Football is/as medicine: the growth of a health promotion movement and a challenge for sociologists

Sir,

The idea that physical activity has a positive impact upon participants' health has been widely accepted for a considerable time. This notion and is based upon almost irrefutable evidence that regular participation in physical activity has physiological health benefits (e.g. Bangsbo et al., 2019; Blair, Cheng, & Holder, 2001; Sallis, 2009; Warburton, Nicol, & Bredin, 2006). Although less conclusive, evidence also suggests that regular physical activity can also be beneficial for participants' psychological health and wellbeing (e.g. Andersen, Ottesen, & Thing, 2018; Bauman, Merom, Bull, Buchner, & Singh, 2016; Coenders, van Mensvoort, Kraaykamp, & Breedveld, 2017). We also agree that sport, exercise and physical activity provide crucial benefits to their participants; we are fundamentally 'for' physical activity promotion for a plethora of reasons. Yet we would also contend that the implementation of physical activity programmes is not perfect, and there is a significant need for further sociological, political and socio-psychological study into the reasons why uptake and maintenance of regular of physical activity can remain low. Indeed, participation rates remain low in many regions (Hallal et al., 2012), leading to concerns about the best way to promote physical activity for health at the population level.

One potential way to promote physical activity for health could be to adapt, target and promote sports participation as a means to be active. Indeed, recent years have seen an increasing shift in the focus amongst sport and exercise agents and organisations towards highlighting the health-promoting characteristics of the activities for which they are responsible. One consequence has been the notion that the sport and exercise sector can be a field in which the promotion of physical activity can be enhanced (e.g. Michelini & Thiel, 2013; Weed, 2017; World Health Organisation, 2019). As a result, sport, exercise and physical activity have become combined in many programmes and policies, particularly when delivered by organisations more often concerned with elite sport (Malcolm, 2014; Malcolm & Pullen, 2017).

As noted elsewhere (Malcolm, 2016; Michelini & Thiel, 2013), the connection between sport and medicine is built upon multiple assumptions which are now largely taken for granted in the sport science community. These include (i) the assumption that regular participation in exercise is synonymous with the adoption of healthy behaviours and/or lifestyles, (ii) that sport/exercise/physical activity are associated with the attenuation of health risks amongst both healthy and ill populations, and, (iii) due to its positive impact upon physical health, sport/exercise/physical activity can be prescribed as both a treatment or prevention option in the management of several non-communicable diseases including as diabetes, cardiovascular disease and cancer (e.g. Krustrup et al., 2018; Warburton et al., 2006). Moreover, there has been an accompanying proliferation of confirmatory research which has underpinned these assumptions, resulting in the construction and dissemination of a bewildering array of claims about the positive benefits of sport and exercise. These claims range from the assertion that sport and exercise can ensure maintenance of participants' physical functionality, to claims which suggest participation in sport and exercise leads to the creation of social capital, group cohesion and even social integration, particularly amongst marginalised groups (e.g. Andersen et al., 2018; Bauman et al., 2016; Krustrup et al., 2018). Such 'movement intellectualism' (Turner, 2012; Williams & Gibson, 2018) remains, for the most part, uncritical towards the potential negative effects of privileging sport over other health promotion programmes. Instead, a primary focus upon demonstrating the positive benefits of sport/exercise/physical activity behaviour has led to it being presented as a panacea, miracle cure or 'polypill' for multiple health and social problems (Khan et al., 2012; Pareja-Galeano, Garatachea, & Lucia, 2015; Sallis, 2009). Indeed, sport and exercise as healthcare has expanded beyond targeting those who are ill, to promotion of healthy behaviours to entire populations as well as specific risky sub-groups (Malcolm, 2014).

Such is the influence of this sport for health movement that this viewpoint has become a dominant narrative in sport science (Papathomas, Williams, & Smith, 2015), such that it now represents a rarely-challenged orthodoxy. This narrative is reproduced for several reasons, including the ongoing search for legitimacy in the sports science community, the perception that the health field is awash with resources, growing commercial interests in sport and changing healthcare burdens in many societies (Malcolm, 2016). Furthermore, the promotion of sport and exercise as healthy lifestyle options has led to the development and propagation of several movements and programmes in which sport is promoted or has been adapted to be a public healthcare option.

Such programmes include the now global 'exercise is medicine' movement (e.g. Berryman, 2000; Lobelo, Stoutenberg, & Hutber, 2014), and several adapted sports programmes. These include 'football is medicine' (Krustrup & Krustrup, 2018; Krustrup et al., 2018), as it is often called by natural scientists, and its other manifestations including 'football as medicine' (Krustrup & Parnell, 2020), which tends to be utilised more in the social sciences, and 'football fitness' (Bennike & Ottesen, 2016; Bennike, Wikman, & Ottesen, 2014; Ottesen, Krustrup, & Mohr, 2016). For clarity, we therefore refer to 'football is medicine' here in relation to evidence from the natural and physical sciences, and 'football as medicine' in relation to social-scientific evidence. Finally, 'football fitness' represents a reconceptualization or adaptation of football to emphasise its fitness-building characteristics in order to provide a health-enhancing, preventative or curative tool in the battle against ill-health (e.g. Krustrup & Krustrup, 2018; Krustrup et al., 2018).

The logic behind such programmes holds that, because sport and exercise are so self-evidently beneficial to physiological and psychological health, the adaptation and promotion of popular sports (such as football) to non-participants offers significant potential for the promotion of good health (e.g. Krustrup et al., 2018; Sallis, 2009). The intention is to 'package' such activities correctly such that they are attractive to new audiences, to raise awareness of their benefits, and to implement them through community-based and targeted programmes, often delivered through sports organisations and governing bodies. The need for such changes has also been driven by shifts in participation trends and consumption patterns in sport, in which many traditional sports have been challenged by individual-oriented forms of exercise, causing many sports organisations to seek to adapt their 'product' to appeal to a wider audience and to compete with private health clubs, gyms and other forms of health-oriented exercise (Bennike & Ottesen, 2016; Bennike et al., 2014, 2020).

As a consequence, the football is medicine movement has developed rapidly over the last few years, and research in the 'football is/as medicine' field has gone through a veritable explosion in both scope and extent. Developing from an initial, tentative focus upon football as prevention [of ill health], through a focus upon football as prevention and treatment [of ill-health], the field has now expanded into a more definitive conceptualisation in some quarters that 'football IS medicine' (Krustrup et al., 2018). Simultaneously, research in the football is medicine field has expanded in a very short time from localised research programmes to a global movement replete with over 150 peer reviewed publications, a handbook and conference, many of which have gained recognition from football's international governing bodies (Krustrup et al., 2018). This body of work has culminated in the production of the 'football is medicine' platform to which several hundred scholars have contributed both directly and indirectly (Krustrup et al., 2018). Again, because evidence that participation in sport leads to increased physical activity, and physical activity if beneficial to physical and psychological health, it is largely accepted that participation in football is good for health in this literature. For example, Krustrup et al. (2018, p. 3) outline how

'small-sided football is an intense, versatile combination of strength, endurance and aerobic high-intensity interval training and that twice-weekly 1-h sessions can be utilized for the prevention, treatment or rehabilitation of non-communicable diseases, such as hypertension, type-2 diabetes, osteopenia and prostate cancer' (page 3).

Moreover, any potentially negative effects of football (such as sports injuries) are presented as avoidable with 'minor adjustments' (Krustrup et al., 2010). The optimal 'dose' of this football medicine is also clearly defined, with some claiming how 'football training for 2 × 1 h per week [can result] in marked positive and simultaneous effects on cardiovascular, metabolic and musculoskeletal fitness' (Krustrup et al., 2018, p. 2). Furthermore, claims that such activities are beneficial to factors beyond physiological markers of health are also increasing, including the notion that football is medicine can improve 'psycho-social wellbeing', motor skills, cognitive functioning and 'learning,' although relatively few studies have demonstrated strong associations with socio-cultural and socio-psychological benefits, and those that have done so focus upon specific groups in specific contexts (e.g. Krustrup, Dvorak, & Bangsbo, 2016; Larsen et al., 2018; Ørntoft et al., 2016). It is not for us to comment on the rigour and efficacy of such research, albeit to say that such evidence is extensive, convincing, and deserves to be taken very seriously. Indeed, there is much to be optimistic about the football is medicine platform, including the way in which evidence from both the natural and social sciences is integrated into the same model. What's more, there is a growing consensus that adapted football programmes can be efficacious means of ensuring health promotion – if people participate (Krustrup et al., 2018).

And therein lays the rub. Getting people to participate is problematic, because the efficacy of sport for health does not automatically equate to effectiveness of sport for health. In other words, it can be problematic to assume that, because sport and physical activity offer an efficacious way of promoting health amongst participants under ideal conditions, it follows that sport is also effective way to promote health and make inactive people in the community more active (Weed, 2017). Such an assumption has yet to be proven conclusively, particularly in light of evidence which suggests that, despite a longstanding awareness that participation in sport is beneficial to health, some groups still do not participate in sport. It is also too simple to conceptually divide the population into participants and non-participants, because some people participate in sport and physical activity sporadically, or at changing frequencies across the life-course (e.g. Pilgaard & Rask, 2016; Weed, 2016, 2017). Indeed, even if we consider physical activity as a comparative health promotion tool, evidence of its effectiveness remains mixed (Cavill & Bauman, 2004).

At the same time, not yet knowing what works best is not the same as saying something will not work. Indeed, we would go so far as to say such a knowledge gap represents a challenge to which sociologists and other social scientists need to rise. A lack of evidence for the effectiveness of sport for health might reduce our ability to be certain about whether football is medicine is effective, but it does not mean that it is ineffective. We simply do not yet know the best ways to implement football as medicine, and we strongly believe that sociologists have a crucial part to play in generating such evidence, whether supportive or critical. It is to an outline of this challenge and some suggestions for future research in this field that our discussion now turns.

Is football actually medicine? The need to examine subjective experiences of football for health

In much of the football is/as medicine literature, particularly that originating from a natural or physical scientific paradigm, there is a lack of reflexivity about the way in which medical terminology is utilised in conjunction with football (e.g. Krustrup et al., 2018). Put simply, subjective meaning-making (and its impact) is largely overlooked. For example, football is variously referred to as a pill or polypill, dosages are prescribed, and health professionals are exhorted to prescribe this wonder drug, whose potential side effects (such as increased risk of injury) are considered controllable and therefore minimal, if they recognised at all. Upon deeper consideration, however, this unequivocal comparison of football with medical terminology is problematic, because the 'taking' of this particular medicine (participation in physical activity or sport) differs in several crucial ways from other more traditional medicine. Here, the term 'medicine' has traditionally had two meanings in English; the treatment of illness, or representative of the wider application of healing (Malcolm & Pullen, 2017). Conversely, football is medicine, even when adapted, differs in several respects from these definitions.

First, as well as being promoted to those with demonstrable or diagnosed health needs, it is suggested that football is medicine should be promoted to those with the pre-cursors of illness, and even those who are ostensibly in good health (i.e. have an absence of illness), because everyone can benefit from improving their physical fitness. As outlined by Malcolm (2018, p. 53) in relation to the 'exercise is medicine' programme, such promotion and utilisation of the football is medicine label appears to consider the risk of ill health and actual disease to be synonymous. This makes the experience of being at risk of developing a disease (e.g. due to sedentary lifestyles) indistinguishable from the illness experience of symptomatic patients, such that illness is presented as an inevitable consequence of non-participation. Such an observation illustrates how physical activity/sport is often promoted as a health promoting intervention to multiple populations without the need to define a specific need (or illness) that needs to be 'cured'. Hence, the prescription of sport becomes pre-emptive, preventative, and prescribed to both the healthy and unhealthy alike, and is administered in the community rather than in the clinic. This is why the need to understand those communities is so crucial. It is important to note that prevention of illness is more cost-effective, efficient and beneficial than curing existing conditions, and preventative policies should represent a key component of any healthy society, whether welfare-based or otherwise (Ibsen & Ottesen, 2003), and yet there is a danger of stigmatisation if we uncritical label a-symptomatic populations as 'risky' or in need or medical support. The effects of this ambivalence upon meaning-making amongst both participants and service providers, would seem to be something that requires additional focus.

Furthermore, given the lack of a specific 'problem' for which football is the cure, and perhaps in contradiction to the evidence presented above, some have suggested the optimal 'dosage' of exercise remains both unclear and is prone to increase over time (e.g. Weed 2017). Yet recommendations about an appropriate dosage are generally applied to multiple groups because participation is assumed to be almost exclusively beneficial. All participation is good participation. Furthermore, unlike many other traditional medications, the course of 'treatment' is never-ending, with no point of destination (Jonas & Phillips, 2012). The focus therefore becomes the management of health, rather than only to provide a cure. Finally, sport and football is medicine is also not subject to the kind of regulation which is applied to most other forms of medication (Malcolm & Pullen, 2017). As noted, for example, the potential deleterious side effects of sports participation, such as increased risk of injury, are considered to be low and therefore manageable (Castagna, de Sousa, Krustrup, & Kirkendall, 2018). And yet, as in any other medical treatment, 'side effects' such as injury, equity or net harms (i.e. privileging sport when other health options are more effective) must be considered when measuring the efficacy of relatively high-risk activities such as sport (when compared with physical activity) as an ethical imperative (Weed, 2017). In short, we also need to recognise and understand the potential unintended consequences of football is medicine programmes if we are to make such programmes better.

Furthermore, we must also consider how football is medicine represents part of a wider medicalisation of society in which iatrogenesis, or medically-generated social problems, are created (Illich, 1975; Malcolm, 2016). This process when applied to the meanings associated with football threatens to subsume many of the other motivational drives to participate in sport, such as the wish to engage in leisure, freedom, sociability or emotional stimulation (Smith, 2016). Indeed, some authors have questioned whether exercise is always medicine, or something else (e.g. Williams, Hunt, Papathomas, & Smith, 2018). Indeed, social-scientific scholars within the football is medicine field appear to be aware of this problem. For example, there are signs that the definitive term 'football is medicine' (which appears to indicate all football is indeed medical) has been softened somewhat to 'football as medicine' (which appears to reflect the notion that a more specific, adapted form of football is being referred to, whilst other forms of football also exist).

In sum, therefore, we need to develop a greater awareness of wider meaning-making in football if we are to understand both the positive and negative impacts of the reconceptualization of football and footballing cultures as health promoting, as medicine or otherwise. Whilst in many pro-football as medicine publications, football and team sports are assumed to be largely positive, or, at worst, value neutral (Krustrup & Parnell, 2020), we must be aware of, and critically analyse, the other potentially contradictory meanings that football cultures are associated with. Lest we forget, wider cultures of football, inclusive of elite, grassroots and recreational football, have been associated with multiple negative characteristics over the years, not least corruption (e.g. Sugden & Tomlinson, 1998), hooliganism and violence (e.g. Dunning, 1999), deviance and doping (e.g. Malcolm & Waddington, 2008), misogyny, sexism and sexual scandal (e.g. Dunning, 2010; Jones, 2008; Lenneis & Pfister, 2015) and racism (e.g. Burdsey, 2012). Although these problems manifest themselves most clearly at elite or competitive level and in specific times and locations, this does not mean they do not occur at lower levels, and such cultural associations may well influence people's contextual preconceptions of football as medicine. We would consequently argue that football cultures are neither singular nor value-neutral. It is into this melting pot of meaning that the football as medicine discourse must tread, and within which it must compete for attention.

Hence, we must be aware of (and account for) the meanings attached to the contextual experience of football itself. Not only this, but we need to mobilise the potential of team sport to create communities and mutually-supportive social relationships. Empowering potential participants to participate in meaning making for themselves and for others is crucial in this case, because many of those who promote football as medicine are key proponents of the game; they (we!) are often football fans, participants, volunteers or coaches. In short they are often people who love football, and who may need to carefully consider new ways to empathise with those who simply do not like team sport. Such knowledge is necessary if we are to ensure that football as medicine is to avoid being labelled just another fitness fad in which the format of a popular activity is simply 'adapted' or tinkered with in order to appeal to a wider audience. We need to be aware that, for many participants, the principally attractive characteristics of a sport like football included enjoyment of competition, facilitation of emotional free-flow, unpredictability and creativity, de-routinisation, socially-permitted self-centredness, risk and teamwork (Elias & Dunning, 1986). We should therefore seek to retain and promote such characteristics in any health-based football programme, whilst also recognising individual freedom of choice. Such activities might appeal to some in a target audience, but not necessarily to all. Furthermore, the assumption that unhealthy or sick participants do not already participate in football because it is risky, unpredictable or competitive is a dangerous generalisation because it implies that all that is needed to 'convince' such individuals to play is to remove or adapt these characteristics. This is unlikely to be the case. Thus, we need to understand that participants in football as medicine are neither rational nor irrational, neither predictable nor homogenous; human beings are complex creatures for whom the long-term adoption of healthy lifestyles is about more than just 'making the right choices,' adapting an activity, or 'getting the message right' (Kelly & Barker, 2016). Such assumptions are based upon a now highly criticised neoliberal view of health in which personal choice and logics of consumption are valorised above all else (Williams et al., 2018). As Williams et al. (2018, p. 4) outline, 'it matters not whether exercise is medicine if few are prepared, or able, to engage with it.'

In short, adaptation of football alone is unlikely to be 'enough' to make football as medicine effective. Instead, we need to understand how football as medicine is interpreted and imbued with meaning, in which sociological inquiry can play a key part. What's more, the effects of interpretation upon the implementation of football as medicine represents the second area of inquiry which we consider to be urgently needed. This requires explanation.

How can football as medicine be implemented effectively?

As outlined above, evidence for the efficacy of participation in physical activity for health benefit is overwhelming. That is, under ideal conditions, it improves participants' health. Similarly, evidence to suggest the same applies to football is highly convincing. Conversely, evidence to suggest whether promotion of sport is an effective way to promote population level health is hotly debated, and some have argued that evidence is lacking, despite the huge number of claims made about, and growing evidence for, the benefits of sport for society (Andersen et al., 2018; Weed, 2016, 2017). Put simply, the fact that an adapted form of football is likely to be good for health if one participates in it does not preclude that participation in football is likely. On the contrary, the effectiveness of programmes such as football as medicine is highly dependent upon multiple, complex socio-cultural and organisational factors which profoundly influence the way the football as medicine platform is implemented (Bennike & Ottesen, 2016; Bennike et al., 2014, 2020). Such factors include the way in which policymakers and football governing bodies prioritise football for health against their other objectives and programmes, together with how they interpret and implement football for health programmes if and when they adopt them. Indeed, emerging evidence suggests that interpretation and prioritisation of football as medicine programmes against other programmes is fundamental in terms of how effective football as a health promoting tool is (Bennike & Ottesen, 2016; Bennike et al., 2014, 2020). Such research suggests that power hierarchies running along implementation chains and within and between sports organisations and organisational cultures can profoundly affect the way in which football programmes and interventions are designed, adopted and delivered by associations, clubs, voluntary organisations and individuals such as coaches, teachers and healthcare professionals.

Put simply, football as medicine cannot be thought of as value-neutral in the way it is implemented. Football as medicine programmes are providers' interpretations of the evidence, and policymakers interpretations of the contexts into which the programme will be delivered. All is interpretation. Hence, the efficacy of football as medicine in the lab or in a randomised control trial does not preclude that the promotion of football as medicine as a priority to policymakers and stakeholders, nor does it automatically lead to increased participation amongst at risk or inactive groups. Football is contested terrain. Indeed, contextual and funding factors in different locations are likely to fundamentally affect the effectiveness of the football as medicine platform (Parnell, Bennike, Ottesen, & Widdop, 2020). As a consequence, there is a specific need for further sociological inquiry into football cultures and contexts, both in terms of organisational structures and policy environments in specific countries where football as medicine might be promoted, and how this promotion is considered relevant to contribute to particular problems.

Conclusion

In summary, we concur with many authors that adapted forms of sport do offer potential to contribute towards health promotion at the population level. We would also like to re-emphasise that the lack of evidence to support its effectiveness is not the same as claiming that adapting sport for health is ineffective; we simply do not yet know the best way to implement such programmes in many contexts such that their effectiveness can be maximised. What is clear, however, is that the efficacy and effectiveness of football for health are not synonymous, and there is a considerable need for additional sociological, socio-psychological and other social scientific research which focuses upon the way in which football as medicine is implemented, how it is interpreted in local contexts and football cultures, and how it is experienced and meanings are created by a host of providers and participants in multiple settings. Whilst football as medicine might have a role to play in the health promotion of the future, sociologists could and should provide a key part in defining this role. We believe the potential for sociological inquiry to have a significant impact in this area is considerable.