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CHAPTER 1.7. THE CONTRIBUTION OF SPORT TO QUALITY OF LIFE AND WELL-BEING

Introduction

7.1 There is a limited literature on QOL and well-being as it relates to sport. While most, if not all, of what we understand as sport involves exercise, not all exercise is sport. Our brief is to focus on the literature as it relates to sport, QOL and well-being, and not exercise or physical activity. ³²⁶ However, in the absence of sport- specific literature, the main sporting agencies - for example sportscotland and Sport England - have drawn on the wider exercise literature to underpin policy making.

7.2 In order to provide context to this area of policy making, we have included references to exercise and its relation to well-being where these references were identified through searches for sport and quality of life or where they were highlighted via the sports agencies' web sites. Sport England, for example, has a specific section in its research database, Value of Sport Monitor on health and psychological health and well-being. All the references in this are concerned with exercise. ³²⁷ Having examined these, we then look at what literature does exist that is specifically related to sport. The majority of the studies included are from the literature in sports psychology, sociology, psychology and health sciences. However we begin this section by reviewing how QOL is defined within the sport and exercise literature.

Definitions

7.3 As concluded earlier, there does not exist a common cross-disciplinary definition of the concept of QOL and, as already noted, it is often used interchangeably with the term Health-Related Quality of Life. The majority of studies into exercise are about psychological condition and are concerned with tackling or controlling aspects of ill-health. What is striking about the literature is that (with the exceptions discussed below) there is usually little or no attempt to define QOL or well-being. There is an assumption that the terms are known and understood and/or that the methods of measurement provide an implicit definition.

7.4 Within the literature it is argued that QOL is related, on the one hand, to subjective well-being "related to present affect and emotion" and, on the other, to life satisfaction "related to past, expectations about the future and goals attained", but most of the studies are concerned with specific psychological states - anxiety, depression, moods etc. ³²⁸ The term health-related QOL is used in these studies with reference to health-related issues - as opposed to wider QOL issues. For Biddle, health-related QOL is regarded as being subjective, concerned with patient/participants' measures of their own health. ³²⁹

7.5 It is only in the studies specifically related to sport that we start to find QOL defined and discussed in relation to other QOL domains such as interpersonal relations, self-determination, social inclusion and rights - although this is limited given the paucity of the literature.

7.6 Rejeski and Mihalko offer a detailed discussion on definitions. ³³⁰ Reviewing the exercise and physical activity literature the authors conclude that there is a lack of consistency in the use of the term, "quality of life". They examine various applications of the term in psychology where QOL is "defined as a conscious cognitive judgement of satisfaction with one's life". This is measured using recognised psychological scaled instruments such as the Satisfaction With Life Scales ( SWLS). ³³¹ In their critique, the researchers favour the definition provided by psychology as being the "only definition appropriate for elevating the term QOL to the level of a physiological construct" but they point out that integrating different areas of study is impossible because of the conflicting and inconsistent use of the terms. ³³² They highlight differences in methodological approaches - some using the SWLS but others employing other indices such as Life Satisfaction Index or the Life Satisfaction in the Elderly Scale. The inevitable conclusion is that a lack of definition leads to a range of approaches with an inconsistency in methods and measurement which in turn makes comparison problematic.

7.7 The authors also examine how the term QOL is used within the literature on ageing and explore how QOL is used as an umbrella term to describe a range of desired outcomes. They quote Stewart and King who identify two major outcomes for QOL in older adults: functioning and well-being. ³³³ The former is concerned principally with physical abilities while the latter is related to emotional well-being, self concept and global perceptions. As the article indicates this is very close to the use of the term health-related QOL which is measured, in a large number of studies, using an instrument called SF-36. This is a generic index of health status based on information on broadly two areas, namely physical and mental health. ³³⁴

7.8 The authors' challenge is as much conceptual as methodological. They argue that in the health-related literature physical function or symptom reporting become important but as they argue, "there are many examples of people who report high quality in their lives with significant functional deficits". ³³⁵QOL is not a set of objective measures, they argue, but related to one's subjective perception of satisfaction.

Studies focused on exercise

7.9 The studies on exercise, QOL and well-being fall broadly into the following categories:

• Reviews of literature relating to psychological benefits of exercise or specific interventions; ³³⁶
• Surveys of populations in relation to exercise and mental health including longitudinal studies; ³³⁷
• Surveys of specific groups within the general population; ³³⁸
• Experimental work with (usually) smaller groups looking at specific conditions or illnesses: for example, exercise and HIV; ³³⁹ multiple sclerosis patients and exercise; ³⁴⁰ participation in the Cardiac Transplant Games; ³⁴¹ and, a swimming programme for children with asthma. ³⁴²

7.10 While, as indicated above, these studies were primarily concerned with exercise, some did review the benefits of exercise in a sports context.

Table 7.1. Exercise-related QOL studies reviewed

Methods

7.11 As argued above, the absence of a single definition of QOL along with the different approaches taken in different disciplines, mean that the methodological approaches are also varied. They include:

• Measurement of physical fitness and physiological conditions (sometimes specific to illness such as multiple sclerosis or HIV);
• Self-completion surveys to attest to mood states, sense of well-being or view of QOL - these studies employ psychological instruments, for example SWLS, as discussed above;
• In-depth interviews;
• Random controlled trials;
• Survey of participants drawn in some cases from the population at large (using sampling methods) but often from specific groups (such as college students).

7.12 The systematic reviews raise a number of issues about methods and approaches. For example, Scully et al in reviewing the relationship between physical activity and psychological well- being, conclude that there are three main reasons why more definitive conclusions about the existence of a causal relationship cannot be reached. These can be summarised as:

• The research base is "thin": lack of empirical data;
• It is not clear how psychological and physiological variables interact to produce the result; and
• The primary mechanisms that underlie the relationship between exercise and psychological well- being remain poorly understood. ³⁴⁷

7.13 In their review of the literature, Biddle et al focus on establishing the link between exercise and the promotion of psychological well-being. ³⁴⁸ The papers included in the publication were commissioned by the Somerset Health Authority thus indicating the growing interest amongst policy makers in evidence of a link between psychological health and exercise.

7.14 However again the authors argue that there are gaps in the research - specifically with regard to implementation and the impact of short and long-term exercise; differences in self- generated activity and that which relies on facilities; the social effects of exercise and well being and the relationship with self efficacy. They also point to a lack of analysis of the cost effectiveness of physical activity as a treatment for mental illness. ³⁴⁹

Discussion of articles based on primary research

7.15 Edwards et al, in studying the relationship between mental health and diverse types of exercise (hockey and health club activities), found that participation in either activity promoted psychological well being in comparison with the control group of non-exercising students. ³⁵⁰ The researchers in this case developed a scale of measurement of QOL by combining two existing approaches by Ryff and Fox. ³⁵¹ They quote Ryff's six dimensions of psychological well-being: self acceptance, positive relations with others, autonomy, environmental mastery, purpose in life and personal growth. ³⁵² As the paper points out, Fox argues that physical self-perception is related to self-esteem, well-being, health and life. ³⁵³ The physical self-perception profile developed by Fox from this link measures self-perception in five categories: sports competence, physical condition, body attractiveness, physical strength, and physical self worth. In combining both these approaches to measurement (using questionnaires) the research team argued that the two scales were "brief, easy to use, reader-friendly and comparable" ³⁵⁴.

7.16 Hills and Argyle undertook a comparative study of the positive moods generated by four common leisure activities: sport/exercise, music, church and watching TV soaps. ³⁵⁵ The study was part of a project looking at personality and measurement of happiness, as part of the Oxford Happiness Project. One of the questions explored was, "Is there a difference between those who participate in leisure activity and those who do not?" The study also looked at the range of "dimensions" of happiness and the different aspects of happiness generated by participation in different leisure activities. Some 275 participants aged 18 to 82 were invited to indicate the intensity of their personal, positive feelings for the items of four measures designed to be representative of each of the activities.

7.17 It was found that each activity was a significant source of positive moods. Factor analysis of the measures showed that they each contained a strong social component, as well as a factor characteristic of each activity. Using the Oxford Happiness Inventory ( OHI) as a measure of happiness, only sport/exercise appeared to result in increased happiness, and the authors explain the reasons for this in terms of the several components of the OHI. The significance of this particular study is that it does attempt to compare engagement in different types of cultural and sporting activities. However, while the results suggest that simply being involved does contribute to feelings of happiness, the difference between different activities is, arguably, related to the methods and may also be linked, as the paper goes on to argue, to differences in personality.

7.18 Another approach to researching the link between exercise and well being is to be found in a study by Currie and Develin in New South Wales, Australia. ³⁵⁶ This looked at the benefits for new mothers of participation in pram walking groups. In this case the researchers undertook a telephone survey of 450 mothers with children aged from birth to 5 years old to identify levels of exercise in the group; the perceived benefits of pram walking, as well as the barriers to undertaking this kind of activity. Further research with focus groups involving a total of 50 mothers identified more precisely the barriers to participation and issues around postnatal depression and exercise. While the survey found that 87% believed that pram walking could benefit mothers with postnatal depression, the focus groups expressed less confidence in the programme's ability to do so and explored issues of stigma and the need for targeted promotion.

7.19 While the authors admit that there are limits on the usefulness of self-reported data obtained through this type of survey work, they argue with reference to Tone (1997), that the mixture of qualitative and quantitative data sources is "an appropriate method of evaluating complex health promotion initiatives". ³⁵⁷ It might also be argued to be a useful approach for policy development in this area and we return to this below.

7.20 Fisher's study, which this time looked at community benefits, evaluated the effects of a neighbourhood walking programme targeted at senior residents (aged 65 and over) in Portland, Oregon. ³⁵⁸ This trial drew on 582 residents in 56 neighbourhoods in the city. Half the neighbourhood took part in "leader-led walking group activities" over a period of six months; the other areas acted as a control and received information about the benefits of exercise on health. The study measured the physical, mental and life satisfaction scores and, as a secondary measure, the amount of neighbourhood walking activity. Improvements were recorded across the board as a result of this experiment. The authors argue that while their study, "did show a significant improvement in QOL in terms of physical functioning, mental well-being, and life satisfaction among the intervention neighbourhoods", there were limitations in interpretation. ³⁵⁹ As they point out, the intervention covers one group only ( i.e. over 65 year olds) and the QOL indicators excluded environmental factors such as air quality and neighbourhood aesthetics. They also suggest that 56 may be too small a number of neighbourhoods and there was an attrition rate of 24%, making some aspects of their analysis very difficult. Their final comment echoes that made in other reports: namely the protocol did not allow for the wider effects of taking part, in itself, on QOL and well-being. As they argue, "the social support of group members, feelings of belonging, and the personalised attention from the walk leaders" are all factors that may have influenced the outcomes. ³⁶⁰

What this literature tells us

7.21 Throughout the literature there is a commonly held position that exercise is good for physical health and has a key role to play in tackling health problems related, for example, to coronary conditions, some forms of cancer and type II diabetes. Previous literature reviews undertaken for sportscotland have argued that there is also an association between exercise and improved mental health. ³⁶¹ Similarly Mutrie's work points to a causal link between exercise and the alleviation of depression and the case is made for the use of exercise as a form of treatment. ³⁶² Biddle et al find that research indicates that there is a relationship between exercise and relief of low/moderate anxiety, promotion of positive mood effect, and increase self-esteem and cognitive function. ³⁶³

7.22 Based on their findings, Alfermann and Stoll maintain that exercise is one, but not the only strategy to improve mental health. ³⁶⁴ This underlines a key issue: the fact that causality, and the direction of causality, is not always clear.

7.23 If we accept that exercise is a key part of sport and that psychological well-being (related to the relief of depression and anxiety) is a key part of QOL, then it can be argued that sport has a role to play in the promotion of QOL. Of course psychological well-being is just one dimension of QOL. The contribution of exercise to other QOL domains is scarcely addressed by the literature. Other neglected issues concern the precise nature of any causal link and how and where the two agendas of sport and exercise or health meet.

Studies focused on sport

Table 7.2. Sport-related Quality of Life studies reviewed

7.24 An early paper by Snyder and Spreitzer examined the relationship between participation in sport with psychological well-being in adults (based on a self-completion questionnaire sent to a sample of households in Ohio). ³⁶⁹ This study makes the link between sport and other voluntary and leisure activities and includes watching sport as well as participation in sport. The findings support the thesis that there is a positive relationship between sports involvement and psychological well-being. The authors reflect on whether sports participation provides a "cathartic function", which, as they point out, is rooted in the ancient Greek philosophers' understanding of the effect of drama, in the form of tragedy, on an audience. ³⁷⁰

7.25 Wankel, and Berger take as their starting point Csikszentmihalyi's (1982) research to develop a model of sport values, and review the research evidence within this framework. ³⁷¹ The four areas explored are personal enjoyment, personal growth, social harmony and social change. They argue that there is evidence that personal enjoyment or "fun" is derived from participating in sport under certain conditions - the most significant of these being the development and testing of one's skills, with challenge remaining intrinsic to the motivation. The question of how far "self efficacy" and other social factors has on the anxiety - reducing effects of exercise is an issue raised by Taylor. ³⁷² He argues that few studies have been undertaken into the issue of "perceived competence, goal-setting, feedback, attentional focus" in exercise setting and reduction.

7.26 Positive adult involvement is also viewed as an important factor in the psychological and social benefits of sport. However the research has some limitations. For example, there is little or no work on adult involvement in sport. And again the issue of causality is raised: how do we know that it is sport that is making the difference? Taylor argues that there is a need to investigate further "how separate enjoyment interludes relate to the overall quality of life". ³⁷³

7.27 Turning to the link between sport and personal growth, Wankel and Berger have both reviewed the literature relating to psychological well-being and looked at the effect of exercise on anxiety reduction and depression. As we have seen, this subject is also covered in the exercise literature. The authors highlight the general lack of research in this area and the lack of evidence about causality in particular. ³⁷⁴

7.28 Finally, in reviewing the link between social integration and sport, the authors assert that despite the "widespread belief that sport has a positive value both for the individual and the society […] there is little empirical evidence". ³⁷⁵ They reference an earlier study (Segrave 1983) on the relationship between delinquency and athletic involvement, which argues that the statistical link between sport and a decrease in delinquency is not proved. ³⁷⁶ They also point to the negative models of sports - in relation, for example, to aggression and drug taking - and conclude that, although much has been written about the social benefits of sport, the impact has been under researched. They reach a similar conclusion on social change - as seen by examining socialisation, social integration and social mobility. While sport may indeed have an impact on these areas, again the evidence is lacking. In conclusion the authors argue for more longitudinal research on the physical, psychological and social benefits of sport.

7.29 More recent work carried out in New Zealand again focuses on the area of psychology. Chalip and Thomas reviewed the research on sport and psychology, specifically linking it with policy implementation. ³⁷⁷ The publication looks at several research studies. The first looked at the involvement of young people in sport and the relationship between self-management of sports activity and motivation to participate. ³⁷⁸ This research involved a qualitative study of adolescents who established and ran a sports centre. Based on interviews with the teenage committee, the research concluded that it is not the sport per se as much as the opportunity to control their own area of activity that attracts the young people in the first place. The authors argue for greater involvement of young people in the decision-making and day-to-day management of sports and leisure facilities.

7.30 A survey by Chalip et al of 700 residents in the town of Hamilton, North Island, examined the motivations and benefits of participation in sport and recreation. ³⁷⁹ Relaxation, social contact and intrinsic pleasure topped the list of "reasons for enjoyment" ahead of physical activity. This was compared with a study of university students. In this group social contact and emotional release are given as important benefits - although enhancement of fitness and health came top of the list. ³⁸⁰ Chalip et al also examined research into the relationship between the migrant workforce and sport. They argued that engagement in sport can provide social support, in other words sport can help immigrants establish (new) social networks. ³⁸¹

7.31 In arguing that well being is enhanced through participation in recreation and sport, the authors also pointed out that the existence of sport facilities is insufficient on its own. They identified the need to structure activities to "enhance the participants" sense of self-efficacy", create positive experiences and encourage progress. ³⁸² However again they returned to the role of sport as a way of building friendship and social networks, belonging and identity - a role that could also be argued for other cultural and leisure activities.

7.32 The role of sport in supporting well-being in the community was explored in a study undertaken by Townsend et al in rural Australia. ³⁸³ The study took as its starting point the relatively poor health record of rural Australians in comparison to their urban counterparts and acknowledged a positive link between physical activity and health. The authors investigated the links between physical activity and health/ well-being in rural areas with particular reference to the literature on social capital. The objectives of the study were:

• To ascertain the extent and nature of community involvement in sporting associations and physical activity groups within the selected communities;
• To assess residents' perceptions of the extent to which participation in sporting associations and physical activity groups contributes to individual and social well- being. ³⁸⁴

7.33 This was a qualitative study based on face-to-face interviews with a sample of individuals in two small towns (23 in one and 20 in another). The semi-structured interviews covered a range of issues including participation in sport, changes in local community sports organisations and the influence of these organisations on the community. From the responses the researchers concluded that sports organisations have an important role to play in the "physical, mental and social" health and well-being of small rural towns and were vital to the sustainability of these communities. However the research did not attempt to answer the question "how?" In what ways does sport contribute to the health and well-being of a community, and are there other interventions which might have similar impacts?

7.34 Cook and Ledger took a different approach in their study of "5 Rhythms Dance" and its effect on the mental well-being of a group of women in the UK. ³⁸⁵ (Dance is considered sport as part of the National Curriculum which is why this study is included here, rather than with the cultural studies). The researchers used a "participatory research" approach. They recruited nineteen women in total to attend four dance workshops on 5 Rhythms dance. As the name suggests this is a form of dance which incorporates five different forms of movement. 90% of participants had a past mental health problem and 74% had a current mental health problem or distress. While the workshops were not targeted at any particular group, it was made clear in advance that the workshop was not suitable for people "who could not at this time take responsibility for their well-being". ³⁸⁶

7.35 Trained teachers rather than therapists led the workshops, as this was specifically not a dance therapy project. Participants completed questionnaires and diaries and participated in peer pair interviews, focus groups and group discussion. Through the qualitative data it was established that the workshops were acknowledged as having had specific effects on the mental health and emotional well being of the participants, with participants experiencing a genuine sense of progress. There were also physical benefits gained from exercise. Although not seen as a therapy, dance was regarded as a tool, which the participants used to look after themselves and their well-being. Usually this was related to dealing with life trauma such as divorce or job interview.

7.36 The use of participatory research marks this study out from others in this review and a larger study might help to confirm the outcomes. The research team acknowledge that the participants' expectations might also play a part in the study outcomes.

Summary of Quality of Life studies focused on sports

The following conclusions emerge from this review of the sport and exercise literature:

• There is a lack of research on the contribution of sport to QOL and well-being. Most of the existing research relates to exercise, and even in this area there are significant gaps, and many of the studies undertaken have specific limitations.

• Within the existing sports and exercise literature there is no clear common definition of QOL and well-being. This lack of conceptual clarity and consistency has led to inconsistent methodological approaches, with widely varying objects of measurement and, subsequently, a lack of comparability between studies.

• A large number of the studies into exercise are in the area of psychology and the conceptualisation and methods found in these are therefore consistent with that discipline. This literature is mainly concerned with psychological well-being, and therefore deals with just one dimension of overall QOL.

• The research findings indicate an association between and aspects of mental/psychological well-being such as the alleviation of depression and anxiety, and the promotion of self-esteem and positive affect. There may also be links between exercise and other aspects of mental health. However there is not sufficient evidence to confirm a causal relationship. There is also a consensus within the literature about the positive association between exercise and physical health.

• Several of the studies have highlighted the probability of more than one variable contributing to causality, and have indicated that exercise or sports participation may play a role in combination with other social factors, for example through the social support, friendship and collective identity gained through participation. Several reviewers argue for longitudinal studies to help explore this issue further, and to allow for the outcomes of participation to emerge over a longer time frame.

• In the sports literature (as opposed to the exercise literature), there is a wider case made for the link between participation in sport and other outcomes such as personal growth, social integration, social support, and community well-being. However, overall, there is neither the empirical evidence to support a causal link nor to help us understand how sports participation, working with other processes, might lead to these outcomes, or whether participation in other types of leisure activity might produce the same type of outcome.

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