The challenge and impact of engaging hard-to-reach populations in regular physical activity and health behaviours: an examination of an English Premier League ‘Football in the Community’ men's health programme

Highlights

• Professional football clubs can attract hard-to-reach men to health programmes.

• Economic, environmental and social barriers to participation were apparent.

• Engagement in the programme resulted in positive psychosocial developments.

Abstract

Objectives

To investigate the challenges that men from hard-to-reach (HTR) populations encounter when attempting to commit to regular participation in physical activity and health behaviours, and to explore the psychological and social effects of participation in a twelve week football-led health improvement intervention.

Study design

A twelve week football specific physical activity intervention targeting men from HTR populations was delivered by Everton Football Clubs' Football in the Community (FitC) scheme as part of a national programme of men's health delivered in/by English Premier League (EPL) football clubs. Men living in homeless shelters and/or recovering from substance misuse were recruited over a period of three months. The programme consisted of a two hour football session, twice weekly, alongside the dissemination of healthy living messages. Football sessions were conducted by a qualified FitC coach.

Methods

This research was conducted during a twelve week period of immersed practitioner-research. Ethnographic and observational methodologies were adopted. Psychosocial issues were discussed with participants through informal client–researcher interactions and data were logged via field notes. Records of attendance were logged. Participants who failed to attend a session were contacted and their reason(s) for non-attendance were recorded. Data were analysed using deductive and inductive reasoning.

Results

Despite the apparent ambition of the participants to regularly participate in the FitC programme, adherence to the programme was poor. Economic, environmental and social barriers to engagement in the programme were apparent. Engagement in the programme resulted in positive psychosocial developments; the development of structure, social interaction and social capital.

Conclusion

Community based football-led health improvement programmes endorsed by professional football clubs appear well positioned to connect with, and attract, men from HTR populations. The evidence suggests that such programmes can improve psychosocial health amongst these populations. However, a bottom-up programme design and management strategy is required in order to reduce the challenges facing HTR participants when attempting to regularly engage in physical activity and health behaviours.

Introduction

Our paper presents the impact of a gender specific health improvement programme for hard-to-reach (HTR) males (including men experiencing homelessness and/or men recovering from substance misuse) delivered by an English Premier League Football Club. By definition, HTR populations are described as ‘those people who are difficult to access and/or engage with due to specific factors such as accommodation, age, ethnicity, gender, income, language, location and religion’.1, 2 Although the term ‘HTR’ has been the subject of much debate,³ it is often used within the health sector when referring to individuals who find it difficult to engage in physical activity (PA) and/or positive health behaviours, or who do not access the allied health services that are available to them.4, 5

Men from HTR populations frequently report poor health statistics⁶ and have therefore been highlighted as a particular area of concern for men's health practitioners and professionals.⁷ It has been argued that participation in regular PA and engagement with health services can significantly improve the overall health and well-being of HTR populations.8, 9 However, people from HTR groups often experience difficulty engaging in PA for a sustained period of time and are reluctant to engage with traditional health services.8, 9, 10 At present, there remains a lack of contextual evidence which provides insight into the difficulties experienced by men from HTR groups when attempting to engage in PA and health behaviours.¹¹ In order to extend our understanding of why men from HTR groups experience difficulty engaging in physical activity and health behaviours, it is critical to understand the contextual barriers and challenges that such populations encounter.¹²

For many years, health promotion efforts (targeting a range of health behaviours) tended to focus primarily on individual lifestyle and behaviour change. Specifically, the accepted approach was to place the onus on the individual to take responsibility for managing or improving their own health.¹³ According to Ball¹⁴ however, this approach was problematic as ‘individuals do not live in a vacuum, rather efforts to modify behaviour are constrained (or facilitated) by a range of social, economic and environmental forces.’ There is now a wealth of evidence to support the notion that physical health, mental health and social well-being are deeply influenced by the social, economic and environmental context of peoples' lives.13, 14, 15, 16, 17

Collins and Kay's¹⁸ review of the literature on sport and social exclusion amongst HTR groups uncovered social, economic and contextual constraints (lack of structure, income, skills, social capital and a sense of powerlessness) as the major barriers to engagement. These barriers resonate with the World Health Organization's Social Determinants of Health.¹⁵ Although social, economic and environmental influences have been identified and recognised as barriers amongst HTR groups, there remains a lack of evidence which gives voice to HTR populations and/or offers an opportunity for them to express their needs and challenges when engaging in sport, exercise, PA and health behaviours.¹⁹

Sport England⁹ argued that it is important to identify what specific health, well-being and social benefits HTR populations can accumulate from regular engagement in PA and positive health behaviours and similarly aligned programmes. Recently, Sherry and Strybosch¹² published findings from their longitudinal survey of Australia's Community Street Soccer Programme (CSSP) for HTR populations. The CSSP programme engaged HTR males (n = 165) in weekly soccer (football) specific training sessions and aimed to promote independence, self-reliance and build social capital. The majority of the participants in this study derived from low socio-economic situations, had past or current experiences of homelessness, and associated social disadvantages including drug and alcohol dependency and long term unemployment. Participants of the scheme were interviewed to investigate the intrinsic benefits and the social outcomes of participation in the programme. The study found that engagement in the programme improved health, developed social capital, built self-esteem, created structure and routine, and created a positive self-identity. However, this study acknowledged that the HTR participants had a range of complex issues which they brought with them and thus, hindered retention and successful implementation of the programme.

The findings of these studies are useful for building an understanding of the barriers to, and impact of, engagement in a football specific programme for HTR male populations. However as Frisby¹⁹ suggested, we need to dig deeper in order to develop rich contextual evidence which examines what lies behind health-related behaviours amongst HTR populations, and more specifically, about the long term effectiveness (or not) of health promotion interventions with these populations.

As highlighted in previous research, an emerging area of men's health in the UK is the provision of health and well-being programmes and activities delivered in, and by, sporting organisations.20, 21, 22, 23, 24, 25, 26, 27 The Royal Society for Public Health²⁸ have endorsed the importance of the setting approach for health improvement and White and colleagues'²⁹ review of men's health in the European member states suggested sport and leisure contexts as channels for connecting men with health promotion activities. Due to the popularity of the English Premier League (EPL), Football in the Community programmes have been championed as a vehicle to reach and connect with HTR populations.21, 30 Such programmes provide a platform for gathering contextual data which aims to offer a real-life appreciation of HTR men's barriers to engagement in regular and sustained physical activity and health behaviours. However, less is known about the impact of programmes engaging HTR men in football settings. Specifically research is needed on the (I) factors that facilitate engagement and the (II) psychosocial effects of participation.

The aim of this research is to examine the distinct challenges that men from HTR populations encounter when attempting to commit to regular participation in a national men's health programme (named Premier League Health) and explore the psychological and social effects of participation in the twelve week physical activity and health intervention using qualitative methodologies (i.e., those that allow for the voices, experiences and insights of HTR populations to be heard).

Through these aims, this study endeavours to provide men's health practitioners with knowledge and guidance for tailoring their approach to physical activity and health behaviour programmes with HTR populations in order to achieve the following; reduce the alleged challenges to engagement, ensure more sustained participation, maximise health and well-being benefits and subsequently ensure successful implementation and maintenance of men's health programmes.