Keywords

Background

Poor mental well-being is one of the most significant health issues both in terms of health and well-being of individuals and their families, and its wider impact on communities, the economy and employment [1]. In any given year 1 in 4 of the population will experience a mental health problem [2] and impaired mental well-being has a very high-cost impact on business and the economy [3]. Misunderstood and feared, the stigma and implications of mental health issues mean that many do not realise they have a health problem or that help can be given; many who do seek help are poorly diagnosed. Men are significantly less likely to seek support or to receive a diagnosis of stress, anxiety or depression [1]. This means that for many their condition and its consequences become significantly worse, with associated problems including alcohol, drugs, relationship breakdown, employment issues, self-harm and suicide.

These issues are more prevalent in more deprived areas, mirroring the traditional heartlands of Rugby League which developed out of the dramatic period at the end of the nineteenth Century which saw the rise of organised sport and the creation of Clubs and leagues, heavily influenced by class, finance and the place of professionalism [4].

Rugby League has a long and proud history of working closely with its local communities, with a key feature of Rugby League being its family appeal: 40 % of regular supporters are female [5] and fans of all ages attend matches and Club-related activities , often in family groups spanning the generations. Each major Club has an independent charitable Foundation which runs community-based activities with local health bodies, councils, schools and charities, providing support and activities on education, training and employment, health and well-being, heritage, social inclusion and of course sport, nutrition and physical activity. Research has shown that using sporting settings and sports clubs is an effective way of reaching local communities, particularly those who are most in need but often regarded as ‘hard to reach’, because media, fans and local people more generally are interested in the Club and the players, and see the players as role models [6–8].

Rugby League Cares (RLC) was created in 2012 to bring together the Rugby League family of charities—the Rugby League Foundation, Benevolent Fund and Heritage Trust—and acts as umbrella and coordinator for the network of local Foundations. Its mission is to enhance and enrich people’s lives through the power and positive influence of Rugby League by working with local communities to help them lead a more positive and healthy life through the delivery of high-quality sports, educational, employment, heritage and health-based activities. In 2012 alone, it worked with 600,000 people, providing services with an added value of some £6 million.

RLC, with local Foundations, therefore decided to take action to promote better mental well-being in its local communities. This Chapter looks at the experience and lessons from the first year of the 2-year project which was funded by Sport Relief.

Aims of the Project

The RLC and Sport Relief Mental Well-being Programme was set up to:

  • Create and deliver projects for ‘at-risk’ groups to improve mental well-being

  • Raise awareness of the services available and promote pathways for those in need

  • Build relationships between Foundations, their local communities and partners—particularly local NHS and expert charities

  • Increase capacity within Clubs, giving staff more confidence and knowledge about mental health

  • Generate new knowledge of how sport and Clubs can reach and positively influence local communities, which could be shared throughout Rugby League and more widely

How the Project Was Set Up

RLC successfully bid to Sport ReliefFootnote 1 for £350k funding over 2 years for RLC to work with 12 local Foundations to design and deliver a range of locally focused projects. Each could select the audience(s) they wished to work with, to reflect local skills, priorities and opportunities, provided that the project was linked to the theme of ‘mental well-being’ and the target audiences were in some way at higher risk of mental ill-health. Each Foundation was to receive £10k in each of the 2 years, subject to satisfactory progress and quarterly reporting.

Nationally, RLC appointed a project manager who provided a ‘toolkit’ including project plan templates, material on evaluation, lessons from previous projects, facts about mental well-being and national contacts as well as providing one-to-one support in reviewing plans and making contacts. Although all Foundations had track records of delivering health projects, most had less experience of mental health and in addition the initial phases of the programme coincided with a significant shift of responsibilities and personnel within Health and local government organisations. RLC also commissioned the Institute for Health and Well-being at Leeds Metropolitan University to carry out an independent review of the process to identify lessons from year 1.

In addition, RLC ran a mental well-being campaign focused over one weekend (the ‘Round 27’ campaign) in collaboration with the NHS Confederation,Footnote 2 NHS ChoicesFootnote 3 and Leeds Metropolitan University.

Delivery of the Project

The ‘Round 27’ Mental Well-being Campaign

In September 2012, RLC, Super League Clubs, Leeds Metropolitan University, NHS Choices and the NHS Confederation collaborated to promote mental well-being to rugby league fans over one weekend. Packs of standard material were sent to Clubs including material for websites, programmes and editorials along with branded t-shirts to all Clubs for use in photos and match warm up. NHS Choices produced a bespoke webpage about mental well-being linked to an assessment tool and further information. RLC and Leeds Metropolitan University also surveyed fans at one match to find out what they thought of Rugby League promoting mental well-being.

Community Projects

Each Foundation designed and commenced delivery of a project tailored to one or more ‘at-risk’ groups within their local communities. Key elements about delivery include:

  • Which audiences were selected and why

  • What partnerships were developed and with what results

  • How resources were used

Foundations could choose one or more audiences within the theme of ‘mental well-being’. Most used their existing knowledge to identify the groups with which they wished to work. In many cases, this built on existing expertise (for instance, Warrington Wolves and Salford City Reds added mental well-being to their existing programmes on employment). Others used local information such as the local authority/health joint strategic needs assessment (JSNA) to identify needs and gaps (Wakefield Wildcats, Featherstone Rovers).

Foundations rely on a small number of staff as well as volunteers and input from staff and players at their Club. All set about building partnerships to ensure that appropriate expertise was to hand, referral routes were clear, and to increase available resources.

As the projects varied, Foundations used the funding in different ways, including:

  • Some additional staff time

  • Travel and subsistence for coaches and participants

  • Facilities including catering (often provided free—particularly by Clubs and Foundations—or at reduced rates, by partners)

  • Laptops and projectors in order to make better quality presentations off-site

  • Materials for events including tailoring existing materials for a new audience

  • Carrying out health checks (including costs of testing kits)

All Foundations used some of their own resources, particularly project management and partnership building, and all of their respective Clubs contributed the time and enthusiasm of their staff and players, several of whom talked openly about their own mental well-being and its importance in their professional and personal lives.

Outcomes and Evaluation

Key Output and Outcomes

The following is a summary of activity (not exhaustive) delivered by each of the Foundations and partners in Year 1.

  • Bradford Bulls: ran fortnightly reminiscence sessions for targeted older people and two school events for a total of 400 Year 11 young people (age 15–16).

  • Featherstone Rovers: responded to an identified gap in services for local carers, holding a Carers’ Rights Day (for 93 people) and establishing a monthly Carers’ Network (+200 users).

  • Huddersfield Giants: targeted young people and adults identified as having (or being at risk of) mental health problems, including a school holidays programme for 30 selected young people.

  • Hull FC: delivered physical activity programmes for 47 adults with mental health problems, together with a programme for 17 inpatients at a local secure unit, as well as engaging 150 Year 11 and 6th Form (age 16–18) young people through eight educational workshops.

  • Leeds Rhinos: trained 28 mental well-being ambassadors in community clubs across the city, with the potential to engage with 10,000 club members.

  • London Broncos/London Rugby League: ran a series of mental well-being roadshows at major events in London and the South East of England, including an event for over 500 Olympic Park construction workers (with top tips for mental well-being provided through social media).

  • St. Helens Saints: reached over 700 men under 25 and over 50 in priority groups (e.g. unemployed, leaving secure accommodation), including weekly sessions with Job Centre Plus (JCP) providing mental well-being and employment support for unemployed young people.

  • Salford City Reds: worked with a local newspaper (readership 234,000) and delivered two match-day events (reaching 7500) to raise awareness of mental well-being and mental ill-health issues.

  • Wakefield Wildcats: trained 20 volunteer ‘buddies’ to support fans with learning disabilities and set up Companion’s Card (administered by Carers Wakefield) to enable fans with learning disabilities or mental health problems to attend matches with a fellow fan.

  • Warrington Wolves: ran workshops for inmates in a local prison and mental health in-patients, and raised awareness of mental health issues and support for 105 young people in seven Further Education Colleges and school 6th Forms; 45 ‘at-risk’ older people also reached through a range of activities showed an improvement in mental health awareness and well-being and Warwick-Edinburgh Mental Well-being Scale (WEMWBS) questionnaires administered to outreach group participants showed a mean score increase from 42.5 to 58.5.

  • Widnes Vikings: identified isolated, vulnerable older people with poor mental health (‘Invisible Vulnerables’) and delivered a programme of social/physical activities and input from local support agencies to increase resilience and feelings of safety and connectedness.

  • Wigan Warriors: delivered a combined mental and physical activity programme to increase resilience and self-esteem (‘Tackle It’) for 54 men aged 24–75: 80 % achieved 100 % attendance, 90 % set goals to achieve/made significant progress towards lifestyle changes, and 75 % made positive mental health-related changes and continued to engage in health-related programmes, fitness or group exercise on a regular basis (25 % going on to join a local gym).

Creating and Delivering Projects for ‘At-Risk’ Groups

Partner feedback confirms all Foundations correctly identified key audiences, successfully engaging groups which tend to be socially isolated and cut off from opportunities for activity (such as those with mental health issues, carers, unemployed) or other groups considered ‘at-risk’ including school pupils, young adults and over 50s.

In several cases, partners were inspired to join in because they recognised that their local Foundation was taking forward an important part of the local agenda. Feedback is that the Foundation and Club’s brand and position in the community have been fundamental in engaging their target populations.

There is a general lack of understanding and therefore a stigma associated with mental health. In many cases people do not realise that their mental health is impaired (or they do not receive a correct diagnosis) or that support is readily available. Whilst people may recognise that they need to look after their physical health, many do not appreciate that they can also take steps to promote their own mental well-being, build resilience and increase their levels of satisfaction with life through relatively simple steps [9], for instance through social networks and physical activity—both objectives of the Sport Relief projects. Participants at schools and Clubs reported increases in understanding and awareness of symptoms, what is ‘normal’, where to obtain support for themselves and others. Some highlighted drugs as a particular concern and Foundations then covered this in more detail in collaboration with local services.

Foundations agree that the public engagement of players and the Club in talking about mental health and their personal challenges has made an important contribution to engaging audiences and tackling stigma. Stressing that physical injury and poor mental health have many similarities has been a useful analogy in stressing the importance of resilience but also how mental ill-health is not the fault of the sufferer.

Physical activity has a beneficial impact on mental well-being and all these activities build social capital, another determinant of mental health status as well as its physical benefits (such as Huddersfield’s Good Mood League). Many participants have reported improvements in their mental well-being (Warrington saw a 16-point rise in the WEMWBS score), with several going on to other programmes including six signing up for a City and Guilds Course following Hull’s programme, and a number reporting that they had joined gyms (Wigan) or were maintaining their activity levels through other programmes.

One of the most interesting findings was that as a result of their work with partners, most Foundations added additional ‘at-risk’ groups once they realised that there were opportunities to reach more people. For instance, from discussions with partners, Saints Foundation found that St. Helens had significant numbers of people aged 18–25 rapidly becoming depressed after losing their jobs. Saints recognised that the Club and Foundation could have a useful role here, given their status in the community and as a result developed a very effective partnership with JCP which has enabled JCP to reach their target audience. JCP commented:

We have worked with Saints for a number of years on projects but the timing of the Saints’ Sport Relief project has helped us to look at local needs in a different way. A number of clients who have health issues around depression are now engaging with Saints which can only benefit these people and help them to return to the job market.

Greater Awareness of Services/Signposting

All Foundations established links with local services for signposting and onward referrals:

  • Many participants said that as a result of the programme they now knew where to get help

  • Foundations were able to enlist GPs, mental health, housing, employment and training specialists to be on hand at events

  • Some ran additional sessions with specialists in response to requests from participants

  • Hull in particular found that they were able to refer on participants who were in need of specialist support but who were not currently under the care of their mental health trust

Given the sensitivity of the information and limited resources, the projects have so far not generated comprehensive data on what happens to those who are signposted or referred on, although proxy measures suggest some success, including take up, retention, numbers of interactions, people asking for literature and feedback from partners.

To promote mental well-being, as set out above, RLC ran a campaign over the weekend of Round 27 (beginning of September 2012). Although the time available was very short, reducing RLC’s ability to promote the initiative as extensively as it would have wished, packs of standard material for websites and programmes and branded t-shirts were sent to Clubs for local adaptation. Several ran mental well-being events often in collaboration with their mental health trust, gaining local press attention.

NHS Choices produced a bespoke webpage about mental well-being with links to an assessment tool and further information. Feedback from NHS Choices was that this was very successful:

there have been 104 visits to the RLC page so far. On first glance this might sound a little disappointing, [but] that is above average for the time period involved. It should also be looked at in the context of the length of time people spent on the page (208 seconds)—this is significantly above average and would suggest (as it’s a fairly short page) that people are taking the time to read it and, perhaps, use the wellbeing assessment on that page. The majority of people coming to this page are likely to have come directly to the site after seeing the URL on the various forms of marketing.

On behalf of RLC, Leeds Metropolitan University surveyed fans at one match about the acceptability of Rugby League promoting mental well-being. Key findings are set out below.

In response to statement 1 (The sport of Rugby League has a role in promoting mental well-being) 91 % agreed to some extent, with the largest proportion (58 %) agreeing strongly. Only 2 % expressed any degree of disagreement.

In response to statement 2 (It is a good idea to use a Rugby League match day for promoting mental well-being) a very large proportion of respondents (95 %) expressed agreement with this statement, with most (66 %) agreeing strongly. Less than 2 % expressed any degree of disagreement and no one strongly disagreed.

There was little difference between sexes and different age groups. No one who initially expressed willingness to complete the survey subsequently declined on learning it was about mental well-being. Several described their own issues with mental health and how important it was that it was being talked about. It showed that RLC and Foundations can take key messages, build partnerships and deliver the messages effectively in ways that have meaning for fans—even in a very short space of time and with limited resources.

Cultural Change and Greater Capacity within Foundations and Clubs

All Foundations and Clubs undertook some training, including running sessions for younger players, coaches and those in community clubs based on ‘mental health first aid’ [10] which increased understanding and experience. Several Foundation staff also undertook additional training as Older People’s Champions with Age UK. Staff reported that gaining confidence that they were doing ‘the right thing’ was one of the most important benefits, and building links with local mental health providers made it easier to know where to signpost people for support. This was particularly important as the sessions generally led to participants wanting to talk about themselves or someone close to them.

Building Links Between Clubs and Communities

All Foundations made links to their communities, engaging thousands of people through awareness and information programmes for the general public, and through a wide range of targeted activities for at-risk groups: including young people, older people, those with mental health issues and those who were isolated.

Partnerships

Although Foundations had a number of strong local connections, these projects enabled them to identify and collaborate with new partners, particularly mental health NHS trusts and specialist charities. A total of 64 external partners were involved from several different sectors: health (primary, mental, public), education, employment, housing, social care, justice, children’s services, arts, media and charities supporting older people, young people, carers and those with specific mental well-being needs.

Partners provided valuable expert input, including refining programmes, managing referrals, recruitment and publicity. Most also came to events, sometimes playing a significant role in delivery and investing many hours of staff time.

Evaluation

To generate learning, all Foundations are evaluating their individual projects. In addition, RLC commissioned Professor Alan White at the Institute for Health and Well-being, Leeds Metropolitan University to carry out an independent review of the process to give RLC some insight into what additional support Foundations would like to receive [11]. The evaluation included a focus group (to establish key areas) followed up by one-to-one telephone interviews with the lead from each project.

Knowledge and Lessons

Feedback from Trusts and independent process evaluation by Leeds Metropolitan University have generated new learning and case studies which can be shared more widely, including about the value of partnerships with statutory and non-statutory bodies; how to engage different populations (such as the value of using local radio to reach out and target carers and working through specialist partners for those with mental health problems); the value of using the Club ground (such as St. Helens); and the success of Foundations in engaging with target populations. More details are below.

Lessons Learnt

  • The importance of Sport Relief’s funding and support : without the resource from Sport Relief, none of these projects would have been developed. Foundations generally have very small numbers of staff. Having funds to bring to the table enabled Foundations to gain the attention—and then the contribution—of partners who reported that they contributed their own time and resources because it was clear that ‘something’ was feasible.

  • Foundations are able to design and deliver programmes, building local partnerships and engaging a range of at-risk groups : key successes include successfully identifying appropriate participants and partners, tailoring activities and effective communications and recruitment.

  • Foundations and Clubs are very valuable partners because people are attracted by the brand, interested in what the Club and players say, and feel comfortable engaging with the Club—particularly at its own facilities—even about very sensitive issues. Most partners cited this as a key reason behind their decision to become involved. Most appear interested in continuing or expanding the programmes.

  • Fans welcome mental health initiatives. To some extent, stigma can be reduced by the public involvement of Foundations and players being open about the issues.

  • Partnerships are very valuable in terms of quality, recruitment, signposting and follow-up.

  • Statutory and charitable bodies recognise the value of working with Foundations because their brand and reputation mean they can attract and influence those considered ‘hard to reach’.

  • Projects show the value of partnership with Foundations bringing brand, attractive and accessible venues and expertise in sport, education and social inclusion, and partners bringing expertise in mental well-being, employment, housing and training.

  • Partners helped to identify appropriate participants and, likewise, Clubs identified and referred on participants in need of specialist support who were not currently in the healthcare system.

Future Work

In the second year of this 2-year project, there will be a focus on identifying how to achieve future sustainability when Sport Relief funding ends, given that all of the Foundations feel strongly that Foundations and Clubs have a significant role to play in engaging people in need and promoting better mental well-being among some of the most disadvantaged in society.