Health promotion and the social gradient: The free swimming initiative for children and young people in Bristol

Summary

Objectives

To examine whether the free swimming initiative in Bristol was associated with higher uptake in more affluent areas (‘inverse use law’).

Study design

Secondary analysis of statistical data on free swimming session attendances in Bristol, recorded from January to June 2010. Individual postcode data were linked to lower-layer super output area (LSOA) of residence and the specific pool attended.

Methods

The dataset comprised 58,582 swims by 13,881 unique individuals between January and June 2010. The influence of age group, gender, season, distance from pool and area deprivation score (English Index of Multiple Deprivation) on swimming uptake rates was examined.

Results

Higher uptake rates were found amongst girls and older children. Higher attendance was also related to proximity to pool and warmer season. No association was found between area deprivation and uptake rate (P = 0.31). Lower uptake rates in deprived areas were more marked if they were further away from a pool and in the winter season (P-value for interactions <0.001).

Conclusions

The termination of the free swimming initiative in England may have removed an opportunity to promote physical activity across the social gradient. The evaluation of public health initiatives should examine effects across the social gradient, and clarify which aspects of interventions enhance the participation of poorer sections of society.

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.