Developing a mental health research agenda for football referees

ABSTRACT

The mental health of football referees at amateur and elite levels has received very little research attention, with the majority of mental health research focused on players. Unfortunately, such a shallow research pool has resulted in a deficit of knowledge which prevents not only the understanding of mental health symptoms and disorders in this population but also the creation of evidence-based interventions. As such, the purpose of this commentary is twofold: 1) to outline the importance of why an epidemiological understanding of mental health symptoms and disorders amongst referees is necessary and desperately needed and 2) to discuss how such epidemiological research can be used to design, deliver, evaluate and disseminate evidence-based mental health interventions to football referees. We provide an overview of the behavioural epidemiology framework and how it may be used to guide and execute future research and intervention endeavours.

Introduction

The mental health of football referees at amateur and elite levels has received very little research attention.¹ Mental health itself is defined by the World Health Organization as ‘… a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community’.² Within this definition, mental health is viewed as a resource, much like physical health, where it allows people to thrive, achieve their potential, cope with challenges and work to make contributions to their respective communities.³ Mental health symptoms and disorders present a negative impact on individual’s cognitions, behaviours, emotions, relationships, occupational functioning and their functioning in daily life. To receive a diagnosis, mental health symptoms and disorders must meet specific criteria regarding their duration, severity and frequency.⁴

Empirical research to date has examined the stress of football referees in a variety of contexts, be it before, during or after matches.⁵ Stress, for referees, can arise from different sources, including conflict with other officials, the requirements and demands of the job itself, evaluation and disciplinary processes, isolation and scrutiny from the media.⁶ Perhaps the greatest source of stress for referees is that which arises from harassment and abuse, where much of the body of literature on stress and football officiating has been situated.⁷ As defined by the International Olympic Committee, harassment, the persistent attacks and criticism of an individual, and abuse, the improper treatment of an individual, are described as forms of non-accidental violence.⁸ Non-accidental violence – be it physical, psychological, sexual or delivered through neglect – results from actual or perceived differentials in power situated in a discriminatory cultural context.⁹ Forms of non-accidental violence can occur individually, or in combination, and be delivered in a variety of ways, including through physical contact, non-contact/verbal, the Internet/online, bullying, hazing and negligence. The results of such non-accidental violence not only impact the individual, resulting in mental health symptoms and disorders, physical illness, injuries, performance challenges, cognitive deficits, relational difficulties and economic losses but also the organization, including reputational damage, loss of players and fans, loss of sponsorship, loss of public confidence and asset depreciation.¹⁰ Studied mostly from the perspective of athletes, non-accidental violence can result in physical, cognitive, emotional, behavioural, relational and economic consequences, all of which have a profound impact on the individual’s mental health and often result in mental health symptoms and disorders. Amongst football referees, research has shown that due to non-accidental violence, many officials are leaving the sport, in some cases rendering amateur levels of play unsustainable.¹¹

In football, the majority of mental health research has focused on players, with limited consideration given to referees. Unfortunately, such a shallow research pool has resulted in a deficit of knowledge which prevents not only the understanding of mental health symptoms and disorders in this population but also the creation of evidence-based interventions. Specifically, little is known about the mental health impact of non-accidental violence or other stressors football referees encounter in their working lives. For strategies to be designed to address mental health symptoms and disorders of referees in football, an epidemiological understanding of the situation is first required. As such, the purpose of this commentary is twofold:

1. to outline the importance of why an epidemiological understanding of mental health symptoms and disorders amongst referees is necessary and desperately needed, and

2. to discuss how such epidemiological research can be used to design, deliver, evaluate and disseminate evidence-based mental health interventions to football referees.

The overarching goal of this commentary is to instigate a mental health research agenda in football, that is rigorous, evidence-based and that can help address the mental health symptoms and disorders of this vulnerable group.

Mental health symptoms and disorders in football referees: what do we know?

Epidemiology is the study and evaluation of the distribution, patterns and determinants of health and disease conditions of specific and defined populations.¹² Epidemiology drives policy decisions and evidence-based practice. It helps identify various risk factors of disease, and their interactions, through careful data collection for a target population. The goal of epidemiology is to identify and understand the aetiology of disease so as to be able to prevent or treat it in the most efficient and effective manner. Here, epidemiological studies must progress from understanding the distribution of disease, or descriptive epidemiology, to understanding the risk factors and determinants of disease in specific populations, or analytic epidemiology.¹³ Within the context of understanding mental health symptoms and disorders amongst football referees, both types of studies, descriptive and analytic, are essential and required.

Descriptive epidemiology is concerned with both prevalence and incidence. Prevalence and incidence are used to measure and better understand the proportion of disease in a particularly defined population. Prevalence rates represent existing cases of a disease in a particular population for a specific period of time, whereas incidence rates represent new cases of a disease in a particular population for a specific period of time.¹⁴

Analytical epidemiology is concerned with identifying risk factors and determinants of disease in a defined population. Risk factors for a disease may vary by age, sex, gender, sexuality, class, race, ethnicity, (dis)ability, work type and geographic location. Analyses that allow for both the examination of disease correlates and causal factors are essential and can include both retrospective and prospective studies.¹⁵

In football, a limited number of empirical research studies have examined the mental health symptoms and disorders of widespread non-accidental violence or other stressors against referees.¹⁶ Research shows that football referees at both amateur and elite levels encounter non-accidental violence, in all forms, and other stressors from athletes, coaches, staff, other officials, fans and the general public.¹⁷ This is a concern and one that has an impact on the mental health of referees in football.

With respect to the epidemiology of mental health symptoms and disorders amongst football referees, few studies have been conducted. The largest of such research endeavours, a 1-year observational prospective cohort study of European professional football referees, conducted by Gouttebarge and colleagues, investigated the prevalence and incidence of mental health symptoms and disorders, including symptoms of distress, anxiety, depression, sleep disturbance, eating disorders and adverse alcohol use.¹⁸ Overall, the results showed levels of prevalence ranging from 6% for distress to 19% for eating disorders. A further study that investigated the prevalence of depressive and anxiety symptoms of Egyptian football referees identified similar findings, where 16.9% of referees experienced mild anxiety symptoms and 4.7% reported mild depressive symptoms.¹⁹ Although both studies showed lower levels of mental health symptoms than those found amongst elite athletes, caution must be taken before making any assumptions given the limited amount of research conducted thus far.²⁰

Both studies mentioned above illustrate that mental health symptoms and disorders exist and are a concern for football referees. However, our descriptive epidemiological understanding of mental health symptoms and disorders in this population is limited given that only males, those who spoke French or English (languages used during data collection), and those who officiated in European (specifically, Belgium, Finland, France, Germany, Norway, Russia, Scotland and Sweden) and Egyptian professional leagues participated in the research. Therefore, the research results available today provide limited information on the prevalence and incidence of mental health symptoms and disorders of football referees.

If explored through an analytic epidemiological perspective, only one study has examined mental health symptoms and disorders in football referees. Research by Kilic and colleagues,²¹ which used the same research data collected by Gouttebarge and colleagues, examined the associations between physical and psychosocial stressors and the incidence of mental health symptoms and disorders. Specifically, their research found that severe injuries and poor satisfaction with social support were correlated with the onset of mental health symptoms. Their findings showed that those who experienced severe injuries were three times more likely to report anxiety and depressive symptoms, while those who experienced poor satisfaction with social support were more likely to report symptoms of eating disorders. But again, our understanding of the associations between these few risk factors and determinants of mental health symptoms and disorders in this particular population is limited, given that the research study involved males, French or English speakers, and those who worked in European professional leagues.

Collectively, these studies illustrate features of both descriptive and analytic epidemiology with respect to the mental health symptoms and disorders of football referees. Future research needs to not only focus on a better understanding of the prevalence and incidence of mental health symptoms and disorders amongst football referees, but a more thorough understanding of various risk factors associated with non-accidental violence and stressors related to more diverse demographic factors that are representative of the target population. Such information would be vital to help design, deliver, evaluate and disseminate appropriate mental health interventions to football referees. The process could be transferred to other sports and help facilitate research and intervention design to help match officials.²² Here, the behavioural epidemiology framework may be used to systematically guide and execute such a research project.

The behavioural epidemiology framework: design, deliver, evaluate and disseminate

The behavioural epidemiology framework was designed by James Sallis and colleagues to provide a series of rationally organized sequential steps and research phases that helped create and deliver evidence-based public health interventions.²³ The framework spans from basic research to programme and policy implementation. The premise behind the behavioural epidemiology framework was to improve the understanding of the public around particular behaviours and health-related outcomes and then to use that knowledge to favourably influence future behaviours for health benefits. The use of knowledge helped create various ecological interventions that were delivered directly to the individual or through environmental policy changes. To achieve such a feat would require descriptive, analytic and intervention-based studies firmly rooted in epidemiological evidence. Therefore, the behavioural epidemiology framework has five phases, where each successive phase builds on the last.²⁴

Phase 1 – Establish links between behaviours and mental health in football referees

Associations between behaviours and mental health symptoms and disorders must be documented. To establish such links, various forms of non-accidental violence and other stressors and mental health symptoms and disorders will require both descriptive and analytic epidemiology studies. Here, as demonstrated by Gouttebarge and colleagues and Kilic and colleagues, both the prevalence and incidence of mental health symptoms and disorders must be captured as well as how such mental health symptoms and disorders are associated with various risk factors, be they different forms of non-accidental violence or stressors in football.²⁵²⁶ Data collected on such associations will allow for an examination of the strength of such relationships between risk factors and mental health symptoms and disorders. This data is essential as it will help identify which risk factors should receive the focus of any future intervention.

Phase 2 – Develop methods to measure the behaviour and mental health outcomes in football referees

Careful attention must be devoted to measurement and research methods. Consideration must be given to different forms of non-accidental violence and other stressors as well as the measurement of mental health symptoms and disorders, prevalent in football referees. Specifically, in order to assess and measure various forms of non-accidental violence and other stressors, self-report questionnaires must be shown to be reliable and valid for the target population. Several sports-centred questionnaires that evaluate mental health symptoms and disorders have been developed and are available for use.²⁷ As noted previously by Reardon and colleagues,²⁸ steps should be taken to minimize response bias, and the use of other diagnostic evaluation methods should be considered, if possible. This may include the use of chart reviews and clinical interviews with trained mental health professionals to minimize any biased responses.²⁹ Such strategies must be carefully weighed against any possibilities of making potential participants feel uncomfortable. Public and self-stigma are two major factors why individuals living with mental health symptoms and disorders do not participate in research or seek treatment.

Phase 3 – Identify factors that may influence the behaviour and health outcome of football referees

Analytic epidemiology strategies can be taken to enhance the field of knowledge of risk factors and determinants of mental health symptoms and disorders of football referees. Specifically, the careful consideration of various demographic factors is essential. As has been noted earlier, our current understanding of mental health symptoms and disorders in football referees is primarily rooted in research with a very shallow demographic pool. Unfortunately, such results are not representative of referees who officiate around the world and as a consequence such findings are not generalizable. To create interventions from such limited data, without a careful understanding of various individual and sociocultural factors would not be useful or ethical as it would not be effective. In a sense, such an intervention would not be culturally competent.³⁰ To better understand the determinants that vary by different forms of non-accidental violence and other stressors, researchers need to consider demographic variables such as age, sex, gender, sexuality, class, race, ethnicity, (dis)ability, geography, training level, league, league level, time of season/off season, time in relation to the match (i.e. before, during, after) and retirement. Furthermore, researchers can identify modifiable (e.g. training level) and non-modifiable factors (e.g. age) and consider how both can be addressed through intervention.

Phase 4 – Evaluate interventions to change the behaviours in football referees

Only after descriptive and analytic epidemiology studies have been completed should steps be taken to design and evaluate interventions to address mental health symptoms and disorders in football referees. Here interventions need to take into consideration valuable lessons learned in phases 1, 2 and 3 in the development of complex interventions.³¹ Researchers should move from small-scale, single-case experimental design studies where proof of concept, feasibility and efficacy are established before moving to larger-scale randomized experimental designs. Although expert statements have outlined that interventions should be rooted in mental health literacy – whereby strategies aimed at strengthening knowledge and attitudes about mental health in order to help establish intentions to seek support³² – no such interventions, informed through an evidence-based research strategy, exist. Although one study has examined the use of mental toughness education over a series of workshops that involved individual and group-based cognitive behaviour therapy, the work of Slack and colleagues did not evaluate mental health symptoms and disorders directly.³³

Phase 5 – Translate and disseminate research

The findings of descriptive, analytic and intervention-based studies need to be published and made publicly available, especially to the target population. Without data sharing, little progress can be made to address the risk factors associated with mental health symptoms and disorders in this population.³⁴ Additionally, this approach may help other researchers better understand not only risk factors and determinants but factors about adjacent behaviours, like what barriers prevent referees, and match officials in other sports, from seeking support.³⁵ Only through collaborative research efforts can advance in practice be made. As has been established as part of the Medical Research Council Framework for Complex Intervention Design, implementation of research findings into practice must be an active process, where research findings are easy to understand, accessible, convincing, specific and rooted in evidence.³⁶ The continual involvement of stakeholders and decision makers is essential. Future research may explore the development of any intervention or practice using qualitative research to better inform any particular design.³⁷

Conclusion

Research that explores the mental health symptoms and disorders of football referees is in its infancy. Although a handful of studies have been conducted, knowledge is limited and not generalizable. The creation of mental health interventions at this stage would be premature and poorly informed. This might result in strategies that are not culturally competent, not organizationally informed, nor mindful of the target population. Such interventions run the risk of causing further harm, rather than actively preventing or addressing mental health symptoms and disorders. Moreover, knowledge is also limited in sports other than football and a wider evidence base needs to emerge transnationally across sports.³⁸ It is only then through careful, rigorous studies, conducted in a sequential process that explore various risk factors, determinants and mental health symptoms and disorders, that a rounded and detailed understanding of the pertinent issues, trends and common factors can emerge.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Notes

1. Gorczynski and Webb, ‘Call-to-action: the need for a mental health research agenda for sports match officials’.

2. World Health Organization, ‘Strengthening mental health promotion’.

3. Gorczynski et al., ‘Developing mental health literacy and cultural competence in elite sport’.

4. American Psychiatric Association, ‘Diagnostic and statistical manual of mental disorders(5th ed.)’.

5. Webb, Rayner and Thelwell, ‘An examination of match official’s perceptions of support and abuse in rugby union and cricket in England’.

6. Webb, Rayner, Cleland and O’Gorman, ‘Referees, match officials and abuse’.

7. Webb, ‘Sports match official research: An evolving narrative, positioning future research’; Cleland, O’Gorman and Webb, ‘Respect? An investigation into the experience of referees in association football’, 960–974; and Webb, Cleland and O’Gorman, ‘The distribution of power through a media campaign’.

8. Mountjoy et al., ‘The IOC Consensus Statement’.

9. Ibid.

10. Reardon et al.,’ Mental health in elite athletes’.

11. Webb, Dicks, Thelwell, van der Kamp, and Rix-Lievre, ‘An analysis of soccer referee experiences in France and the Netherlands’.

12. Porta, ‘A Dictionary of Epidemiology’.

13. Ries Merikangas, Nakamura and Kessler, ‘Epidemiology of mental disorders in children and adolescents’, 7–8.

14. Ibid.

15. Ibid.

16. Gorczynski and Webb, ‘Call-to-action’.

17. Webb, Rayner, Cleland and O’Gorman, ‘Referees, match officials and abuse’.

18. Gouttebarge, Johnson, Rochcongar, Rosier and Kerkhoffs, ‘Symptoms of common mental disorders among professional football referees’, 13–14.

19. El Bakry, ‘A survey on the significance of psychological and psychiatric assessment among qualified African football referees’, 87–88.

20. Gouttebarge et al., ‘Occurrence of mental health symptoms and disorders in current and former elite athletes’, 701–705.

21. Kilic, Johnson, Kerkhoff, Rosier and Gouttebarge, ‘Exposure to physical and psychosocial stressors in relation to symptoms of common mental disorders among European professional football referees’, 3–4.

22. Webb, Rayner, Cleland and O’Gorman, ‘Referees, match officials and abuse: Research and implications for policy’; Webb, Rayner, and Thelwell, ‘An explorative case study of referee abuse in English Rugby League’; Webb, Rayner and Thelwell, ‘An examination of match official’s perceptions of support and abuse in rugby union and cricket in England’.

23. Sallis, Owen, and Fotheringham, ‘Behavioral epidemiology’, 294.

24. Ibid., 295.

25. Gouttebarge, Johnson, Rochcongar, Rosier and Kerkhoffs, ‘Symptoms of common mental disorders among professional football referees’, 13–14.

26. Kilic, Johnson, Kerkhoff, Rosier and Gouttebarge, ‘Exposure to physical and psychosocial stressors in relation to symptoms of common mental disorders among European professional football referees’, 3–4.

27. Reardon et al., ‘Mental health in elite athletes’.

28. Ibid.

29. Gorczynski, Coyle, and Gibson, ‘Depressive symptoms in high-performance athletes and non-athletes: a comparative meta-analysis’, 1351.

30. Gorczynski et al., ‘Developing mental health literacy and cultural competence in elite sport’.

31. Craig et al., ‘Developing and evaluating complex interventions: the new Medical Research Council guidance’.

32. Gorczynski et al., ‘Developing mental health literacy and cultural competence in elite sport’; Webb and Gorczynski, ‘Factors influencing the mental health of sports match officials’; Gorczynski, Gibson, Thelwell, Harwood, Papathomas, and Kinnafick, ‘The BASES Expert Statement on Mental health literacy in elite sport’, 6–7.

33. Slack, Maynard, Butt and Olusiga, ‘Understanding mental toughness in elite football officiating’.

34. Gorczynski et al., ‘Developing mental health literacy and cultural competence in elite sport’.

35. Webb, Rayner, Cleland and O’Gorman, ‘Referees, match officials and abuse’.

36. Craig et al., ‘Developing and evaluating complex interventions’.

37. Coyle, Gorczynski and Gibson, ‘“You have to be mental to jump off a board any way”’; Webb, Gorczynski, Moghadam, and Grubb, ‘Experience and Construction of Mental Health Among English Female Football Match Officials’.

38. Gorczynski and Webb, ‘Call-to-action’.