An occupational justice perspective on playing football and living with mental distress

ABSTRACT

Physical inactivity is a global public health priority, yet people living with a disability or long-term health condition, such as those who experience mental distress, continue to face inequalities and barriers to participation in sport and physical activity. These inequalities are considered an occupational injustice, in terms of participation in health enhancing occupations being restricted for these groups of people, despite them wanting to be more active. This study aimed to gain an in-depth understanding of the nature and value of participating in a UK based community football project, for people with experience of mental distress. Twenty-three people took part in this first strand of a larger participatory action research study, which used the World Café as a method for structuring and recording conversations. Data from the three World Café events were analysed collectively and thematically. The study’s findings reveal tensions, nuances, and subtleties that exist in relation to the reciprocal relationship between playing football and people’s health and well-being. The complexity of enabling participation in sport and physical activity amongst marginalised groups, such as people with experience of mental distress, is highlighted.

KEYWORDS:

• Occupational science
• Complexity
• Football
• Physical activity
• Sport
• Occupational justice

Physical inactivity is a global health priority (World Health Organization, 2018a) which has close relevance to occupational science due to being fundamentally concerned with the reciprocal relationship between what people do and their health and well-being. The definition of physical activity adopted by the World Health Organization (2018) and used within this paper is “any bodily movement produced by skeletal muscles that results in energy expenditure” (Caspersen et al., 1985, p. 126). The term physical activity is preferred to exercise, as it is more inclusive, encompassing sport and leisure occupations, and other everyday occupations like mowing the lawn, cycling to work, and hanging up the washing.

This paper seeks to position people with experience of mental distress as equal citizens. Therefore, the term people with experience of mental distress is used, which is intended to be inclusive of all experiences. This term is used rather than descriptive biomedical terms such as psychiatric disorder, mental illness, or mental health problem, and is intended to be inclusive of all experience of mental distress, whether formally diagnosed or not, whether in receipt of secondary mental health services or not, and whether perceived as a current episode of distress or not. This term was discussed and agreed with the Research Steering Group that shaped this research study.

Literature Review

Generally, people with a long-term health condition or disability face difficulties and exclusions to participating in sport and physical occupations and are reported to be less physically active than the general population. People with experience of mental distress are reported to be the least active (Department for Culture Media and Sport, 2015; English Federation of Disability Sport, 2013; Sport England, 2016). This is despite these marginalised groups reporting a wish to be more active (English Federation of Disability Sport, 2013). They face a range of complex political and social structures that limit and restrict participation in sport and physical occupations. These include social isolation, financial difficulties, a perceived lack of opportunities to access community resources, and fear of benefit sanctions (Activity Alliance, 2018; Cole, 2010; Hodgson, 2012; Williams & Fullagar, 2019). This evidence challenges dominant neoliberal health and sport policies, which assert individualistic governance trends and encourage participation in sport and physical occupations through the logics of self-care, personal responsibility, and choice (Public Health England, 2016; Pullen & Malcolm, 2018; Sport England, 2016; Williams & Gibson, 2018).

The resultant inequality in participation can be considered an occupational injustice in that “breaches to occupational justice occur when participation in health enhancing occupations is inequitable across different groups in society, with some people unfairly benefiting and others subjected to patterns of occupation that are detrimental to health and well-being” (Hocking, 2017, p. 33). Furthermore, article 30 of the United Nation’s Convention on the Rights of Persons with Disabilities provides a legislative context, stating that its signatories “recognise the right of persons with disabilities to take part on an equal basis with others in cultural life” (defined as participation in recreation, leisure, the arts, sport, and tourism) (United Nations, 2006, p. 3).

Five outcomes of occupational injustice have been named, which are distinguished as: occupational deprivation, occupational alienation, occupational imbalance, occupational marginalisation, and occupational apartheid (Hocking, 2017; Stadnyk et al., 2010). Occupational deprivation is concerned with individuals and communities being prevented from engaging in occupations due to external restrictions, such as stigma and a low income. Occupational alienation is a state that arises from people performing occupations that lack positive meaning and purpose. Occupational imbalance results when individuals are either under or over-occupied. Occupational marginalisation is typically concerned with discrimination, which results in individuals having limited choice and control in their everyday occupations and being relegated to occupations that have less value in society. Occupational apartheid results from the systematic segregation of groups of people, which deliberately denies them access to occupations as a result of prejudices about their capacities or entitlement to valued occupations (Hocking, 2017; Townsend & Wilcock, 2004).

These concepts can be related to people with experience of mental distress feeling unable to participate in a mainstream community football club due to stigma and a low income. Furthermore, it could also be viewed as an occupational injustice that efforts to provide inclusive and accessible sports opportunities for people with experience of mental distress tend to be restricted to specialist mental health projects. Such projects are often based on narrow, individualised, and biomedical understandings of mental distress, with the participation conceptualised as an adjunct to conventional mental health treatment and care (Friedrich & Mason, 2017). Such limited and segregated opportunities arguably perpetuate and compound the marginalisation that people with experience of mental distress encounter in their everyday lives (Magee et al., 2015; Pettican & Bryant, 2007).

Despite a rapid growth in women’s participation in recent years, in most countries football currently remains a mass participation sport played in the majority by men. Nevertheless football has been described in the UK as the national game, engaging one in five adults (Friedrich & Mason, 2017). Football is a particularly inclusive sport, with very little skew towards different income groups, ethnic groups, or educational role, and can therefore be seen as having a potentially strong role in developing social capital and promoting occupational justice (Delaney & Keaney, 2005; Friedrich & Mason, 2017; Magee & Jeanes, 2013). Yet to date there has been a paucity of occupational science research and scholarship that explores men’s experiences of occupations, such as football (Hocking, 2012). This research study addresses this knowledge gap, with a particular focus on people with experience of mental distress.

The transactional relationship between playing football and the health and well-being of people with experience of mental distress has been explored by a small number of researchers (Dyer & Mills, 2011; Friedrich & Mason, 2017, 2018; Lamont et al., 2017; Moloney & Rohde, 2017). Playing football can have many benefits for people with experience of mental distress, identified by participants in several studies as improving their physical health and mental well-being, and providing valuable structure and purpose to their lives (Carless & Douglas, 2008; Henderson et al., 2014; Hodgson et al., 2011; Moloney & Rohde, 2017; Such et al., 2019). Other benefits include positive experiences of accomplishment, distraction from experiences of mental distress, and the opportunity for a role shift from a mental health service user to a football player (Dyer & Mills, 2011; Hodgson et al., 2011; Mason & Holt, 2012; Moloney & Rohde, 2017). However, the predominant focus on the benefits of participation obscures the underlying complexity of participation. Being more active is presented as a straightforward process of moving from being inactive to being active and that the simple solution to inactivity is engaging in some form of sport or physical occupation (Carless & Douglas, 2008a, 2008b; Carless & Sparkes, 2008; Hodgson, 2012; McGale et al., 2011).

In contrast, a study by Lamont et al. (2017) examined four therapeutic mental health football projects, established in conjunction with two geographical National Health Service (NHS) Boards in Scotland, emphasised the complexities of participation. Findings particularly bring to the fore two essential ingredients of playing football—competition and collaboration—and how these might have to be prioritised differently by the players. Participants spoke of the competitive element of the football being a motivation, but not of primary importance. There was a sense of this competition being balanced against the therapeutic purpose of the projects, and a concomitant process of ‘toning down’ any emphasis on competitiveness when new participants arrived. Participation in sport can therefore be paradoxical, simultaneously encouraging competition and collaboration (Perks, 2007; Such et al., 2019).

The potential for occupations to be considered paradoxical links to occupational science having been criticised for its sustained and overriding focus on occupations that are perceived to restore or maintain good health, promote social engagement, and develop vocational skills (Kiepek et al., 2019; Twinley, 2013). It has been asserted that this limitation silences a significant proportion of human experience, in terms of occupations that are considered by dominant worldviews and social groups to be ‘non-sanctioned’, that is, deviant, illegal, and/or unhealthy (Kiepek et al., 2019). Similarly, the dark side of occupation is a construct that has been developed to deepen understanding of occupations as complex and multidimensional (Twinley, 2013; Twinley & Addidle, 2012). A team sport such as football is such an example, as it is potentially competitive, divisive, exclusive, and elitist, alongside also having the capacity to be fun, health-enhancing, and to provide a sense of purpose.

Contemporary health and sport policy often promotes participation in sport and physical occupations as a universal panacea and solution to national inactivity problems (British Medical Association, 2014; Department for Culture Media and Sport, 2015; Hagell, 2016; Royal College of Psychiatrists, 2012a, 2012b, 2013; Sport England, 2016). However, literature has challenged these prevailing governance trends, which tend to be both responsibilising and individualistic (Mansfield et al., 2019; Smith & Perrier, 2014; Williams, 2017; Williams & Gibson, 2018) and construct participation in sport, exercise, and physical occupations within a biomedical frame; ‘exercise as medicine’. This tendency fails to account for the complex social demands and risks participation entails (Pullen & Malcolm, 2018; Williams et al., 2018). Published research examining factors that influence those people who give up participating in sport or physical activity is absent. Further longitudinal research is required to explore participation and non-participation within the context of people’s life course, to understand how engagement and benefits might be maximised (Darongkamas et al., 2011; Hart et al., 2016; McGale et al., 2011).

There is, however, some preliminary evidence that people with experience of mental distress who play football can experience outcomes for their physical health, emotional well-being, and social context, and that these outcomes can be both positive and negative (Darongkamas et al., 2011; Get Set to Go Research Consortium, 2017; Hodgson et al., 2011). However, the complex nature of participation is under-explored, as are the many factors that might mediate the relationship between being physically active and health and well-being, within the everyday lives of people with mental distress. Furthermore, professional researchers and/or the people responsible for delivering such interventions have dominated the design of research. With the exception of Such et al. (2019), people with experience of mental distress have had no involvement in the design and focus of the research studies detailed above. Therefore, participatory research is needed, in part to redress power imbalances inherent in health research and knowledge production, and to ensure that knowledge is advanced in directions that are meaningful to the everyday lives of the marginalised groups who are its focus.

This paper is focused on research conducted in collaboration with the Positive Mental Attitude (PMA) Sports Academy, a community project in the UK, which involved predominantly men identified as at risk of, or with experience of, mental distress playing football together. The project had sites in London and Yorkshire, in the North of England. The study had three data collection strands. This paper is concerned with reporting the first of these three strands. The aim of the study was to explore the nature and value of participation in the PMA from the perspectives of those that took part.

Methodology and Methods

A participatory action research (PAR) methodology was used to bring together those involved in the study, as co-researchers. PAR has been defined as “a process in which we, researchers and participants, systematically work together in cycles to explore concerns, claims or issues that impact upon or disrupt people’s lives” (Koch & Kralik, 2006, p. 27). PAR is described as having the following four characteristics: “Democratic, enabling the participation of all people. Equitable, acknowledging of people’s equality of worth. Liberating, providing freedom from oppressive, debilitating conditions and Life enhancing, enabling the expression of people’s full potential” (Koch & Kralik, 2006, p. 27). PAR exists within a broad and diverse group of action research practices (Bradbury-Huang, 2010). This type of research arose from dissatisfaction with the narrow research subject role and a wish for active participation and emancipation, in order to achieve meaningful social change (Beresford, 2005, 2013). Bryant et al. (2017) has previously discussed the alignment between PAR and working towards occupational justice.

The research steering group

To meaningfully enact the study’s PAR methodology, a Research Steering Group was formed following the decision that a research study would be taking place with the PMA. The Research Steering Group involved both players and staff employed by the PMA (see Table 1 for details of the Research Steering Group members). The purpose of the group was agreed as utilising group discussion and decision-making to direct the study for its entire duration.

Table 1. Research Steering Group Members.

Pseudonym (Male/Female)	Age	PMA role	Mental health care	Living arrangements
Sid (M)	Mid 50s	Player/coach	Secondary	Supported housing
Keith (M)*	Mid 30s	Player	Primary	Supported housing
Jalpesh (M)	Early 50s	Player	Secondary	With family
Tim (M)	Mid 40s	Player	Primary	With family
Jake** (M)	Early 30s	Player	Secondary	With family
Donell (M)	Mid 30s	Player	Primary	Supported housing
Aaron (M)	Mid 30s	Player	Secondary	With family
Bret (M)	Mid 40s	Player	Secondary	Supported housing

*Intermittent involvement due to fluctuations in health and circumstances; **Withdrew after meeting five due to family commitments.

Participants

The study used purposive sampling (Robson, 2011), a form of non-probability sampling, in that it involved people who took part in the PMA Sports Academy in some way (e.g., as a player or coach). Participation was also open to anyone who currently or previously had an interest and/or role in supporting the work of the PMA Sports Academy in some way (e.g., as employees, family members of players, funders, or trustees). Participants were required to be willing and able to give informed consent, engage in the data collection and complete the research study. Details of the participants are provided in Table 2.

Table 2. World Café Participants.

Name (Male/Female)	Age	PMA role	Mental health care	Living arrangements
London World Café (1)
Rebecca (F)	Mid 30s	Player	Secondary	Independent
Janesh** (M)	Late 20s	Player	Secondary	Supported housing
*Sid (M)	Mid 50s	Player/coach	Secondary	Supported housing
Tom (M)	Early 30s	Player	Secondary	Supported housing
Lee (M)	Mid 40s	Player	Secondary	Independent
Kate (F)	Mid 40s	Staff	N/A	N/A
*Jalpesh (M)	Early 50s	Player	Secondary	With family
Jeffrey (M)	Mid 50s	Player family	N/A	N/A
*Tim** (M)	Mid 40s	Player	Primary	With family
Sam** (M)	Late 30s	Player	Secondary	Inpatient
London World Café (2)
*Donell (M)	Mid 30s	Player	Primary	Supported housing
Rishi (M)	Late 20s	Player	Secondary	Independent
*Aaron (M)	Mid 30s	Player	Secondary	With family
Len (M)	Mid 20s	Player/Coach	Secondary	Independent
*Bret (M)	Mid 40s	Player	Secondary	Supported housing
Wakefield World Café
Adrian (M)	Early 30s	Player/mentor	Primary	Independently
Jake (M)	Late teens	Player	N/A	With family
Steve (M)	Late teens	Player	N/A	With family
Josh (M)	Early 20s	Player	N/A	With family
Russell (M)	Early 30s	Player/mentor	Secondary	Supported housing
Kyle (M)	Late teens	Player	N/A	With family
Wayne (M)	Late teens	Player	Secondary	Supported housing
Brad (M)	Early 20s	Player	N/A	With family

*Research Steering Group members; **Participants who returned to participate in the London World Café (2)

Data were collected via three World Café events, two in London and one in Yorkshire. Fifteen people participated in the two London-based World Cafés, and eight people participated in the Wakefield Café. There was only one World Café held in Wakefield due to it being a smaller group of players. The sample included 21 males and two females, with an age range of 17-55. One paid member of PMA staff and one family member attended, with the remaining 21 participants all being PMA players.

Ethical considerations

Research ethics approval was granted from Brunel University London, School of Health Sciences and Social Care Research Ethics Committee (13/05/PHD/03) and the University of Essex Faculty Research Ethics Committee. From the outset of the study, the Research Steering Group ensured that the research topic and focus remained relevant to the lives and values of those that took part, as each stage of the research process was planned, negotiated, and agreed. The active involvement of people with direct experience of the research topic being studied has also been considered within the literature for its potential to increase the ethicality of the resulting research (Abell et al., 2007; Evans & Goldacre, 2011). It is suggested that involving the public with designing a study’s consent process ensures that potential research participants receive the information they want and need, that the information is delivered in a way that is reflective of their interests and concerns, and written information is clear and accessible (Involve, 2012).

Cameron and Hart (2007) suggested that the process of informed consent can be enhanced by the decision-making task being simplified and by presenting information as separate elements rather than in an uninterrupted form. Time and effort were therefore initially given to general awareness raising around the research study taking place with the PMA, to provide a period of several months in which people could access information and ask questions before defined data collection events and activities began. The Research Steering Group developed the documentation relating to participant recruitment and consent, which enabled the lead author to provide oral and written information about the purpose of the study to participants and stressed that participation was voluntary and withdrawal possible at any stage.

Data collection and analysis

World Café is a recognised way of structuring and recording conversations, organised around a series of questions that are allocated to different tables. Participants rotate around each table to consider the questions and record their thoughts and conversations on the paper tablecloths (Brown & Isaacs, 2005). Each table considered a different question, which had been decided by the Research Steering Group and were phrased to align with the overarching research question. The formulation of the table questions was particularly shaped by the Research Steering Group’s stated interest in better understanding the unique PMA ‘methods’, such as what was required for participation, what motivated people to participate, and what arose from people’s participation. The World Café is a method concerned with enabling the collaborative construction of knowledge and therefore aligned with the study’s PAR methodology, which seeks to enable “democratic dialogue and reform through bringing people together in a safe place” (Koch & Kralik, 2006, p. 13). It was agreed that players would be invited to choose a table and record their responses and discussion relating to the table question on a paper tablecloth. Players were free to move around the café tables in whatever order they wished, with the intention that each table (and ultimately question) being visited and considered by all the players at some point. Some players chose to discuss the questions with their peers and respond collectively via one or two scribing, while others chose to respond individually.

The two London-based World Cafés took place on two different training days, in the upstairs café area. It was not possible to hold just one café in London as several of the players had leave restrictions under Section 17 of the Mental Health Act (2007), and therefore holding two events maximised access and inclusivity. Several players chose to attend both café events, with a sense of beginning their participation on the first day, staying until they were able to do so (some had to leave early due to other commitments, leave restrictions and/or for health reasons), then returning to complete their contribution on the second day. In addition, one player appeared to use the first café as an opportunity to observe people’s participation, to inform their own thinking on whether to participate more actively in the second café, which they did then decide to do. The first café was attended by 10 people and the second café by eight people, which included three returners. However, these three returners were counted only once as their participation continued on their return, rather than repeated. This means a total of 15 participants in the two London cafés. Most café participants were players in the PMA, although some were individuals who also at times assumed coaching and refereeing positions. In addition, one PMA paid staff member and a family member of a player participated.

A third World Café event took place with the two PMA teams that train with the Yorkshire PMA Academy in Wakefield. The Wakefield World Café followed a very similar procedure to the two previous London cafes and occurred immediately prior to a training session to minimise disruption for potential players (e.g., in terms of travel). All three cafés occurred within the same 2-hour time frame, in terms of how long the café space was available for participants. Eight players attended and took part; six of whom were players participating in the PMA due to the Wakefield academy securing funding to also work with an adolescent population identified as Not in Education, Employment, or Training (i.e., NEET). There is no universally accepted definition of NEET, but it is generally understood to include people aged 16-24 years old, who are not currently accessing education or any other form of training or employment, who could therefore be seen as at risk of experiencing mental distress (Yates & Payne, 2006). There were a further two participants who were Wakefield players with experience of mental distress, who had been part of the PMA for several years and were now providing mentorship to the newly recruited NEET players.

The data from the three Research World Cafés was in the form of 15 annotated paper tablecloths – five from each of the café events. In addition, the lead author’s observations and reflections were noted in a fieldwork journal. This supported reflexivity and enabled examination of their own conceptual lens, explicit and implicit assumptions, pre-conceptions and values, and how these affected their decision-making during the study (Korstjens & Moser, 2018). Analysis of the first strand data took an inductive, ‘bottom-up’ approach and a broad thematic analysis was used to organise and describe data and to relate patterns of the data to the research question (Stringer, 2007). A benefit of using thematic analysis is its previously acknowledged accessibility to co-researchers (Braun & Clarke, 2006) and therefore it is well suited to emancipatory, participatory inquiry. Additionally, the usefulness of themes in disseminating and actioning findings for their applicability to health contexts has been highlighted in the literature (Sandelowski & Leeman, 2012).

The below description of the data analysis process imposes a linearity and neatness that does not accurately reflect the iterative cycles and messiness that a collaborative data analysis process realistically involves. The stages of thematic analysis detailed by Braun and Clarke (2006) were used, as well as their terminology in terms of codes, categories, and themes. Iterative cycles of the lead author working with the data alone and then returning to the Research Steering Group for further discussion and refinement, followed processes described by Stringer (2007).

Familiarisation with data

Collective data analysis began within the action of the research café, as some players discussed, debated, and refined their thoughts through collaborative conversations, before recording them on the tablecloths. This aligns with other research studies that have utilised World Café as a method (Teut et al., 2013) and meant that there was already a level of familiarisation with the data, as the lead author had facilitated each of the café events and several of the Research Steering Group members also participated in a café event. The 15 paper tablecloths were then brought back to the Research Steering Group, for further collective discussion and analysis in the weeks immediately following the cafés.

Generation of initial codes

During the data collection it became clear from observing the research participants that utilising the familiar context of a café appeared to provide a safe and productive space for those participating in the research. As such, the lead author decided to capitalise on this by beginning the collaborative and dynamic process of data analysis by sharing a large photograph (of the very familiar) changing room at the Hackney Marshes Centre, as a visual template for depicting the ‘hanging up’ and organising of a large amount of information, but also with a sense that things could easily be moved and repositioned as new insights and information became available. This appeared to be a relevant and helpful metaphor that supported the group in organising and grappling with large amounts of data at the initial data analysis stage. The Research Steering Group members had frequently voiced a wish that the research study highlight differences in perspectives as well as commonalities, and it was hoped the image of different ‘pegs’ with differing information (and perspectives) hung on them would enable this. Additionally, the collective analysis was aided by using small, circular coloured stickers. Research Steering Group members chose the categories of red to depict an ‘important’ point, and blue to represent a ‘popular’ point, which they felt reoccurred several times within the tablecloth data.

Generation of initial themes

Once the sticker annotation and related discussion had been completed over a series of meetings of the Research Steering Group, it was agreed that the lead author would draft, based on the initial analysis, some preliminary themes. They did this by looking across the groupings that the stickers and collective discussions had enabled and worked backwards and forwards multiple times between the tablecloths, the lists of patterns, and codes that had been collectively identified. From this a thematic map was generated that consisted of three over-arching themes: The value of being part of a team, Funding and resources, and Keeping well through football.

These themes were then shared with the Research Steering Group. Of benefit here was that the raw tablecloth data was still relatively accessible and visually available to participants, along with the agreed sticker annotations. This meant that although the lead author had worked alone to construct the over-arching themes, the group were able to very easily cross-reference themes against the raw data. It was therefore relatively straightforward to present the three over-arching themes in draft form, while also making available and referring to the original tablecloth data within the Research Steering Group. The lead author created a summary for each theme with illustrative stories and vignettes selected from the tablecloths and the discussions that had occurred. The material was presented with an invitation for the Research Steering Group members to question, clarify, amend, or confirm. During this interactive exercise omissions and anomalies within the raw data and the three draft themes were discussed. Reasons and explanations for particular issues being absent within the raw data were also debated. The lead author was particularly mindful within this exercise to relay information, stories, and accounts from the Wakefield research café event, as none of the participants of that café were part of the Research Steering Group and they were also a somewhat different group due to their younger age range and NEET status.

Reviewing the initial themes and refining and naming collective themes

The discussions that resulted from the interactive exercise led to the addition of a fourth theme and the retitling of the three themes. This was important, in order to use the language of those that took part in the PMA. The intention was that this was a collaborative and iterative process, with ideas and initial themes continuously being refined through re-engagement with the Research Steering Group and the raw data. After the final agreement around naming the (now) four themes, the Research Steering Group verified that the themes felt sufficiently clear and wide-ranging to provide distinct pegs on which to ‘hang-up’ related stories, quotations, ideas, and discussions, again utilising the changing room metaphor to organise collective thinking and discussion. In every case, quotations illustrate the themes. Ultimately this process sought to ensure the credibility of the café findings as participants were involved in the analysis of the data and confirming the findings as authentic representations of their experiences (Carpenter & Suto, 2008).

Writing up the themes

Writing up qualitative research has been identified within the literature as an ongoing part of the analysis process (Holloway, 2005; Wolcott, 2009), whilst collaborative writing is acknowledged as one of the most challenging elements of participatory research (Nind, 2011). Therefore, writing up the themes required some revisiting of stages three and four, to ensure that everyone felt they accurately reflected the raw data, and that there was adequate illustrative data for each one. After writing up the four themes, they were presented back to those that had taken part in the café events. This process included the lead author and a Research Steering Group member travelling to Wakefield to share the findings with those participants.

Findings

The Research Steering Group agreed four themes that were grounded in the discussions that had occurred during the World Cafés and had been recorded on the paper tablecloths. The presentation order of the four themes was also discussed and agreed by the Research Steering Group, in terms of order of perceived importance. The four themes were: Restricted and restricting resources, The two sides of taking part, Being part of a team, and Developing and staying well through football.

Restricted and restricting resources

This was an important and dominant theme within the Research Cafés, and was echoed in the analysis process and numerous Research Steering Group discussions. The PMA’s increasing financial vulnerability as a charitable third sector organisation shaped, compromised, and distorted participation. This was reflected not just in the construction of tablecloth statements such as: “more funding for day trips” and “extra days like weekends if you attending college”, but was also visually represented through the proximity to other statements concerned with the amounts of money relating to premiership players, for example “Garef Balle 125 million” [sic] to reflect the recent reporting of a premiership player’s transfer cost. There was a sense within the analysis that the PMA’s financial situation has become a vicious cycle, with some players leaving due to (what they considered to be detrimental) changes that were made in an attempt to secure more funding, and then the reduced player numbers meaning certain teams were short of players on occasions, which undermined authentic and meaningful participation as a competing team. This is a point at which this theme and the second theme closely inter-relate, in terms of the contradictory nature of taking part.

The two sides of taking part

This theme seeks to capture the complex and paradoxical nature of participation in the PMA. Whilst statements such as “fun” and “enjoy playing football” captured the positive aspects of player’s participation and the construction of a positive sense of self, there were also statements that reflected the challenges associated with taking part, such as: “players [should be] signed to a team at start of season – then set – no swapping of players between teams – need to balance fairness/taking part and winning/being best”, and how attempts to ‘even up’ two teams could result in a loss of positive meaning and purpose for some players. Such statements had been made in the context of discussing the dwindling PMA resources and the resultant reductions in player numbers, meaning swapping players between teams was felt to become necessary to enable a fair game. Indeed, during the cafés there were frequent discussions relating to the competitive nature of the football participation, and keenness that this was protected, maintained, and taken seriously, as it was felt to be fundamental to why people took part and the value they derived from participation. This was also linked to football frequently being an occupation people had engaged in prior to experiencing crises or ill health, and therefore it was important that such participation was authentic to truly enable and represent a return to health.

Being part of a team

This theme relates directly back to the study’s research question in terms of both the value and nature of people’s participation in the PMA. It is intended to reflect the numerous statements on the tablecloths and the discussions that took place in the cafes, which related to the opportunities that participation in the PMA was felt to offer. For example, to “play … as part of a team”; “meet new friends” and “get out of the house”. These and related statements occurred frequently across the tablecloths and were presented and discussed not just as benefits and outcomes of participation, but also as a reason for taking part. For example, several players outlined that they were sometimes driven to attend even when intrinsically feeling unmotivated, because they were aware of their role in being part of a team and the consequences that might result if they were not there to play their position on the pitch. Certainly, the collective and associational nature of being part of a team appeared to provide both social confidence and occupational opportunities. For example, the developmental nature of the PMA was felt to offer the opportunity to participate in various ways and was reflected in statements such as “gain qualifications” and “to build confidence, new skills and move into work and independence”. Such statements tended to be longer that the typically three to four-word statements elsewhere on the tablecloths, perhaps indicating the importance players attached to them or that it was difficult to express this value in any fewer words.

Developing and staying well through football

The fourth theme related to the expectation that taking part in the PMA involves more than just playing football; it was an integral part of players keeping and staying well, as well as enabling their recovery. Discussions in relation to this were frequently linked with the PMA’s logo, which includes the statement ‘changing lives through sport’. In this sense the theme seeks to reflect what players felt to be the uniqueness of the PMA, in terms of it being an organisation that was not problem focussed and sought to be about more than just playing football. Also, the culture of acceptance and inclusion was discussed, as players acknowledged the varying occupational opportunities that were provided and the active role they could take in the running of their team and the academy. This was reflected in tablecloth statements such as: [taking part in the PMA] “take[s] you outside [your] comfort zone”; “prevent relapse” and “become a role model”. However, the limited availability of resources and staff time was discussed as undermining such benefits. Again, this is a point at which this theme and the ‘Restricted and restricting resources’ theme inter-relate.

Discussion

The four themes presented above depict the complexity of participation in football by people with experience of mental distress. The findings support previous research that has highlighted both positive and negative aspects of playing football for people with experience of mental distress (Darongkamas et al., 2011; Get Set to Go Research Consortium, 2017; Hodgson et al., 2011; Perks, 2007; Such et al., 2019). The findings also highlight factors that might mediate the benefits that are derived, for example resources and feeling part of a team. These findings sit alongside calls for research that extends understanding about how participation in sport is best organised, to maximise engagement and benefits for people with experience of mental distress (Department for Culture Media and Sport, 2015; Hart et al., 2016).

This study has provided new knowledge about the tensions, nuances, and subtleties that occur in relation to the transactional relationship between playing football and people’s health and well-being. The findings include a range of factors that might enable or restrict people with experience of mental distress when they want to play football, with sufficient funding and resources being emphasised as particularly important both within the data and in the collective ordering of the themes. The importance of funding and resources was related to people’s potential discontinuation, as limited resources led to player numbers dwindling and the perceived authenticity of the game being undermined. This extends previous research, which identified the experiences associated with mental distress and the side effects of medication (lethargy and weight gain) as being the main challenges for people continuing to play sport as part of an organised physical activity programme (Hodgson et al., 2011).

Furthermore, there are occupational risk factors that are particularly pertinent to the participants’ experiences and relate to the findings outlined above. Across the four themes there is a sense of several players experiencing external restrictions, such as financial resources being lacking, thus connecting with occupational deprivation. This was closely related to occupational alienation, due to the perceived authenticity and meaning of the football being undermined by reducing player numbers and actions to ‘even up’ teams (Hocking, 2017). For some participants, this had led to discontinuation.

These findings illustrate how accessible sporting opportunities being limited to third sector charitable initiatives can result in some people’s access to health enhancing occupations, such as football, being inequitable, thus resulting in occupational injustice. Taking account of such existing inequalities and contextual factors has been identified as integral to ensuring health interventions do not exacerbate health inequalities (Williams, 2017). However, there is a paucity of research that explores in depth the factors that influence people to give up participating in sport and other physical occupations. Such research should include an in-depth analysis of playing sports such as football: from making the first move to join a club or organisation like the PMA, to deciding to leave. This would enable more precise support to be offered where it is needed, which has been identified as critical in enabling and sustaining participation in sport and physical occupations (Get Set to Go Research Consortium, 2017; Hodgson et al., 2011).

This study’s findings also extend previous work relating to the complex and multi-dimensional nature of occupation. To date, the literature relating to the dark-side of occupation (Twinley, 2013, 2017; Twinley & Addidle, 2012) and non-sanctioned occupations (Kiepek et al., 2019) has focused almost exclusively on occupations that are obviously deviant, illegal, and/or unhealthy (rape, sexual assault, violence). Therefore, the various dimensions of occupations such as football are under considered. The findings of this study demonstrate the potential for participating in football to be somewhat paradoxical at times, invoking a range of emotions and experiences. This challenges policy and literature that constructs participation in sport as a universal panacea (British Medical Association, 2014; Department for Culture Media and Sport, 2015; Hagell, 2016; Royal College of Psychiatrists, 2012a, 2012b, 2013; Sport England, 2016) and also individualistic governance trends, which emphasise individuals completing certain types and amounts of physical activity (Public Health England, 2016; Pullen & Malcolm, 2018; Sport England, 2016).

Limitations

Several limitations are acknowledged in relation to this research study. Literacy appeared to be a particular issue for the Wakefield café, although attempts were made to overcome this by the lead author offering to scribe. Some players did accept this offer, but this did appear to alter players’ engagement (e.g., standing at the tables while the lead author sat and scribed) and highlights a limitation to the World Café method when researching with individuals with literacy issues, as there is such an emphasis on words and written text. One player chose to write an individual response to each of the questions on a separate piece of paper, which they then placed (and later stapled) on the tablecloth before moving on to the next table, thus illustrating the flexible nature of the World Café method.

It is a limitation that Wakefield players were not otherwise involved in the data analysis process, and this is possibly reflected in the fourth theme being quite focused on mental health and recovery. That theme was possibly not relevant to the majority of the Wakefield players as they were participating in the PMA due to their NEET status, rather than their experience of having mental distress, as in the case of the London project. However, some of the Wakefield players did also have experience of mental distress.

A further potential limitation of the World Café method was its collective nature, as this did not afford participants a private, individual space to share and explore their experiences. This was acknowledged within the research steering group afterwards and informed decision-making around data collection methods for the second and third strands of the study.

Conclusion

This study revealed various tensions and nuances that exist in relation to people with experience of mental distress playing football. It has highlighted the potential to use occupational justice as a conceptual lens through which to consider inequalities relating to participation in sport and physical occupations, particularly in terms of ensuring that structural factors and social processes are not overlooked when working with marginalised groups who wish to be more active. An occupational justice perspective acts as an important counter to health and sport policies, which are often overly reliant on individual behaviour change. Furthermore, the findings demonstrate the need to fully consider the complex, multi-dimensional nature of occupations such as football. The use of a participatory action research approach enabled knowledge to be advanced in directions that are relevant and meaningful to people with experience of mental distress.

Acknowledgements

The authors thank the people from the Positive Mental Attitude Sports Academy who took part and generously shared their time and experiences, which made the study possible. Thank you also to the Constance Owens Trust and Elizabeth Casson Trust, who both provided funding towards the study. In particular to the Elizabeth Casson Trust for providing additional funding to enable this paper to be published open access.

Disclosure Statement

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