Original ResearchHealth promotion and the social gradient: The free swimming initiative for children and young people in Bristol
Introduction
In 1980, the Black report highlighted the link between lower social class, poorer health outcomes and inequalities in the use of medical services.1 The argument was reiterated some 20 years later in the Acheson report,2 and reducing health inequalities was identified as a government priority.3, 4, 5 However, recent targets are unlikely to be met and, in some cases, the gap between rich and poor is widening.6, 7 In response, the Marmot review made a number of recommendations including strengthening the role and impact of ill health prevention programmes.8
Increasing rates of obesity in children and adolescents have severe implications for long-term health,9, 10, 11 and evidence suggests that low socio-economic status is a risk factor for obesity in industrialized countries.12 Recent Department of Health campaigns have highlighted the importance of regular physical activity.13 A physically active lifestyle during childhood and adolescence can influence later lifestyle in adulthood,14, 15 and is likely to assist in reducing future chronic disease.16, 17 However, boys tend to be more active than girls,18, 19 and a decline in physical activity during adolescence is a consistent finding in the literature.19 Interventions to promote physical activity amongst young people are influenced by a range of psychological, cultural and social factors, as well as structural issues relating to access, provision of facilities, and national and international policies.20 Barriers to participation include transport, lack of time and money, personal safety, inadequate facilities, lack of motivation, feelings of incompetence or self-consciousness, and privacy when getting changed.21, 22, 23
In April 2009, as part of a broader plan to secure a legacy from London hosting the 2012 Olympic and Paralympic Games, a 2-year free swimming initiative began in England, through which participating local authorities provided free swimming for children aged ≤16 years and adults aged ≥60 years.24 A further aim of the initiative was to contribute to the national Change4Life campaign to promote more active lifestyles.25 Local authorities were responsible for collecting monthly data as part of a national evaluation.26 However, the Government announced it was withdrawing funding for the initiative in the summer of 2010, citing an unprecedented financial situation and the need for budgetary constraints.27
Universal health promotion initiatives are often taken up by those in higher socio-economic groups whilst being less effective in changing the behaviour of socially disadvantaged and hard-to-reach groups.28, 29, 30, 31 This ‘inverse use law’ is analogous to ‘the inverse care law’ proposed by Tudor Hart whereby areas with greatest health needs paradoxically receive less care than expected.32 In acknowledging this, the Marmot review8 asserted:
Wherever ill health prevention and health promotion take place, whether in primary care, a school or in a leisure centre, evaluations should assess effectiveness across the social gradient. For example, free swimming initiatives and efforts to improve physical activity associated with the Olympics should be evaluated across the social gradient, which involves more than simply assessing the increase in numbers. (p. 150)
The present authors hypothesized that provision of the free swimming initiative in Bristol would be associated with higher uptake rates for children aged ≤16 years in more affluent areas, after accounting for residential distance to swimming pools.
Section snippets
Setting
Bristol is the largest city in the South West (population > 400,000) and one of eight ‘core’ English cities.33 Although a relatively wealthy city,34 Bristol has a diverse population with over 13% (32 of 252) of lower-layer super output areas (LSOAs) amongst the most deprived 10% nationally.35 Locally, the free swimming initiative was promoted by Bristol City Council (BCC) in partnership with Sport and Leisure Management Ltd who managed the council-owned leisure facilities.36 The initiative
Results
Of 68,151 free swims between January and June 2010, 3570 had conflicting or missing data for key variables (swimmer ID, age, sex, LSOA) and 3835 swims were by non-residents of Bristol city. These were excluded from the analyses. Population denominator estimates were only available for 0–15 year olds (16 year olds are included in an older age group), so 2164 further swims by 16 year olds were also excluded from rate calculations. These exclusions resulted in a dataset of 58,582 swims by 13,881
Discussion
Swimming is acknowledged as a popular recreational and sporting activity for people of all ages and abilities in the UK.39, 40 However, social patterning has been identified: people from higher socio-economic groups are more likely to swim than people from lower socio-economic groups,41 and, for children, maternal education and higher socio-economic group have been associated with a higher frequency of swimming.42 Overall, young people have much higher participation rates in swimming than
Conclusions
Health-promoting initiatives that focus on educational messages often result in inverse-use patterns. The authors believe that initiatives that challenge structural barriers, including financial barriers, may be more successful in addressing this problem. Termination of the free swimming initiative in England may be a short-sighted decision that removed an opportunity to promote physical activity across the social gradient. It is important that future research explores effects across the social
Ethical approval
Not sought.
Funding
This work was undertaken with the support of the Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer), a UKCRC Public Health Research Centre of Excellence. Funding from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council (RES-590-28-0005), Medical Research Council, the Welsh Assembly Government and the Wellcome Trust (WT087640MA), under the auspices of the UK Clinical Research Collaboration, is
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The impact of a community free swimming programme for young people (under 19) in England
2015, Sport Management ReviewCitation Excerpt :Central government offered local authorities in England the opportunity to implement a free swimming programme for under 16s (and over-60) in England in 2008/09 for two years. It was implemented by 61% of the 354 local authorities (UK Parliament, 2010), although the funding was withdrawn after 16 months following the 2010 general election (Audrey, Wheeler, Mills, & Ben-Shlomo, 2012). The funding per annum for the free swimming programme for young people was £19.6 million (Pricewaterhouse Coopers, 2010).
Evidence of the impact of sport policies on physical activity and sport participation: a systematic mixed studies review
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2019, Health Promotion International