Sport is a subset of physical activity that can be particularly beneficial for short-and-long-term physical and mental health, and social outcomes in adults. This study presents the results of an updated systematic review of the mental health and social outcomes of community and elite-level sport participation for adults. The findings have informed the development of the ‘Mental Health through Sport’ conceptual model for adults.
Nine electronic databases were searched, with studies published between 2012 and March 2020 screened for inclusion. Eligible qualitative and quantitative studies reported on the relationship between sport participation and mental health and/or social outcomes in adult populations. Risk of bias (ROB) was determined using the Quality Assessment Tool (quantitative studies) or Critical Appraisal Skills Programme (qualitative studies).
The search strategy located 8528 articles, of which, 29 involving adults 18–84 years were included for analysis. Data was extracted for demographics, methodology, and study outcomes, and results presented according to study design. The evidence indicates that participation in sport (community and elite) is related to better mental health, including improved psychological well-being (for example, higher self-esteem and life satisfaction) and lower psychological ill-being (for example, reduced levels of depression, anxiety, and stress), and improved social outcomes (for example, improved self-control, pro-social behavior, interpersonal communication, and fostering a sense of belonging). Overall, adults participating in team sport had more favorable health outcomes than those participating in individual sport, and those participating in sports more often generally report the greatest benefits; however, some evidence suggests that adults in elite sport may experience higher levels of psychological distress. Low ROB was observed for qualitative studies, but quantitative studies demonstrated inconsistencies in methodological quality.
The findings of this review confirm that participation in sport of any form (team or individual) is beneficial for improving mental health and social outcomes amongst adults. Team sports, however, may provide more potent and additional benefits for mental and social outcomes across adulthood. This review also provides preliminary evidence for the Mental Health through Sport model, though further experimental and longitudinal evidence is needed to establish the mechanisms responsible for sports effect on mental health and moderators of intervention effects. Additional qualitative work is also required to gain a better understanding of the relationship between specific elements of the sporting environment and mental health and social outcomes in adult participants.
The organizational structure of sport and the performance demands characteristic of sport training and competition provide a unique opportunity for participants to engage in health-enhancing physical activity of varied intensity, duration, and mode; and the opportunity to do so with other people as part of a team and/or club. Participation in individual and team sports have shown to be beneficial to physical, social, psychological, and cognitive health outcomes [1,2,3,4,5,6,7]. Often, the social and mental health benefits facilitated through participation in sport exceed those achieved through participation in other leisure-time or recreational activities [8,9,10]. Notably, these benefits are observed across different sports and sub-populations (including youth, adults, older adults, males, and females) [11]. However, the evidence regarding sports participation at the elite level is limited, with available research indicating that elite athletes may be more susceptible to mental health problems, potentially due to the intense mental and physical demands placed on elite athletes [12].
Participation in sport varies across the lifespan, with children representing the largest cohort to engage in organized community sport [13]. Across adolescence and into young adulthood, dropout from organized sport is common, and especially for females [14,15,16], and adults are shifting from organized sports towards leisure and fitness activities, where individual activities (including swimming, walking, and cycling) are the most popular [13, 17,18,19]. Despite the general decline in sport participation with age [13], the most recent (pre-COVID) global data highlights that a range of organized team sports (such as, basketball, netball volleyball, and tennis) continue to rank highly amongst adult sport participants, with soccer remaining a popular choice across all regions of the world [13]. It is encouraging many adults continue to participate in sport and physical activities throughout their lives; however, high rates of dropout in youth sport and non-participation amongst adults means that many individuals may be missing the opportunity to reap the potential health benefits associated with participation in sport.
According to the World Health Organization, mental health refers to a state of well-being and effective functioning in which an individual realizes his or her own abilities, is resilient to the stresses of life, and is able to make a positive contribution to his or her community [20]. Mental health covers three main components, including psychological, emotional and social health [21]. Further, psychological health has two distinct indicators, psychological well-being (e.g., self-esteem and quality of life) and psychological ill-being (e.g., pre-clinical psychological states such as psychological difficulties and high levels of stress) [22]. Emotional well-being describes how an individual feels about themselves (including life satisfaction, interest in life, loneliness, and happiness); and social well–being includes an individual’s contribution to, and integration in society [23].
Mental illnesses are common among adults and incidence rates have remained consistently high over the past 25 years (~ 10% of people affected globally) [24]. Recent statistics released by the World Health Organization indicate that depression and anxiety are the most common mental disorders, affecting an estimated 264 million people, ranking as one of the main causes of disability worldwide [25, 26]. Specific elements of social health, including high levels of isolation and loneliness among adults, are now also considered a serious public health concern due to the strong connections with ill-health [27]. Participation in sport has shown to positively impact mental and social health status, with a previous systematic review by Eime et al. (2013) indicated that sports participation was associated with lower levels of perceived stress, and improved vitality, social functioning, mental health, and life satisfaction [1]. Based on their findings, the authors developed a conceptual model (health through sport) depicting the relationship between determinants of adult sports participation and physical, psychological, and social health benefits of participation. In support of Eime’s review findings, Malm and colleagues (2019) recently described how sport aids in preventing or alleviating mental illness, including depressive symptoms and anxiety or stress-related disease [7]. Andersen (2019) also highlighted that team sports participation is associated with decreased rates of depression and anxiety [11]. In general, these reviews report stronger effects for sports participation compared to other types of physical activity, and a dose–response relationship between sports participation and mental health outcomes (i.e., higher volume and/or intensity of participation being associated with greater health benefits) when adults participate in sports they enjoy and choose [1, 7]. Sport is typically more social than other forms of physical activity, including enhanced social connectedness, social support, peer bonding, and club support, which may provide some explanation as to why sport appears to be especially beneficial to mental and social health [28].
Thoits (2011) proposed several potential mechanisms through which social relationships and social support improve physical and psychological well-being [29]; however, these mechanisms have yet to be explored in the context of sports participation at any level in adults. The identification of the mechanisms responsible for such effects may direct future research in this area and help inform future policy and practice in the delivery of sport to enhance mental health and social outcomes amongst adult participants. Therefore, the primary objective of this review was to examine and synthesize all research findings regarding the relationship between sports participation, mental health and social outcomes at the community and elite level in adults. Based on the review findings, the secondary objective was to develop the ‘Mental Health through Sport’ conceptual model.
This review has been registered in the PROSPERO systematic review database and assigned the identifier: CRD42020185412. The conduct and reporting of this systematic review also follows the Preferred Reporting for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [30] (PRISMA flow diagram and PRISMA Checklist available in supplementary files). This review is an update of a previous review of the same topic [31], published in 2012.
Nine electronic databases (CINAHL, Cochrane Library, Google Scholar, Informit, Medline, PsychINFO, Psychology and Behavioural Sciences Collection, Scopus, and SPORTDiscus) were systematically searched for relevant records published from 2012 to March 10, 2020. The following key terms were developed by all members of the research team (and guided by previous reviews) and entered into these databases by author LW: sport* AND health AND value OR benefit* OR effect* OR outcome* OR impact* AND psych* OR depress* OR stress OR anxiety OR happiness OR mood OR ‘quality of life’ OR ‘social health’ OR ‘social relation*’ OR well* OR ‘social connect*’ OR ‘social functioning’ OR ‘life satisfac*’ OR ‘mental health’ OR social OR sociolog* OR affect* OR enjoy* OR fun. Where possible, Medical Subject Headings (MeSH) were also used.
The titles of studies identified using this method were screened by LW. Abstract and full text of the articles were reviewed independently by LW and NE. To be included in the current review, each study needed to meet each of the following criteria: (1) published in English from 2012 to 2020; (2) full-text available online; (3) original research or report published in a peer-reviewed journal; (4) provides data on the psychological or social effects of participation in sport (with sport defined as a subset of exercise that can be undertaken individually or as a part of a team, where participants adhere to a common set of rules or expectations, and a defined goal exists); (5) the population of interest were adults (18 years and older) and were apparently healthy. All papers retrieved in the initial search were assessed for eligibility by title and abstract. In cases where a study could not be included or excluded via their title and abstract, the full text of the article was reviewed independently by two of the authors.
For the included studies, the following data was extracted independently by LW and checked by NE using a customized Google Docs spreadsheet: author name, year of publication, country, study design, aim, type of sport (e.g., tennis, hockey, team, individual), study conditions/comparisons, sample size, where participants were recruited from, mean age of participants, measure of sports participation, measure of physical activity, psychological and/or social outcome/s, measure of psychological and/or social outcome/s, statistical method of analysis, changes in physical activity or sports participation, and the psychological and/or social results.
A risk of bias was performed by LW and AP independently using the ‘Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies’ OR the ‘Quality Assessment of Controlled Intervention Studies’ for the included quantitative studies, and the ‘Critical Appraisal Skills Programme (CASP) Checklist for the included qualitative studies [32, 33]. Any discrepancies in the ROB assessments were discussed between the two reviewers, and a consensus reached.
The search yielded 8528 studies, with a total of 29 studies included in the systematic review (Fig. 1). Tables 1 and 2 provide a summary of the included studies. The research included adults from 18 to 84 years old, with most of the evidence coming from studies targeting young adults (18–25 years). Study samples ranged from 14 to 131, 962, with the most reported psychological outcomes being self-rated mental health (n = 5) and depression (n = 5). Most studies did not investigate or report the link between a particular sport and a specific mental health or social outcome; instead, the authors’ focused on comparing the impact of sport to physical activity, and/or individual sports compared to team sports. The results of this review are summarized in the following section, with findings presented by study design (cross-sectional, experimental, and longitudinal).
The model describes two key pathways through which sport may influence mental health: physical activity, and social relationships and support. Several likely moderators of this effect are also provided, including sport type, intensity, frequency, context (team vs. individual), environment (e.g., indoor vs. outdoor), as well as the level of competition (e.g., elite vs. amateur).
The means by which the physical activity component of sport may influence mental health stems from the work of Lubans et al., who propose three key groups of mechanisms: neurobiological, psychosocial, and behavioral [64]. Processes whereby physical activity may enhance psychological outcomes via changes in the structural and functional composition of the brain are referred to as neurobiological mechanisms [65, 66]. Processes whereby physical activity provides opportunities for the development of self-efficacy, opportunity for mastery, changes in self-perceptions, the development of independence, and for interaction with the environment are considered psychosocial mechanisms. Lastly, processes by which physical activity may influence behaviors which ultimately affect psychological health, including changes in sleep duration, self-regulation, and coping skills, are described as behavioral mechanisms.
Playing sport offers the opportunity to form relationships and to develop a social support network, both of which are likely to influence mental health. Thoits [29] describes 7 key mechanisms by which social relationships and support may influence mental health: social influence/social comparison; social control; role-based purpose and meaning (mattering); self-esteem; sense of control; belonging and companionship; and perceived support availability [29]. These mechanisms and their presence within a sporting context are elaborated below.
Subjective to the attitudes and behaviors of individuals in a group, social influence and comparison may facilitate protective or harmful effects on mental health. Participants in individual or team sport will be influenced and perhaps steered by the behaviors, expectations, and norms of other players and teams. When individual’s compare their capabilities, attitudes, and values to those of other participants, their own behaviors and subsequent health outcomes may be affected. When others attempt to encourage or discourage an individual to adopt or reject certain health practices, social control is displayed [29]. This may evolve as strategies between players (or between players and coach) are discussion and implemented. Likewise, teammates may try to motivate each another during a match to work harder, or to engage in specific events or routines off-field (fitness programs, after game celebrations, attending club events) which may impact current and future physical and mental health.
Sport may also provide behavioral guidance, purpose, and meaning to its participants. Role identities (positions within a social structure that come with reciprocal obligations), often formed as a consequence of social ties formed through sport. Particularly in team sports, participants come to understand they form an integral part of the larger whole, and consequently, they hold certain responsibility in ensuring the team’s success. They have a commitment to the team to, train and play, communicate with the team and a potential responsibility to maintain a high level of health, perform to their capacity, and support other players. As a source of behavioral guidance and of purpose and meaning in life, these identities are likely to influence mental health outcomes amongst sport participants.
An individual’s level of self-esteem may be affected by the social relationships and social support provided through sport; with improved perceptions of capability (or value within a team) in the sporting domain likely to have positive impact on global self-esteem and sense of worth [64]. The unique opportunities provided through participation in sport, also allow individuals to develop new skills, overcome challenges, and develop their sense of self-control or mastery. Working towards and finding creative solutions to challenges in sport facilitates a sense of mastery in participants. This sense of mastery may translate to other areas of life, with individual’s developing the confidence to cope with varied life challenges. For example, developing a sense of mastery regarding capacity to formulate new / creative solutions when taking on an opponent in sport may result in greater confidence to be creative at work. Social relationships and social support provided through sport may also provide participants with a source of belonging and companionship. The development of connections (on and off the field) to others who share common interests, can build a sense of belonging that may mediate improvements in mental health outcomes. Social support is often provided emotionally during expressions of trust and care; instrumentally via tangible assistance; through information such as advice and suggestions; or as appraisal such feedback. All forms of social support provided on and off the field contribute to a more generalised sense of perceived support that may mediate the effect of social interaction on mental health outcomes.
Participation in sport may influence mental health via some combination of the social mechanisms identified by Thoits, and the neurobiological, psychosocial, and behavioral mechanisms stemming from physical activity identified by Lubans [29, 64]. The exact mechanisms through which sport may confer psychological benefit is likely to vary between sports, as each sport varies in its physical and social requirements. One must also consider the social effects of sports participation both on and off the field. For instance, membership of a sporting team and/or club may provide a sense of identity and belonging—an effect that persists beyond the immediacy of playing the sport and may have a persistent effect on their psychological health. Furthermore, the potential for team-based activity to provide additional benefit to psychological outcomes may not just be attributable to the differences in social interactions, there are also physiological differences in the requirements for sport both within (team vs. team) and between (team vs. individual) categories that may elicit additional improvements in psychological outcomes. For example, evidence supports that exercise intensity moderates the relationship between physical activity and several psychological outcomes—supporting that sports performed at higher intensity will be more beneficial for psychological health.
There are several limitations of this review worthy of consideration. Firstly, amongst the included studies there was considerable heterogeneity in study outcomes and study methodology, and self-selection bias (especially in non-experimental studies) is likely to influence study findings and reduce the likelihood that study participants and results are representative of the overall population. Secondly, the predominately observational evidence included in this and Eime’s prior review enabled us to identify the positive relationship between sports participation and social and psychological health (and examine directionality)—but more experimental and longitudinal research is required to determine causality and explore potential mechanisms responsible for the effect of sports participation on participant outcomes. Additional qualitative work would also help researchers gain a better understanding of the relationship between specific elements of the sporting environment and mental health and social outcomes in adult participants. Thirdly, there were no studies identified in the literature where sports participation involved animals (such as equestrian sports) or guns (such as shooting sports). Such studies may present novel and important variables in the assessment of mental health benefits for participants when compared to non-participants or participants in sports not involving animals/guns—further research is needed in this area. Our proposed conceptual model also identifies several pathways through which sport may lead to improvements in mental health—but excludes some potentially negative influences (such as poor coaching behaviors and injury). And our model is not designed to capture all possible mechanisms, creating the likelihood that other mechanisms exist but are not included in this review. Additionally, an interrelationship exits between physical activity, mental health, and social relationships, whereby changes in one area may facilitate changes in the other/s; but for the purpose of this study, we have focused on how the physical and social elements of sport may mediate improvements in psychological outcomes. Consequently, our conceptual model is not all-encompassing, but designed to inform and guide future research investigating the impact of sport participation on mental health.
The findings of this review endorse that participation in sport is beneficial for psychological well-being, indicators of psychological ill-being, and social outcomes in adults. Furthermore, participation in team sports is associated with better psychological and social outcomes compared to individual sports or other physical activities. Our findings support and add to previous review findings [1]; and have informed the development of our ‘Mental Health through Sport’ conceptual model for adults which presents the potential mechanisms by which participation in sport may affect mental health.
