Walking football for people with chronic breathlessness – has it got legs?

Posted by Callum Bradford, Research Associate, Teesside University

Following on from the recent success of the England Women’s football team, and with the Men’s World Cup final just around the corner, now seems like a good opportunity to talk about our walking football project, designed exclusively for people with chronic breathlessness. What is walking football you ask? Well it's football, without running (you don’t say?!), and the physical contact is a bit more restricted. Thankfully, FIFA hasn't got its hands on walking football just yet, with the World Cup being an example of why we perhaps should avoid such a thing.

 

Chronic Breathlessness is predominantly caused by pulmonary conditions, such as chronic obstructive pulmonary disease (COPD), impacting 75 million people globally. With Covid-19 and an ageing population this number is expected to rise, increasing the burden on families, carers, and health and social care services. For individuals, breathlessness is associated with a lower quality of life, decreased capacity to do exercise, and higher levels of anxiety and depression

Pulmonary rehabilitation is recommended for everyone with breathlessness. Consisting of both exercise and education, its benefits on health are unequivocal, however, any benefits gained by patients are often reduced three months after completion. This is primarily because patients go back to doing less physical activity once the programme has finished and support from healthcare professionals is removed. With this in mind, we wanted to develop an intervention that could step-in when patients finish their rehabilitation, offering a form of exercise maintenance and continued social support. Given the nation's love of football (most of the time), we believed walking football might have potential.

To develop the intervention, we initially consulted pulmonary physiotherapists, and a local walking football team. The physios were initially very sceptical, raising concerns that the pace would be too fast, and highlighting the number of people with breathlessness who required oxygen or walking-aids. Walking-aids?! Oxygen?! I hadn't even considered that. I was starting to worry that this idea might be a complete non-starter.

So next stop was to see some walking football for myself at Middlesbrough’s Herlingshaw Centre. I left the session with mixed feelings. They played three-touch, meaning everyone got the opportunity to play, forcing that one player who thinks they're Allan Saint-Maximin to pass the ball. It was also proactively refereed to the benefit of everyone, with players encouraged to talk to the ref if they felt the pace of the game was too fast. However, after giving it a go myself, the pace was still surprisingly quick, despite what Father Ted might have you believe, bringing back concerns as to whether it would be too high an intensity. What I really needed to know was what patients themselves thought of walking football.

So we linked up with Breathe Easy Darlington, a local support group for people with lung conditions. Describing the input from Breathe Easy members as invaluable to our research over the last few years would be a massive understatement. So much so that, as a small thank you, we held a fundraiser for them last month on World COPD Day, raising £1120.76.

Their opinions would be vital to walking football’s success... however, they were also dubious of the idea. Again, concerns were raised about the speed, the walking-aids, and the balance required to play. So I asked, under what circumstances – if any – would they consider giving walking football a go? They stated that if the football was exclusive to people with breathlessness like themselves, they would give it a try, as they would be able to dictate the pace of the game and not feel too self-conscious of their footballing abilities. Our original plan involved asking patients to join onto sessions at the Herlingshaw. Luckily, by consulting with Breathe Easy members, I now understand how that plan – to mix people with and without breathlessness - would have likely ended in disaster, demonstrating the importance of including end-users when designing research studies.

Twelve Breathe Easy members agreed to play and the stage was set for our walking football taster sessions, and as you can see from our video, I don't think it could have gone much better.

The players embraced the competitive aspect of football, stating that “On the pitch you forget about breathlessness”; and the concern for walking-aids was turned on its head after we agreed that hitting the ball with a walking-stick is a perfectly fine way to score a goal. Our coach, Monty Towers, was key to its success, mixing up the session with fun games, while allowing everyone to play football at their own pace. In our follow-up conversations, members also suggested implementing a buddy system, where more experienced participants take responsibility for introducing new patients to the group so they feel more welcome – a brilliant idea that we intend to implement in the future.

Throughout 2023 we will be assessing the feasibility of walking football following pulmonary rehabilitation in collaboration with both North Tees & Hartlepool and South Tees NHS Foundation Trusts, plus the North Riding FA; and I’m confident if it’s anything like our sessions with Breathe Easy members, it will be a great success.

And if you’re still upset about the World Cup, don’t worry, I’m sure our walking football team will bring it home next year.

The views and opinions expressed by the author are those of the author and do not necessarily reflect those of Teesside University or Fuse, the Centre for Translational Research in Public Health.

Father's Day is a reminder that men’s mental health is everyone’s concern

Posted by Heidi Stevens and Katie Webb, Researchers from the Department of Health Sciences at University of York.

** Content/trigger warning: mental health, depression, suicide **

It cannot have escaped your attention that Sunday was Father’s Day (happy belated wishes to all the dad’s out there!), but did you also know that it was the culmination of Men's Health Week?

The campaign run by the Men’s Health Forum encourages men everywhere to give their bodies and minds an MOT and includes resources to boost mental wellbeing.

This and other campaigns like Movember try to raise awareness that, for our sons, fathers, brothers, partners…for wider society… men’s mental health is everyone’s concern. Sadly, men’s mental health in general is looking quite poor.

Having just completed work as a research associate on an NIHR Applied Research Collaboration North East and North Cumbria (ARC NENC) funded project focused on severe mental illness, I started a fresh project in a completely different area of mental health at the University of York. Namely, men’s mental health.

Until I applied to work on this research, I had honestly never considered men’s mental health as I had generally always been female gender focused. Traditionally, women’s poor health is viewed as a product of social circumstances, while men’s poor health has been seen as a product of men’s ‘bad behaviour’. Working on this research has revealed a completely different perspective and as such I have developed a lot more empathy towards men’s health.

In England, suicide is highest among men and is the leading cause of death for men aged 20-34 (Men's Health Forum). Similarly, records within NHS ambulance services indicate that the risk of suicide amongst paramedics who are men is 75% higher than the general population (Mars, 2020). Other industries also show higher rates of depression amongst workers who are men, such as construction workers and utility workers, sometimes due to long or unsociable work hours.

Despite this poor picture, only 36% of referrals to psychological therapies are men (Mental Health).

So why is this?

Sjustdoitright, CC BY-SA 4.0, via Wikimedia Commons

Barriers to improving men’s mental health relate to hegemonic ideals. Although men range in class, age, sexuality and ethnicity, the theory of hegemonic masculine identity in western society embodies shared attributes of stoicism and restriction of emotions to which many men may have been socialised or expected to conform. As such, some men may find it challenging to express or take action in response to ill health as they feel this may make them appear weak or not masculine (Galdas, 2005 )

For example, 38% of employed men with mental health concerns feel that their employer will think badly of them if they take time off for a mental health appointment (Men's Health Forum).

Then there is the use of coping strategies such as substance misuse. Generally, men tend to deal with health problems by seeking refuge in addictions or ignoring treatment needs, as such common mental illness such as depression often remains undiagnosed. In the UK, since 2001, rates of alcohol-specific deaths for men have consistently been more than double those for women (ONS).

The World Health Organization (WHO) states that achieving gender equality requires men to be engaged in transforming patterns of care, including self-care. This may include tailoring health interventions to men and involving men from all backgrounds in the role of mental healthcare co-production and promoting the positive aspects of masculinity such as humour and goal-orientation.

This year in the UK, the All-Party Parliamentary Group (APPG) on men and boys’ issues have been urging the Government to develop a men’s health strategy with a focus on inequalities stating that this would benefit not just men and boys but also women and girls. So, for our sons, fathers, brothers, partners…for wider society, let’s promote a wider understanding of men’s health issues.

Our research in the Mental Health and Addictions Research Group (MHARG) at the University of York aims to prevent the development of common mental illness among male frontline NHS workers. With funding from Movember, we will deliver a brief Behavioural Activation intervention which will be carefully tailored to men with guidance from our consensus group of NHS staff from diverse roles. Behavioural Activation is an evidence based talking therapy which aims to break the cycle of avoidance created by low mood or anxiety, by reinstating valued and meaningful activities.

To find out more please see our links below or feel free to contact us.

• www.balmprogramme.co.uk
• @BALMprogramme
• Scan the QR code to find out more about our men's health research.

Images: 

1. 'FVHjjxFXEAAaBos' with thanks to Men's Health Forum.
2. Sjustdoitright, CC BY-SA 4.0, via Wikimedia Commons.

The other third wave: a mass epidemic of very individual pain

Posted by Jack Nicholls, Lecturer in Social Work at Northumbria University

*Content/trigger warning: mental health, depression, suicidal feelings.

This post is a contradiction. It starts with the experience of one person, extrapolates out from that to consider the potential hardships faced by others, and then argues that this extrapolation may be unsafe from a policy and practice perspective. Our topic is the long-term mental health consequences of the pandemic, of lockdown and social restrictions, and of its easing – specifically, those consequences we have not necessarily seen coming, because to those who do not know, they do not seem logical.

Katsushika Hokusai: The Great Wave off Kanagawa

I have knowingly lived alongside depression for nearly two decades. There have been long periods where it has been minimal and manageable, and others where it has nearly destroyed me. Many who experience mental ill health in any form will recognise this undulating pattern, and that the peaks and troughs can have exactly nothing to do with how well life is going objectively. I’ve felt perfectly steady in situations of very high pressure. Conversely, the lowest point of the last few years was at a prestigious conference. I was presenting my work – an opportunity I had been looking for since starting my research – while internally considering whether I wanted to remain alive. I doubt any of the audience would have suspected, because I performed the role of the good presenter. I did what was expected – by them, by me, by the world. More recently, but less severely, I had a short but acute period of utterly disabling depression after submitting my PhD thesis. Something excellent and long-awaited had happened. Celebration was expected, even in lockdown, but I wanted only drawn curtains and my duvet.

During the pandemic, we have had over a year of restriction, upheaval, loss, fear and strain. There has been some discussion of the impact on psychological wellbeing, but nowhere near enough. It has become an afterthought to vaccines and viral containment, which is understandable, and to macro-economics, which may be less so. Alongside we mental illness veterans, hundreds of thousands of people have consciously experienced moderate or severe mental ill health for the first time in their lives.

What particularly concerns me however is the psychological impact of the easing of lockdown. With all its hardship, pandemic restrictions have been our reality. The end of lockdown will represent a change to that reality. It will be accompanied by returning to workplaces, pubs, cinemas, planes, trains and shopping centres.

For some, the change back will be more jarring than they can currently anticipate, even if, like the submission of my thesis, it is on the face of it a ‘good thing’. We are facing a third wave of mental distress. There are those of us who have managed symptoms for years, and those who recognised their genesis in lockdown. There is a strong chance that after the jubilation, many will start noticing that they aren’t feeling how they think they should. They may try to rationalise it – ‘I wasn’t on the frontline, I didn’t lose anybody, I wasn’t furloughed – why the hell do I feel like this?’. If we are not careful, no-one will tell them that this is normal, if awful, and they are entitled to help.

I am unbelievably fortunate. I understand my condition well. I am by-and-large not shamed by it. I have friends, family and colleagues who understand it and me. I have a job with a degree of flexibility. For all of those wonderful protective factors and others, all that privilege of acceptance, the first stage of any episode is still denial, and the second is the instinct to run, hide and dynamite all my bridges. For anyone going through this for the first time, and particularly going through it when they think they should be celebrating like it is VE day, the loneliness, alienation and self-doubt could be pernicious and devastating. It could be fatal. In the context of public policy, planning and rebuilding, and particularly for those who do not want to go back to ‘normal’ but to create a fairer reality, we need to be prepared to offer a pro-active and public response to varied and individual suffering. At the point of both collective relief and collective exhaustion, we need to be ready to be accepting and kind. And we need to do it now.


Below are links to support organisations relating to the issues raised in the post: 

• www.samaritans.org
• Samaritians phone number: 116 123 (for free, 24 hours a day, 365 days a year)
• www.mind.org.uk
• www.mhm.org.uk
• www.thecalmzone.net
• womensmentalhealthnetwork.com
• www.mentalhealth.org.uk/tags/bame
• mindout.org.uk
• www.rethink.org

Link to an interview with Owen Paterson MP, who lost his wife to suicide last year

• www.bbc.co.uk/news/av/health-56751320

Image: Katsushika Hokusai, (CC0 1.0), via Wikimedia Commons

Stress is a universal experience, but is it unequally distributed across society?

Posted by Dr Joanne-Marie Cairns and Dr Emily Henderson, Durham University and Fuse.

How are you feeling today? Stressed at all?! If so, you are in good company.

Stress is so pervasive in our society that it contributed to a shocking 9.9 million working days lost in 2014/15(1), which equates to an average of 23 days per person. From an evolutionary perspective, stress is useful to animals such as humans to help us react to physical and social threats, commonly known as the ‘fight or flight’ response. According to Danielsson(2) and colleagues, stress can simply be defined as an imbalance between demands placed on us and our ability to cope with them. But if stress continues over a long period of time then a permanent imbalance may arise between the body’s degenerative (reduced growth) and regenerative (regrowth) functions. Stress can also lead to everyday problems including poor performance at work, low mood, lack of motivation, fatigue, sleep disturbance and chest and muscular pain as well as major life-limiting health problems such as high blood pressure, depression and chronic pain.

In light of these concerns, we organised a Health Summit on inequalities-related stress, with colleagues from the Local Area Research & Intelligence Association (LARIA), the Wolfson Research Institute for Health and Wellbeing, and Fuse - the Centre for Translational Research in Public Health. This event was hugely popular and brought together a wonderful mix of delegates and speakers from policy, practice and academia, from the North East and across the UK. The programme, which includes a list of speakers and a description of the talks, can be found here.

While stress can be a universal experience, it doesn’t manifest equally amongst certain population groups. For instance, Thoits(3) conducted a review which highlighted how unequally high exposure to stress by women and people in lower socioeconomic and minority groups lead to inequalities in health outcomes. Moreover, we see health inequalities accumulate over the life course as a result of this unequal distribution of disadvantage, for example Thoits refers to a study conducted by Turner and colleagues(4) that examined the effect of cumulative stressors in adults. These stressors that accumulated over time, explained a significant 50 per cent of the Socioeconomic status (SES) gap in depressive symptoms.

What are health inequalities then? These are differences in health status or determinants of health between different population groups. There are also intersecting inequalities, for example, if you are a lone parent but also on a low income, living in a disadvantaged area. Moreover, coping mechanisms sometimes adopted to mitigate stress can be health-damaging and lead to other forms of health problems, such as smoking or alcohol misuse. John Watson (Deputy Chief Executive, Action on Smoking & Health (ASH) Scotland) quite rightly argues that smoking IS NOT A LIFESTYLE ISSUE; rather in his words it is a form of medication to society’s maladies. Just think of the current global economic downturn as a societal issue that can be at the root cause of individual depression. As well, unequal access to jobs (at least good jobs that aren’t precarious in nature or that might lack autonomy) or good schools, which already limit an individual’s future prospects and may as a result contribute to psychosocial stress and poorer health highlighting the structural factors that are beyond the individual. Furthermore, stress at the population-level can manifest into geographical health inequalities. Data published by the Health and Social Care Information Centre (HSCIC) shows that the North East Strategic Health Authority (SHA) had the highest admission rate due to anxiety of any of England's 10 SHAs (just under 24 per 100,000 of the population), while South Central SHA had the lowest (at nearly 11 per 100,000), mirroring other health outcomes and shows the stark North-South health divide in England.

‘Lifestyle’ is used ubiquitously in current public discourse, and can be understood as a set of factors that describe a person’s daily living. Obesity-related lifestyle often refers to people’s behaviours and apparent food choices(5). These so-called behaviours are ways in which individuals respond to challenging circumstances. They are not choices in the purest sense of the word. Rather, an individual may be experiencing financial difficulties and, feeling the demands in their life which outweigh their ability to cope, may respond to the situation by smoking, drinking or comfort eating. But what is actually causing the financial difficulty in the first place? Are individuals to blame for reacting to the bleak reality of poverty and the social gradient they find themselves in? The seminal work by Sir Michael Marmot tells us that we instead need to consider the “causes of the causes” of inequality, not just the symptoms. Politics is also important, as we have seen in the government’s release of the new obesity strategy which continues to support healthy choices, and maintains the voluntary efforts by industry by suggesting a 5 per cent sugar reduction in children’s food and drink. The chairwoman of the Health Select Committee, Dr Wollaston, told BBC Radio 5 live that “it does show the hand of big industry lobbyists and that’s really disappointing”(6). A key political talking point relates to the fact that what was a 50-page document was shortened to a mere 10 pages which does not do something as complex as obesity justice – it was “weak and watered down”.

To sum up, the discussions from our Health Summit supported the principle of moving away from individualised and stigmatising conceptions of unhealthy behaviours; after all it is not just poor people that behave poorly!


References:

1. Figures obtained from: http://www.hse.gov.uk/statistics/causdis/stress/ [last accessed 17/08/16]
2. Danielsson M, Heimerson I, Lundberg U, Perski A, Stefansson C-G, Ákerstedt T. 2012. Psychosocial stress and health problems. Scandinavian Journal of Public Health, 40(9):121-134.
3. Thoits PA. 2010. Stress and Health: Major finding and policy implications. Journal of Health and Social Behavior, 51(s):41-53.
4. Turner R, Jay and William R. Avison. 2003. Status Variations in Stress Exposure: Implications for the Interpretation of Research on Race, Socioeconomic Status, and Gender. Journal of Health and Social Behavior,44:488–505.
5. Nettleton S. Lay health beliefs, lifestyles and risk. The sociology of health and illness. 2nd ed. Cambridge: Polity Press; 2006. p. 33-70.
6. http://www.bbc.co.uk/news/health-37108767 [last accessed 19/08/16]

Too stressed for words? Involving those experiencing stress in research

Post by Fuse members Natalie Forster, Senior Research Assistant, Northumbria University and Sonia Dalkin, Lecturer in Public Health at Northumbria University

On this National stress awareness day, we wanted to take the opportunity to reflect on the ethics of involving those experiencing stress in research.

Fuse researchers are currently undertaking a realist evaluation to understand how, when and for whom, Citizens Advice Bureau (CAB) interventions improve people's health. CAB provide independent, impartial, confidential, and free advice to everyone on their rights and responsibilities. This includes advice on debt, benefits, employment, housing and discrimination.

Changes to physical health take a long time to show, and are therefore difficult to capture in the evaluation timescale. The impact of CAB on stress therefore forms a core focus of the study. As we know already that stress is linked to many mental and physical health outcomes, determining if and how CAB services reduce stress should enable us to project the potential health impact of CAB.

At the point when people approach CAB, they are often under considerable strain. Two in three people accessing CAB services report feeling stressed, depressed or anxious as a result of the problem or problems that they are experiencing, more than one in five people have had to move home or are worried about losing their home, and almost one in five are experiencing difficulties in relationships with other people.

We have had much discussion as a research team, together with CAB staff, around how to design the research in a way that generates sufficient data to assess the impact of the service, but which remains sensitive to what clients are experiencing. Imagine a scenario for example, whereby you approach a service for help already under significant stress, you are anxious to resolve a financial problem, yet before you can start to address the issue you're asked to fill in a lengthy questionnaire about your health. Furthermore, CAB have projects specifically designed to support those diagnosed with cancer. In the case of CAB clients who are currently undergoing treatment for, or supporting a family member with cancer, stress is likely to remain in spite of addressing financial concerns, and to ask if their health has improved would be inappropriate.

These are just some of the issues we've been grappling with and which have informed our decisions about which client groups we invite to participate, when we contact potential participants, and what they can reasonably be asked to take part in. A decision was made for instance, not to include a project for patients and families with cancer among those being evaluated. Baseline questionnaires will not be delivered before, but rather during or just after clients’ initial appointments. The number of questionnaires clients will be asked to complete has been carefully considered and where possible, shorter versions of questionnaires have been used in order to avoid over-burdening participants.

That said, we're also conscious of the risk of excluding people from taking part by making too many presumptions about participant preferences. We have often reflected during involvement with previous research on how generously people have shared their time and experiences even when undergoing difficult circumstances. We therefore continue to consider the balance between participant protection and autonomy when recruiting potentially stressed participants. In research with people experiencing difficult circumstances, involving potential participants and organisations working with them in designing data collection strategies is key to ensuring their appropriateness.

Photo attribution: Photograph ‘Anxious 1’ (File ID #1431663) by Joana Croft via freeimages.com, copyright © 2007: http://www.freeimages.com/photo/anxious-1-1431663

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