versus their original sports bras (* = P < 0.05). b. Frequency of responses from Likert scale questions regarding sports bra-related issues experienced by athletes in their original and prescribed sports bras. c. Athletes rating of their breast and bra knowledge before and after the individual bra assessment and prescription (n = 30)
Twenty-six of the 30 athletes (87%) reported benefitting from involvement in this intervention; benefits were less breast movement (improved support) = 22 (73%), greater garment comfort = 16 (53%), improved sporting performance = 5 (17%), improved aesthetics = 5 (17%) and less breast pain = 4 (13%). Athletes reported behaviour change since the intervention; replacing their bras more regularly = 18 (60%), wearing different sports bra styles for different activities = 16 (53%), wearing different sports bra styles = 10 (33%), professional bra fittings = 9 (30%). Sixty-three per cent reported their breasts/bra knowledge improving pre- to post-intervention, with the number of athletes reporting good breast/bra knowledge post-intervention increasing by 81% ().
Discussion
Phase one: initial breast/bra survey and assessment
This study reached 142 elite female athletes within the UK High Performance System preparing for the Tokyo Olympic and Paralympic Games, across 27 sports, with bra sizes 30–44 underband, A-H cup. Overall, 111 surveys were completed, with 83% of athletes initially reporting their breast/bra knowledge as average or poor. Most (73%) had never been professionally fitted for a sports bra and most (33%) replaced their sports bra over a year ago. Breast pain was experienced by 25% of all athletes in this study and 25% of these reported breast pain affecting their ability to give 100% during training/competition. Breast pain prevalence in this elite cohort is substantially less than previously reported in general (Scurr et al., Citation2014), active (Brown, White, Brasher, Scurr et al., Citation2014a) and elite populations (Brisbine et al., Citation2020). In phase one, 50% reported breast pain, which is comparable to previous literature (44%; Brisbine et al., Citation2020); however, in phase two, breast pain prevalence was significantly less. This may have occurred because phase one athletes engaged due to issues they had with their breasts or bras, compared to phase two athletes who may have engaged to receive a free bra.
Phase two: breast/bra assessment and bra prescription
Across all athletes, most reported that they wore a sports bra (99%), and similar to previous general population research, this was mostly a compression sports bra (Brown et al., Citation2021). Individual bra assessments revealed that most athletes were unaware of other sports bra styles and most wore ill-fitting bras, with loose underbands and limited support. When educated on alternative sports bra styles, 32% opted for a different style (encapsulation over compression). As 97% of athletes reported their prescribed bra to be better than their original bra, this suggests that on its own, education on sports bra styles may be useful for future sports bra interventions.
In general, athletes preferred non-underwired, racerback bras, with adjustability and maximum coverage. Similar to previous research, athletes identified comfort, fit and support as most important when selecting sports bras (comfort, support, fit (Sharland et al., Citation2021); aesthetics, comfort, practicalities of purchase, support (Risius et al., Citation2012); comfort, support, fit (Brown et al., Citation2021)). Rubbing/chafing and shoulder straps digging in were the most common sports bra issues. Sports bra preferences and issues for elite athletes appear comparable to other populations (Brown et al., Citation2021), suggesting that the bra industry faces similar bra design challenges when catering for elite athletes as other active populations.
Although not reported previously, athletes highlighted the need for aesthetic and structural variety in their sports bras to enable compatibility with their outer kit. This study demonstrates the opportunity for the sports bra industry to consider not only the functional requirements of the garment but also the environment and sports rules and regulations in which the athletes operate.
Phase 3: post-intervention evaluation
In post-intervention surveys 97% of athletes reported their prescribed bra as better than their original bra accepting hypothesis one. Overall rating, fit and support of the prescribed bras were significantly better than athletes’ original bras. Prescribed bras reduced bra-related issues (such as rubbing and chafing), accepting hypothesis two. Contradictory to previous research (Bowles et al., Citation2012) the tightness of the prescribed bra was the most liked feature. This could be due to greater sports bra habituation for these elite athletes compared to general or active populations.
When evaluating this study, 87% of athletes reported benefitting from their involvement. Importantly for this intervention, 17% reported that the intervention improved their sporting performance, accepting hypothesis three for these athletes. Even if the prescribed bra provided no actual performance benefit, the placebo effect may manifest in an actual improvement in performance, as reported in other athlete interventions (Beedie & Foad, Citation2012). Athletes also reported positive breast/bra behaviour change since their involvement in this project, with 60% replacing their bras more regularly. Hypothesis four is accepted for 63% of the athletes who reported improvements in breast/bra knowledge due to this study. The results suggest that this study provided short-term benefits (reduced upper body pain for example), longer term benefits (improved breast support), sporting benefits (self-reported improvements in performance) and health benefits (utilizing professional bra fittings) for female athletes.
Limitations
Low post-intervention response rates were disappointing, and it may be that those who gained more from the intervention completed the post-intervention survey, skewing results. However, the postponement of the Tokyo 2020 Olympics and Paralympics meant that some athletes who attended bra assessments initially were unable to use their prescribed bras due to changes in aspects such as team selection or body composition changes, although this was only anecdotally reported.
In conclusion, this novel research reached 142 athletes within the UK High Performance System preparing for the Tokyo Olympics/Paralympics. The results demonstrated low breast/bra knowledge initially (83% reporting ≤average knowledge), which improved following the intervention. Multiple breast/bra issues were reported, individual breast/bra assessments revealed most athletes wore ill-fitting bras, with loose underbands, offering limited support and athletes were unaware of sports bra styles beyond compression. Bra assessment enabled the development of two sports bras, which included adjustable racerback straps, maximum coverage and moisture management; these were prescribed to 112 athletes. This sports bra intervention was highly successful with 97% of athletes reporting their prescribed bra as better than their original bra. Eighty-seven per cent reported benefitting from involvement in this intervention, with 17% reporting performance benefits. This multi-phase intervention was effective at assessing sports bra needs, developing and implementing a solution, which improved knowledge and perceived sporting performance for some elite athletes within the UK High Performance System preparing for the Tokyo Olympics/Paralympics.
Data availability
The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.
Acknowledgments
Sigi Rabinowicz, at the time of this study, was Head of Research and Development at Clover Global Ltd. Athletes and support staff for supporting this project.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Additional information
Funding
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