Developing a theory-driven framework for a football intervention for men with severe, moderate or enduring mental health problems: a participatory realist synthesis

Figures & data

Table 1. Three “clusters” of participants in the consultative exercise, including PPI participants.

Players (PPI)	Football sector/providers	Mental health service providers/ practitioners
Three discussion groups Total of 12 men who were mental health service users involved in football interventions	Professional football club Community Trust coaches/project leads (4) Regional football governing body disability officer (1) Volunteer community coaches (2)	Occupational therapists (3) Hospital-based fitness instructor (1) NHS Foundation Trust Physical Activity Lead for mental health service users (1)

Figure 1. PRIMSA flow diagram (Moher, Liberati, Tetzlaff, & Altman,2009).

Table 2. Included studies’ characteristics and main findings.

Paper	Participants	Methods	n	Main findings
Battaglia et al. (2013)	Male Aged 18+ Diagnosis of schizophrenia	Randomised Controlled trial	18 Action (10); Control (8)	Overall improvement in psychophysical health • 10.5% improvement in physical component measure from baseline. • 10.8% improvement in mental component measure from baseline. Reduction in antipsychotic medication-related weight gain Statistically significant improvement in physical test measures e.g. 30 m sprint
Brawn et al. (2015)	Male (implied) Aged 25–63 Range of MH conditions from mild to severe	Qualitative interviews	7	Valued components: “connection stories” shared between players encourages ongoing involvement; also connects players to society Ethos of mutual respect “Safe environment”’ that encourages mutual aid Participation has “restorative power” to build confidence Players display a “recovery identity”: connection to the younger (well) self are important Fosters feelings of belonging and community (unity); “supportive reciprocal relationships” League helps build “team identity” with unity, respect and support at centre Football an “empowering setting”
Darongkamas et al. (2011)	Male Aged 24–50 Low SES Severe and enduring mental health problems MH service users	Survey questionnaire	10	Football enjoyable/fun and highly rated by participants Players felt comfortable and valued in the team; offered support/a network for recovery Felt benefits of socialising: camaraderie and friendship (reported inclusion as a strong outcome) Playing improved how players felt about themselves and their outlook on life Reported change in attitude towards their illness (self-stigma) – saw MH as only a part of themselves/the person Improved confidence and self-esteem; “spill over” to other life areas e.g., education, employment Easier to cope with MH symptoms and stressors
Douglas and Carless (2012)	Mixed male/female Serious mental illness	Qualitative interviews Documentary analysis Routine data analysis Service user feedback forms	21 25	Positive experiences e.g. friendly, “safe” place, supports trajectory of recovery, gives confidence Structural funding over time improved interventional reach, improved partnership developments and enabled continuity of service Range of sessions met different needs of those during their recovery from SMI Service users’ contributions to the development of programme was empowering and satisfying Structure and ethos of sessions – friendly, welcoming, accepting, caring, not overly competitive, offered reciprocal support. Must see the connection, friendships, schedule of the intervention in the light of the very limited and limiting experiences that go along with SMI – isolating, lonely, boredom, trauma Qualities of leaders/coaches critical - friendliness, accepting nature, relaxed demeanour, respectfulness, flexibility, supportive, approachable, and encouraging. Also – allow to play at own level whilst gently pushing for improvement and can offer skills training (encouraging mastery)
Derby County in the Community (2010)	Male Aged 18–49 (mean 32) Mental health problems	Focus groups	20	Improved sociability, friendship connections; evidence of sociability between players outside of formal sessions Important attention paid to timing (afternoon), cost (subsidised), regularity (weekly, same time each week), local venue [enabling access to the intervention] and value structure to sessions and training with coaching from a qualified coach Reports of reducing MH symptoms e.g. anxiety, reduction in stress Referred to as “normal” activity; distracts from problems Family support and improved relationships facilitated participation Improved confidence, motivation Value of teamwork, developing skills Family feel of club valued Improved physical fitness Desire to see integration with non-MH participants
Edwards (2006)	Young men with mental illness	n/a Intervention development description	n/a	Travel to/from training can become self-supporting as players devise friendship networks through football Motivation to attend training mitigated by mental illness; can be frustrating Suggests offering football as a sport and not a MH referral service can usefully separate treatment and everyday life Helpful if players can organise/take ownership over time Notes that players socialise outside of football Comments on need to sensitise and train coaches on some of the challenges of mental illness
Henderson et al. (2014)	83% male at baseline 49% unemployed at baseline Unclear: age and MH conditions	Focus groups Survey questionnaire	5 182	Valued components: social contact and interaction Part of a structured week – routinisation and normalisation Liked being treated as an equal by staff Reported easily accessible and welcoming; in particular, not too much paperwork Reported improved self-esteem and confidence in players Physical health improvements reported by players No significant difference reported in development of social capital using objective measure Significant difference in the development of personal skills between baseline and follow-up
Time to Change (2013)	82% male Adult Broad definition of mental health problems	Survey questionnaire Focus groups Routine data analysis	196 5	Different way of attracting traditionally hard to reach group; Football appealing Helps reduce isolation – interaction and sense of community, social connection, increased social capital Provides purpose Benefit of non-traditional treatment environment; opportunities for informal discussion and further referrals Assisted participants to feel empowered to challenge stigma and discrimination. Projects affiliated to football clubs reached large numbers of people with key messages about mental health stigma and discrimination Despite positive qualitative feedback the evaluation did not show a statistically significant change in wellbeing using WEMWBS
London Playing Fields Foundation (2010)	93% male Adult (96% in 20s–40s) Low SES Many with drug/alcohol dependency (“dual diagnosis”) Chronic mental ill health	Interviews Survey questionnaire	21 61	Addresses stigma – not a MH group; a football group Reduces isolation – friendships; Promotes belonging Provides structure and reduces boredom Identity: Connects to previous identity when well; Reconceptualization of self-player/skilled/active; Promotes positive sense of self -positivity associated with football “Safe” environment – free expression and mutual support Helps devise pathways to employment/education Improves confidence/self-esteem; Enhanced wellbeing Improves physical fitness Keeps participants engaged – may normally at high risk of dropping out of services
London Playing Fields Foundation (2013)	Gender – unclear Age 16-45+ Low SES Enduring/chronic mental health problems Many with drug/alcohol dependency	Survey questionnaire	94	Reduces boredom; Provides structure to life Friendships/sociability created; Meet other service users with similar problems so isolation feelings reduce; Promotes sense of belonging Supports clients to build friendships and be more social to others Football is more than a hook – positive football environment more important than the activity itself Football associated with a positive sense of self-worth, confidence and self-esteem Clients consider it a football group with friends rather than a medical intervention; recognition it is therapy but more fun than other models Alternative way of attracting and retaining traditionally hard to reach groups, especially Black, Asian and minority ethnic service users Pathway in employment and training Client users are able to remain with the programme even when MH treatment has ended
London Playing Fields Foundation (2015)	93% male Age 13+ “Chronic mental ill health” Many with drug and alcohol dependency Low SES	Survey questionnaire	167	Greater sense of self and self-worth Football provides a positive to life Isolation feelings reduced; Sense of belonging to a broader (football) community Social calendar alongside football activity encouraged social connection Developed friendships with others similar to self Confidence increased through feeling able to cope and deal with problems Football-first approach valued
Magee et al. (2015)	Male 18–40	Qualitative interviews	38	Three organising themes – stigma, social isolation and engagement with support services Non-clinical environment valued, non-stigmatising Premier League “hook” was attractive. Engagement – primary attraction of football. Practice of engaging disengaged. Coaches creating positive atmosphere – fun, respect, enjoyment Teamwork – relies on unity, responsibility – Team ethic assistive Developing relationships with other service users –playing and through group therapy: safe place for expressing emotion Potential to enhance client-patient trust; “therapeutic alliances” through group work, workshops. Enhance access/engagement with recovery. Positive symbolism of football – positive masculine identity Group activity raises self-confidence Group contact reduces social isolation/shame – social connectedness; developing relationships with other service users Competitive nature of football – may exacerbate mental illness e.g. aggression and violence; winners/losers; performance anxiety, stress.
Mason and Holt (2012)	Male Age 20–45 Severe and enduring mental health conditions Low SES	Qualitative interviews	19	Six themes 1. Service with a difference – support not problem focussed but person-centred. Different experience to “therapy” 2. Identifying with past self-memories of football pre-illness. Positive and enjoyment 3. Opening up the social world 4. Psychological safety – self-expression, mutual support and belonging. “Family atmosphere” – helps development of bonds and trust. Shared identity/issues with other participants and common understanding (low stigma setting) 5. Feeling good – fitter, healthier, weight loss, stopping smoking 6. Empowerment – increased confidence and self-esteem strong outcome
McElroy et al. (2008)	Male Age 16-65 MH conditions/severity not described	Survey questionnaire	131	71% felt much less isolated 80% felt happier because of regular involvement 81% felt enthused and energised 81% increased confidence 69% increased levels of self-esteem 77% reduced stress and anxiety 66% improved coping skills 90% agreed/strongly agreed MH had improved

MH: Mental Health; SES: Socio-Economic Status; SMI: Serious Mmental Illness.

Table 3. TIDIieR checklist of interventional components (Hoffmann et al.,2014).

Item 1 Name	Football for mental health recovery
Item 2 Why?	Football in a group setting can support mental health recovery for men with serious and/or enduring or moderate mental health problems
Items 3 and 4 What? “Ingredients” and procedure	Football training with a qualified (voluntary and/or professional) coach including:  Warm up  Progressive football skills development  Team play/friendly competition  Cool down  Social interaction with peers, coaches and others Optional: employability and “life skills” support Optional: leagues and/or tournaments (NB carries risk)
Item 5 Who provided?	Participating OTs/HPs/support workers with football/physical activity interest Coach with mental health experience (personal and/or professional) Empathetic “soft skills” evident in delivery Optional: Player-led organising group/team management
Item 6 Modes of delivery	Group-based; big enough for team play Supporting contact from organiser – phone, text Supportive/empathetic ethos across all participants/organisers
Item 7 Where?	Convenient setting, local to the player Consistency of location for training Non-clinical setting Links to public transport
Item 8 When and how much?	Daytime/daylight Weekday Afternoons At least weekly Regular times Ongoing engagement dependent on other commitments/stage in recovery
Item 9 Tailoring	Frequency of engagement, intensity of activity and skills component tailored to the player e.g. levels of confidence, experience, physical ability, medication side effects, co-morbidities

Figure 2. CMOc for football for mental health intervention.

Table

Database	Search terms	Number of articles
Medline	Football OR soccer Mental health OR mental condition OR mental disorder OR mental illness OR anxiety OR depression OR bipolar OR mood disorder OR panic OR phobia OR post-traumatic stress disorder OR substance abuse Men OR male* #1 AND #2 AND #3	106
CINAHL via EBSCO	Football OR soccer Mental health OR mental condition OR mental disorder OR mental illness OR anxiety OR depression OR bipolar OR mood disorder OR panic OR phobia OR post-traumatic stress disorder OR substance abuse Men OR male* #1 AND #2 AND #3	111
Web of Science	Football OR soccer Mental health OR mental disorder OR mental illness OR anxiety OR depression OR bipolar OR mood disorder OR panic OR phobia OR post-traumatic stress disorder OR substance abuse OR eating disorder Men OR male* #1 AND #2 AND #3	82
PsycInfo	Football OR soccer Mental health OR mental disorder OR mental illness OR anxiety OR depression OR bipolar OR mood disorder OR panic OR phobia OR post-traumatic stress disorder OR substance abuse OR eating disorder Men OR male* #1 AND #2 AND #3	324
Total		623

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