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Health Disability Sport Partnership:

A Social Return on Investment Analysis

CATHERINE CHIN

Physiotherapist

AUGUST 2016

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Executive Summary The Health Disability Sport Partnership (HDSP) is a joint partnership between Betsi Cadwaladr

University Health Board (BCUHB) and Disability Sport Wales (DSW), supported by a Sport Wales

grant. Through a process of up-skilling health professionals, and supporting them to signpost

disabled people towards physical activity (including sport) opportunities via a Health Disability Sport

Pathway, the aim of the HDSP is to improve the health and wellbeing of disabled people. The

purpose of this study was to assess the social value created by the HDSP, and examine if the HDSP is

a cost effective intervention that should be rolled out across Wales. Participants were selected from

the 282 disabled people who actively engaged in physical activity (including sport) following

signposting. Ten disabled people (3 females and 7 males), and an additional three young talented

athletes, were included in the study. A social return on investment analysis (SROI) was conducted,

establishing what outcomes disabled people and their family/friends have experienced from their

involvement in the HDSP, and presenting the outcomes in terms of monetary values. Participation in

physical activity (including sport) has improved the physical and mental health and wellbeing of the

disabled people who were involved. Positive impacts were also found for the health and wellbeing of

some family members of disabled people. The results found that for every £1 invested in the HDSP,

£124 of added social value was created. The SROI demonstrated that the HDSP is a cost effective

model for increasing levels of physical activity (including sport) amongst disabled populations,

creating social value through improved health and well-being of disabled people, and that of their

families. Health and (disability) sport working in partnership represents a cost effective intervention

that can contribute to reducing the burden of physical inactivity.

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Table of Contents

1.0 Introduction ......................................................................................................................... 3

2.0 The Social Return on Investment Analysis (SROI) model ..................................................... 5

3.0 Methodology ........................................................................................................................ 9

3.1 Participants (Stage 1: Establishing scope and identifying key stakeholders) ............................... 9

3.2 Procedures .................................................................................................................................. 10

3.2.1 (Stage 2: Mapping outcomes) .................................................................................................. 10

3.2.2 (Stage 3: Evidencing outcomes and giving them a value) ....................................................... 11

3.2.4 (Stage 4: Establishing impact) .................................................................................................. 12

4.0 Results ................................................................................................................................ 19

4.1 (Stage 5: Calculating the SROI) ................................................................................................... 19

4.2 The SROI ratio ............................................................................................................................. 22

5.0 Discussion ........................................................................................................................... 25

5.1 Limitations .................................................................................................................................. 26

5.3 Recommendations ...................................................................................................................... 27

6.0 Conclusion .......................................................................................................................... 28

References ............................................................................................................................... 29

Appendix 1: Impact (participants 1-10) ................................................................................... 31

Appendix 2: Impact map (talented athletes, participants 11-13) ........................................... 32

Appendix 3: Stakeholders and their reason for inclusion/ exclusion in the SROI ................... 33

Appendix 4: Outcomes for each participant ............................................................................ 35

Appendix 5: Attribution ........................................................................................................... 36

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1.0 Introduction The Health Disability Sport Partnership (HDSP) is a joint project between Betsi Cadwaladr University

Health Board (BCUHB), the Health Board of North Wales, and Disability Sport Wales (DSW), the

official body of disability sport in Wales. The HDSP is the first project in the UK with a Health Board

and a sport body working in partnership. The three-year project was funded by a Sport Wales Calls

for Action grant of £150,000, running from December 2013-December 2016. Through a process of

up-skilling health professionals to create a strong and sustainable relationship between DSW and

BCUHB, the aim of the partnership is to increase the health and wellbeing of disabled people in

North Wales by increasing the numbers of disabled people who are physically active (including

playing sport). The health sector (Health) is the only institution which is anticipated to come into

contact with every disabled person, and therefore working in partnership with Health increases the

opportunities to engage with disabled people about physical activity (including sport) opportunities

(DSW, 2012). To support health professionals in signpost disabled people towards physical activity

(including sport) opportunities in the community, a ‘Health Disability Sport Pathway’ was created.

The pathway was designed to be accessible for health professionals in all settings, and provide

support, through the local DSW development officers, for disabled people to find suitable

opportunities for increased physical activity (including playing sport) (Figure 1.1).

The Health Disability Sport Partnership is a pilot project, and therefore evaluating and reporting is

important (Leon et al., 2011). The aim of the pilot project was to establish a strong and sustainable

partnership model across North Wales, that can be rolled out across the rest of Wales, adapted to

suit the needs of the area (DSW, 2012). Initial evaluation of the HDSP included a health impact

assessment (HIA) (Chin, 2015), people stories (stories from disabled people who had been

signposted via the pathway), and health professional stories. A HIA is a qualitative stakeholder study

where information was collected on the impact the HDSP has had on the health and wellbeing of

those involved in, or affected by, the work undertaken by the HDSP. The HIA, people stories, and

health professional stories found positive impacts on the health and wellbeing of disabled people

and their families, a resultant increase in capacity for health professionals, and improved

communication between disabled people and DSW (Chin, 2015). The qualitative evidence collected

in the previous analysis’ has provided positive feedback that the HDSP is having positive effects on

the intended stakeholders. The next stage of evaluation is to quantify the HDSP outcomes (the social

value) in financial terms against the grant investment. A SROI enables exploration and measurement

of the social, environmental and economic value being generated by an activity (The SROI Network,

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2012). The SROI will provide quantitative monetary figures for the social value against the

investment, providing important information as to whether the partnership model is a good use of

public funded money. Therefore, the aim of this study was to assess the impact of the HDSP in terms

of social return on investment using an SROI model.

Figure 1.1: The Health Disability Sport Pathway

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2.0 The Social Return on Investment Analysis (SROI) model

Social return on investment analysis (SROI) was developed from the cost-benefit analysis (CBA)

model, enabling exploration and measurement of the social, environmental and economic value

being generated by an activity (Banke-Thomas et al., 2015). A SROI allows the potential financial

return of a project to be established by giving monetary values to outcomes that do not always have

a value in the financial market place (The SROI Network, 2012). The monetary value given to an

outcome is the social value. A SROI is about social value, not about money (The SROI Network,

2012). Monetary values are used as they provide a common unit that can be used to compare

interventions and support decisions on which interventions are worth investing in (The SROI

Network, 2012). In previous investment analyses, outcomes that did not have an obvious monetary

value as they are non-tradable goods, such as increased confidence, would be excluded from the

analysis. By excluding outcomes that do not have an obvious monetary value there is a significant

risk of underestimating the true social return of a project (The SROI Network, 2012). Social return on

investment is a holistic model and involves engaging with stakeholders, thus allowing outcomes that

are important to a given population to be recognised, providing a more accurate picture of a

projects’ true social value (Banke-Thomas et al., 2015). Social Return on Investment is becoming

increasingly important in both the public and private sectors as a means of demonstrating added

social, environmental and economic value (Cabinet Office, 2012). A systematic review of economic

evaluation tools found SROI to be the best model for evaluating changes in public health

interventions as it can present outcomes across the broader socio-economic and environmental

outcomes, and captures changes across the whole spectrum of an initiative (input to outcomes)

(Banke-Thomas et al., 2015).

Social Return on Investment follows a set of seven key principles (Table 2.1) within a framework,

through a six stage model (Table 2.2). The central tool for a SROI is the ‘impact map’ (Appendices 1-

2). The impact map is used to present all of the data that is collected during an SROI. The impact

map includes all of the project inputs, outputs and the outcomes (The SROI Network, 2012). Stages

1-4 of the SROI are highlighted on the impact map and can be followed as each stage is presented in

the method of a SROI (Appendices 1-2). Having calculated the SROI there will be two numbers, the

financial value of the investment, and the financial value of the social outcomes (The SROI Network,

2012). The social values are divided against the investment value and presented as a ratio of return

per £1 of investment (The SROI Network, 2012). This study conducted a SROI on the HDSP to

establish the social value created though supporting disabled people be become physically active

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(including playing sport), and reports this against the project delivery cost to establish whether the

pilot project is cost effective and a suitable use of public monies.

The Housing Association Charitable Trust (HACT) provides a model for measuring the social impact of

community investment using a wellbeing valuation approach (Trotter et al., 2014). The wellbeing

valuation approach enables community interventions to be valued in relation to the impact they

have on increasing an individual’s or a community’s wellbeing (Trotter et al., 2014). A ‘Social Value

Bank’ was created by HACT to demonstrate these values for the use of community projects (Trotter

et al., 2014). The value bank supplies clear figures as well as clear guidance on how the data is to be

used, which ensures that the tool is reliable, and enables different types of projects to be compared

based on their social value (Trotter et al., 2014). The HACT’s wellbeing valuation model, and social

value bank, are shown to be consistent with the principles of SROI and can therefore be used in

conjunction with the SROI for setting values for outcomes (Trotter et al., 2014). The HACT’s social

value bank was used in this study for the setting of social value figures.

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Table 2. 1: The 7 Key Principles of SROI (adapted from The SROI Network, 2012)

Key Principle Brief Description

1. Involve Stakeholders

Stakeholders are people, groups or organizations that affect a project or experience change as a result of a project (Freeman et al., 2010). Stakeholders need to be identified and involved in consultation throughout the SROI process. Involving stakeholders will ensure that what is important to those involved in, or effected by a project are the focus of the SROI.

2. Understand what changes

Projects are designed to bring about change (Sokowski, 2015). Understanding what changes have happened and evaluating social, economic and environmental outcomes provide the evidence about the social value created. Outcomes can be intended and unintended, positive and negative. A SROI will also evaluate to what extent a change has occurred.

3. Value what matters

To establish the social value each outcome is given a notional monetary value. As well as revealing the social value, setting monetary values helps to determine how significant each outcome is (The SROI Network, 2012). Each monetary value set is an approximation as monetary values are being assigned to outcomes that do not necessarily have a market value if they are non-tradable goods. Existing literature is consulted to set values, including the HACT wellbeing valuation model (Trotter et al., 2014).

4. Only include what is material

Ensuring that relevant information and evidence is included to provide an accurate and transparent report, enabling stakeholders to draw reasonable conclusions about the impact of the project.

5. Do not over-claim

Only claim the outcomes that can be attributed to the project. Outcomes that would have happened anyway need to be removed, and any drop off in activity also needs to be accounted for.

6. Be transparent Be clear on how all decisions have been made and all conclusions reached. Include explanations on how stakeholders have been involved, how data is collected and how values were set.

7. Verify the result Due to the nature of SROI decisions involve a degree of subjectivity. Enough detail must be provided through the SROI to allow appropriate independent review of the decisions made.

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Table 2.2: SROI 6 Stage Model (adapted from The SROI Network, 2012

Stage

Brief description of stage

1. Establishing scope and identifying key stakeholders

Establishing what the SROI is analysing and being clear on why the analysis is taking place. Analysis can be of a whole project, or part of a project. If part of a project is being analysed the amount that was invested in that particular part of the project will need to be established. Stakeholders are identified and a decision is made on which stakeholders will be involved, and how they will be involved. Stakeholders can be involved in a number of ways, including interviews, questionnaires or workshops.

2. Mapping outcomes Through engaging with stakeholders, outcomes are established. Outcomes are the impacts that the project has on the particular stakeholder. Outcomes can be positive and/ or negative. Outcomes may differ from the project intended changes, and allows for what is important to the stakeholder to be identified. Outcomes can only be established by engaging with the stakeholders to understand what changes have actually occurred for them. Outcomes are recorded on an impact map that demonstrated the relationship between the project inputs (including financial investment) and the outcomes.

3. Evidencing outcomes and giving them a value

Research is conducted to establish whether outcomes have happened, and if so, to how many of the project target population, and by how much. Each outcome is given a value. Values are set in a range of ways depending on the outcome.

4. Establishing impact. The outcome data is reviewed. The data is adjusted to account for changes that may have happened without the project, and drop-off rates expected as other factors contribute to ongoing outcomes.

5. Calculating the SROI. All of the benefits are added up, subtracting any negatives. The total is then compared against the project inputs to provide a conclusion on the social return on investment.

6.Reporting, using and embedding.

Findings are shared with stakeholders. Relevant action is taken based on the SROI findings.

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3.0 Methodology

3.1 Participants (Stage 1: Establishing scope and identifying key stakeholders) An evaluative SROI was conducted on the Health Disability Sport Partnership (HDSP). The HDSP had

a broad range of stakeholders. Stakeholders were identified and decisions were made on whether to

include or exclude them from the SROI (Appendix 3) (The SROI Network, 2012). The stakeholders

that were included in the study were DSW, BCUHB, Sport Wales, disabled people and their

family/friends/carers.

From April 2014 – June 2016, 460 disabled people have been signposted via the Health Disability

Sport Pathway. For this study a sample was taken from the 282 disabled people who had actively

engaged in physical activity (including sport) following signposting. Those who did not engage, or

partly engaged, were not included in this study, however further studies could include them. Of the

282 disabled people who actively engaged in the HDSP, there were disabled people with a range of

impairments; physical impairment (ambulant) (n=97), physical impairment (wheelchair-user) (n=33),

Deaf/hard of hearing (n=5), blind/visually impaired (n=11), and learning disability (n=130), with some

not declaring their impairment (n=12). It was recognised that a number of disabled people may have

more than one impairment and therefore fit into more than one of the impairment group. A sample

size power calculation to determine the sample size could not be undertaken as no comparable

research upon which to base figures was found (Gray et al., 2013). In the absence of a power

calculation, a sample size was selected to ensure there was representation, where possible, for each

impairment group (The SROI Network, 2012). The mean age of participants could not be provided as

a large proportion of the data was missing, and gender was not recorded. In order to ensure the

sample was representative of disabled people with all impairments involved in the HDSP, indirect

sampling sought to recruit one adult and one child from each of the impairment groups. Every effort

was made to ensure that the sample was representative of gender by including males and females.

To account for potential differences across the six North Wales LAs, stakeholders were included

from each LA. To account for potential differences in outcomes based on the type of physical activity

(including sport) that participants were engaged in, effort was made to include participants who

were engaged in a variety of different opportunities.

A sample of ten disabled people (participants 1-10) were identified through indirect stratified

sampling (Tourangeau et al., 2014) via the DSW development officers across the 6 North Wales local

authorities (LAs). The HDSP had identified three talented athletes. Talented athletes are defined as

athletes who are representing their country in their chosen sport (DSW, 2012). The three young

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athletes in question were signposted via the Health Disability Sport Pathway and have since

represented Wales in their chosen sports. In order to determine if talented athletes experience

different outcomes and result in different social, environmental and economic value, they were

included in the study (participant’s 11-13) and analysed in a separate impact map (Appendix 2).

Participants 1-10 (n=10) were a mean age of 25.3 16.81 years; n=3 females (19 10.44 years), n =

7 males (28 18.95 years). The talented athletes (participants 11-13; n=3) were all males and were a

mean age of 12.3 1.53 years.

3.2 Procedures

3.2.1 (Stage 2: Mapping outcomes) Stakeholders’ inputs into the project were identified and valued (Table 3.1). The input value for

BCUHB was calculated with support from the BCUHB finance team to account for the time health

professionals spent attending up-skilling sessions. Although training was delivered during team

meetings or planned training times, this represents a cost to the health board. The input value for

DSW was calculated with support from DSW to account for the time DSW Development Officers

spent delivering work for the HDSP. No value is placed against the input of time for disabled people

and their family/friends/carers; these stakeholders give their time to access the services delivered by

the HDSP secondary to the inputs from SW and DSW, they do not input into the delivery of the

project itself and therefore do not represent a delivery cost.

Table 3. 1: Value of inputs

Stakeholder Input Value

Disabled people Time £0

Family/friends/carers of disabled person Time £0

BCUHB Time £27,702.08

DSW Time £18,918.90

Sport Wales Grant monies £150,000

Outcomes of the HDSP for each stakeholder group were identified. Outcomes were extracted from

previous analysis of the HDSP, including a HIA (Chin, 2015), people stories (from disabled people and

their families) and staff stories (BCUHB health professionals). A number of outcomes were identified,

additional to the pre-project intended outcomes, and further outcomes were added during

stakeholder interviews (Table 3.2).

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3.2.2 (Stage 3: Evidencing outcomes and giving them a value)

Indicators were set for each outcome, established from the previous analysis of the HDSP (Table

3.3). Interviews were conducted with the 13 participants, and where relevant their

family/friend/carer. Interviews consisted of open and semi-structured questions. Each transcript was

examined against the list of outcomes to establish which outcomes had occurred for each

participant. No additional outcomes were identified. The outcomes for each participant were

recorded, and the total number of people experiencing each outcome was totaled to arrive at the

‘quantity’ of outcomes (Appendix 4).

Outcomes are expected to last beyond the duration of the three year funded project as disabled

people continue to be physically active (including playing sport). It was not possible to measure how

long outcomes have actually lasted at this stage in the HDSP as the project is still ongoing (The SROI

Network, 2012). Comparable projects could not be identified to establish the duration of the

outcomes. Assumptions and estimates were used to determine outcome durations, based on the

stakeholder engagement and additional literature (Table 3.4) (The SROI Network, 2012).

Existing literature was consulted to establish values for each outcome (Table 3.6). Where the

outcomes were available the HACT Social Value Bank was used (Trotter et al., 2014). Outcomes that

could not be combined together, as this would result in double counting, are clearly identified on the

impact map under the financial proxy (Appendices 1 - 2). Outcome quantities were adjusted to

account for outcomes that could not be applied together; the outcomes with the lowest value were

removed (Appendix 4). Adjusted outcome quantities were recorded on the impact maps

(Appendices 1-2). The cost of health appointments was established through the BCUHB finance team

and CSP cost calculator (CSP, 2016). Discussions with DSW established that putting a value on

increased brand awareness for DSW was complex and difficult to establish. It was decided to exclude

this value from the SROI and focus on the outcomes for disabled people and the

family/friends/carers as this was the primary aim of the HDSP.

One intended change for BCUHB was a reduction in pressure on services due to increased capacity,

secondary to a reduction in the interventions required by disabled people who were discharge

sooner, and potential future reduction of co-mobility risk, due to becoming more physically active.

Although a reduction in the amount of allied health professional interventions required by

participants was identified, it was not possible to establish if this had an impact on the pressure on

NHS services, and this would not be anticipated at this early stage. It is anticipated that there may be

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a potential long term impacts on NHS services, which is an outcome that will be challenging to

assess. In order to avoid double counting and over exaggeration of social value (The SROI Network,

2012), the outcomes for BCUHB of discharging disabled people sooner from services was not

counted as this was included under outcomes for disabled people in relation to cost savings for

reduced number of appointments (Appendices 1-2). Outcomes for Sport Wales were also excluded,

again to avoid double counting, as the social value created by increased participation in physical

activity (including sport) was recorded under outcomes for disabled people and their

family/friends/carers.

3.2.4 (Stage 4: Establishing impact) Outcomes were analysed to establish the true impact of the HDSP. Each stakeholder group was re-

evaluated to establish to what extent the outcomes were produced by the HDSP (attribution), what

may have happened anyway (deadweight), and what will reduce in time as other factors influence

the outcomes (drop-off) (The SROI Network, 2012). Attribution estimates were conducted based on

the engagement with stakeholders; attribution was estimated at an individual participant level and

then averaged across the samples (Social Value Lab, 2014), resulting in a mean attribution rate of

20% (Appendix 5). As no deadweight was identified by stakeholders in the HDSP a value of 5%

deadweight was set in line with other studies (The SROI Network, 2012; Kimani-Murage, et al., 2016;

Jones, 2012). In the absence of drop-off data SROI guidance recommends a standard approach of

10% drop off per year (The SROI Network, 2012). Ten percent was deducted from each outcome for

each year during calculation. For the outcome of ‘disabled people were able to manage their health

conditions better’, relating to the indicator of fewer appointment with health professionals (not

including doctors), a drop-off rate of 30% was applied as it was anticipated that the allied health

professionals associated with delivering these appointments would be working to reduce their level

of input each year regardless of the HDSP

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Table 3. 2: Outcomes

Stakeholder Outcomes

Disabled people Disabled people were more confident due to being physically active (including playing sport)

Disabled people have made new friends and spent more time socialising (both new and old social circles)/reducing social isolation

Disabled people have become regular volunteers

Playing sport has changed how others perceive some disabled people. Young disabled people report no longer being bullied due to their involvement in physical activity (including sport)

Being involved in sport has given disabled people a reason to do their rehabilitation/more time being physically active/allowed them to set meaningful goals and improve their physical fitness.

Disabled people have improved mental health and overall wellbeing since becoming physically active (including playing sport)

Disabled people are able to manage their health conditions better, and being more physically active has helped prevent secondary conditions.

Family/friends/carers of disabled person

Family members have increased their levels of physical activity. They feel healthier and fitter. Family member also have improved mental health and wellbeing. Family members are going out and socialising more, making new friends and/or developing a support network

BCUHB

Health professionals report discharging disabled people sooner due to their involvement in physical activity (including sport)

DSW

The Partnership with the BCUHB has helped disseminate the message of inclusion, increasing awareness of the DSW brand.

Identification of latent demand in opportunities has support the development of new opportunities.

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Table 3. 3: Indicators

Outcomes Indicators Disabled people were more confident due to being physically active (including playing sport)

Disabled people report increased confidence


Regular attendance in clubs/sessions Disabled people report changes in personal wellbeing/feeling less isolated Disabled people report making new friends.

Disabled people have become regular volunteers Regularly volunteering at a club/group


Disabled people (children) report no longer being bullied


More time spent doing rehabilitation. More time being physically active/playing sport. Disabled people reports improvements in their physical fitness


Disabled people reported improvements in their mental health and wellbeing (feeling happier)

Disabled people are able to manage their health conditions better, and being more physically active has helped prevent secondary conditions

Fewer visits to the doctor annually and disabled people report improvements in overall health/ Fewer appointments with other health professionals

Family members have increase their levels of physical activity. They feel healthier and fitter. Family member also have improved mental health and wellbeing

Family members report increase physical activity and improvements in their physical fitness/Family members report improvements in their mental health and wellbeing/Family members report reduced levels of depression/anxiety

Family members are going out and socialising more, making new friends And/or developing a support network

Increased visits out of the home/more time socialising/attending a club regularly

Health professionals report discharging disabled people sooner due to their involvement in physical activity (including sport)

Number of appointments available due to discharging disabled people

The Partnership with the BCUHB has helped disseminate the message of inclusion, increasing awareness of the DSW brand.

Increased awareness of DSW and the opportunities available for disabled people to engage with physical activity (including sport)

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Table 3. 4: Duration of outcomes

Outcome Duration (years)

Rationale

Disabled people were more confident due to being physically active (including playing sport)

3 Increased confidence in young people (Social Value Lab, 2014) and older people (Social Value Lab, 2011) is expected to persist over time (Kimani-Murage, 2016). Previous SROI set durations for increased confidence between 3 (Social Value Lab 2011; Social Value Lab 2014) and 5 years (Kimani-Murage et al., 2016). Engagement with stakeholder revealed they have become more confidence as they have continued to participate in physical activity (including sport); a number of the stakeholders were signposted via the HDSP in 2014. Stakeholders all revealed they plan to continue to engage in physical activity (including sport).


3 Relationships are expected to continue as disabled people continue to participate in physical activity/ sport opportunities (Social Value Lad, 2011).

Disabled people have become regular volunteers

3 The value will only last as long as volunteering continues. One participant identified that they have become a regular volunteer; they reported volunteering for over two years and they plan to continue with this activity.


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Disabled children reported being bullied in primary school. Bullying stopped when they were on average in the final year of primary school secondary to their participation in physical activity/ sport (two children were now in secondary school at time of interview). It is anticipated that the benefits of no longer being bullied will have long lasting effects (Highmark Foundation, no date; Reijntjes et al., 2010). A duration of 5 years had been set to reflect the average minimum amount of time that the children are expected to remain in education (secondary school years 7-11); the transition from secondary school is an important development milestone for children and young people (Fromme et al., 2009) and therefore other factors are likely to have an impact on outcomes at this stage.

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Outcomes Duration (years)

Rationale

Being involved in sport has given disabled people a reason to do their rehabilitation/More time being physically active/It has allowed them to set meaningful goals and improve their physical fitness.

3 A physical activity initiative found that those who completed the programme and were reviewed one year later had increased their level of activity by a further 14% (BHF, 2013). Stakeholders reported that they planned to continue with their engagement in physical activity/ sport.


3 Lifestyle changes are expected to continue with lasting effects (Social Value Lab, 2011). Previous SROI set durations for improved health and wellbeing at 3 (Social Value Lab 2011). As stakeholders continue to engage in physical activity/ sport, improvements in overall health and wellbeing are expected to continue.

Disabled people are able to manage their health conditions better, and being more physically active has helped prevent secondary conditions

5 Disabled children reported reduced levels of physiotherapy interventions secondary to becoming more physically active. Previous levels of physiotherapy intervention may have continued until reaching adult services at age 18. A maximum of 5 years has been set for durations.

Family members have increase their levels of physical activity. They feel healthier and fitter. Family member also have improved mental health and wellbeing

3 When a disabled person becomes more physically active this can have a positive impact on family members’ levels of physical activity (Let’s Move, no date). Family members are expected to continue to be more physically active along with continued participation by their relative/ friend.

Family members are going out and socialising more, making new friends and/or developing a support network

3 Stakeholder are expected to continue to attend physical activity/ sport opportunities alongside their relative; engagement of the disabled person is expected to continue.

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Table 3. 5: Values for outcomes

Outcome (all values are per person, per year) Financial Proxy Value (£) Source

Disabled people were more confident due to being physically active (including playing sport)

Value of increased confidence for children

9,455.00 HACT's Social Value Bank (Trotter et al., 2014)

Value of increased confidence for adults



Value for attending regular clubs.


Disabled people have become regular volunteers Value of regularly volunteering 3,199.00 HACT's Social Value Bank (Trotter et al., 2014)


Economic cost of bullying prevention

The social value of bullying prevention.docx

50,800.00 (Beckman and Svensson, 2015)


Value of frequent moderate exercise



Value for good overall health 19,913.00 HACT's Social Value Bank (Trotter et al., 2014)

Disabled people are able to manage their health conditions better, and being more physically active has helped prevent secondary conditions.

Consultation with Doctor

181.00 CSP Cost Calculator (CSP, 2016)

Appointment with allied health professional

58.48 BCUHB Finance team

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Outcome (all values are per person, per year)

Financial Proxy Value (£) Source

Family members have increase their levels of physical activity. They feel healthier and fitter. Family member also have improved mental health and wellbeing.

Value of frequent moderate exercise


Value for good overall health 19,913.00 HACT's Social Value Bank (Trotter et al., 2014)

Value for relief from depression/ anxiety


Family members are going out and socialising more, making new friends and/or developing a support network

Value for attending regular clubs 1,875.00 HACT's Social Value Bank (Trotter et al., 2014)

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4.0 Results

4.1 (Stage 5: Calculating the SROI)

Calculations were completed using the Excel spreadsheet devised by the SROI Network (2012) for

both impact maps; participants 1-10 (Appendix 1) and participants 11-13 (talented athlete; Appendix

2).

The impact was calculated individually for each outcome:

(Financial proxy value) x (quantity) = total value

(Total value) – (dead-weight) – (attribution) = impact

Example:

Outcome = disabled children report increased confidence (participants 1-10; Appendix 1).

(Financial proxy value) £9,455 x (quantity of people reporting increased confidence) 3 = (total value)

£28,365

(Total value) £28,365 – (Dead-weight) 5% - (attribution) 20% = (impact) £21,557.40

The impact of each outcome was then calculated for the projected duration that they were

anticipated to last for. For each outcome, the designated amount of drop-off (10%) was subtracted

from the impact value each year that the outcome was projected to last for. Drop-off was not

subtracted for year one, as drop off relates to future time periods (The SROI Network, 2012).

Example:

Outcome = disabled children report increased confidence (participants 1-10; Appendix 1).

Duration = 3 years

Impact year 1 = £21, 557.40 (no drop-off)

Impact year 2: (Year 1 impact) £21,557.40 – (drop-off) 10% = £19,401.66

Impact year 3: (Year 2 impact) £19,401.66 – (drop-off) 10% = £17,461.49

The impact for all outcomes were totaled for each year to arrive at an overall impact value for each

year (Table 4.1). The impact totals for years 4 and 5 are lower as the majority of outcomes were

projected to last for a duration of 3 years only.

20

Table 4. 1: Impact totals for each year that the HDSP is anticipated to create outcomes (participants 1-10; Appendix 1).

Year Total impact

Year 1 £317,925.45

Year 2 £285,892.90

Year 3 £257,135.61

Year 4 £28,556.84

Year 5 £25,618.83

The next step was to calculate the present value by adjusting the impact value for each year in order

to reflect the ‘time value of money’ (The SROI Network, 2012); this discounting process recognises

that money may be worth more to people if paid now rather than in the future, due to risks of not

being paid, or opportunity costs to invest the money (The SROI Network, 2012). A discount rate of

3.5% was applied to the projected values for years 1-5, as recommended as the basic rate for public

sector interventions (HM Treasury, 2015) (Table 4.2). All present values were totalled to arrive at a

total present value (Table 4.2).

Table 4. 2: Present value for each year that the HDSP is anticipated to create outcomes (participants 1-10; Appendix 1).

Year Total Impact Present Value

Year 1 £317,925.45

£307,174.35

Year 2 £285,892.90

£266,884.08

Year 3 £257,135.61

£231,921.59

Year 4 £28,556.84

£24,885.63

Year 5 £25,618.83 £21,570.37

Total Present Value:

£852,436.02

The SROI ratio was calculated: Total present value / Value of inputs.

21

The SROI ratio shown on the impact maps (Appendix 1 and 2) are for the participants included in

each map only. Appendix 1 shows the SROI ratio if all of the project investment was spent on

participants 1-10; Appendix 2 shows the SROI ratio if all the project investment was spent on the

three talented athletes, participants 11-13. In order to calculate the SROI for the whole project (n =

282) the total present value was divided by the number of participants to arrive at a mean present

value for one individual (Table 4.3).

Table 4. 3: Present value per participant

Total present

value

Mean present value for one individual

(total present value/number

participants)

Participants 1-10 £852,436.02 (total present value / 10 participants)

£85,243.60

Participants 11-13

(talented athletes)

£592,547.58 (total present value / 3 talented

athletes) £197,515.86

To arrive at a present value for all disabled people engaged with the HDSP (n=282), the mean

present value per for one individual was multiplied by the number of disabled people who were

actively engaged in the HDSP. The mean present value for a talented athlete (participants 11-13)

(£197,515.86) was found to be much higher than the mean present value for a disabled person who

was not considered to be a talented athlete (‘normal population’, participants 1-10) (£85,243.60).

Due to the significantly higher mean present value, the three talented athletes were excluded from

the overall population numbers during calculation of the present value for the whole population,

therefore n=279 (n=282 – 3 talented athletes). The mean present value for participants 1-10

(£85,243.60) was used to calculated the total present value as participants 1-10 were reflective of

the wider HDSP population. The mean present value was multiplied by n=279. The total present

value for the talented athletes was added afterwards to arrive at a total present value for the HDSP

(Table 4.4).

The SROI ratio was then calculated: Total present value HDSP/ total investment (Table 4.4).

22

4.2 The SROI ratio

The SROI ratio for the HDSP is £124/ £1. For every £1 invested in the HDSP there is a social value

return of £124 from outcomes identified by disabled people and their family/friends/carers.

Table 4. 4: SROI ratio

As recommended by the guidance, a sensitivity analysis was conducted on the SROI in order to

assess the changes in SROI ratio if some of the assumptions made were changed (The SROI Network,

2012). The SROI was recalculated for a scenario that each outcome would last for one year only

(Table 4.5). If each outcome lasted for a duration of 1 year, the SROI ratio for the HDSP would be

£44.56/£1.

The SROI was recalculated for a scenario that not all disabled people who engaged with the HDSP

remained physically active for a period long enough to achieve outcomes. Research on the National

Exercise Referral Scheme (NERS), an exercise on prescription initiative, reported a 56% drop-out rate

(WAG, 2010). The SROI figures were adjusted to reflect a 56% drop out rate (WAG, 2010) in the

number of physically active disabled people, resulting in a population of n=123 (Table 4.6). If 56% of

the disabled people who initially engaged in the HDSP did not remain active and therefore did not

result in any social return, the SROI ratio for the HDSP would be £56.34/£1.

Total present value (Participants 1-10)

£852,436.02

Mean present value for one individual (total present value/10 participants) £85,243.60

Total present value for all disabled people engaged in HDSP (excluding talented athletes) (Mean present for one individual x number of active disabled people) (£85,172.72 x 279)

£23,782,964.40

Total present value for talented athletes (Participants 11-13)

£592,547.58

Total present value for HDSP (Total present value all disabled people + total present value talented athletes)

£24,375,511.98

Total investment

£196,620.98

Social Return (per £ invested) (Total present value for HDSP/ total investment)

£123.97

23

Finally, the SROI was recalculated for a worst case scenario that there was a 56% drop-out rate

(WAG, 2010), and durations lasted for one year only (Table 4.7). With a drop-out rate of 56% and

durations of outcomes set at 1 year, the SROI ration for the HDSP would be £23.48/£1.

Table 4. 5: SROI ratio: adjusted for outcome durations of 1 year

Table 4. 6: SROI ratio: adjusted for a 56% drop-out rate in the number of physically active disabled people

Total Present Value (Participants 1-10) assuming outcome durations of 1 year

£307,174.35

Mean present value per participant (Total present value/10 participants)

£30,717.44

Total present value for all disabled people engaged in HDSP (excluding talented athletes) (Mean present value per participant x number of active disabled people) (£30,690.71 x 279)

£8,570,165.76

Total present value for talented athletes (Participants 11-13) assuming outcome durations of 1 year

£190,737.00


£8,760,902.76

Total investment

£196,620.98


£44.56

Total Present Value (Participants 1-10)

£852,436.02

Mean present value per participant (Total present value/10 participants)

£85,243.60

Total present value for all disabled people engaged in HDSP (excluding talented athletes) assuming a drop-out rate of 56% (279 – 56% = 123 people) (Mean present value per participant x active disabled people) (£85,172.72 x 123)

£10,484,962.80

Total present value for talented athletes (Participants 11-13)

£592,547.58


£11,077,510.38

Total investment

£196,620.98


£56.34

24

Table:4.7: SROI ratio: adjusted for a 56% drop-out rate in the number of physically active disabled people, with outcome duration of 1 year

The aggregate social value created by the HDSP (for the three-year pilot period) is projected to be

approximately £24,375,512. The HDSP’s SROI ratio of £124/ £1 implies that, for every £1 invested in

the HDSP, £124 of social value is created for society in terms of the physical and mental health and

wellbeing benefits for disabled people, and their family/friends/carers.

Total Present Value (Participants 1-10) assuming outcome durations of 1 year

£307,174.35

Mean present per participant (PV/10)

£30,717.44

Total present value for all disabled people engaged in HDSP (excluding talented athletes) assuming a drop-out rate of 56% (279 – 56% = 123 people) (Mean present value per participant x active disabled people) (£30,717.44 x 123)

£3,778,245.12

Total present value for talented athletes (Participants 11-13) assuming outcome durations of 1 year

£190,737.00


£3,968,982.12

Total investment

£196,620.98


£20.19

25

5.0 Discussion Improvements in physical fitness through the HDSP were associated with a reduction in health care

interventions with allied health professionals, in this incidence physiotherapy and dietetics.

Participants who have reduced the level of intervention they required from physiotherapy reported

that this was directly due to increased levels and physical activity and improved physical fitness, but

they also reported that they felt more motivated to do the exercises they had been prescribed by

their physiotherapist in order to improve in their chosen sport. The total present value of the

reduction of allied health professional appointments was estimated to be £106,240 for the project,

equating to a mean value of £376 saving per disabled person who engaged in the HDSP. As the SROI

analysed 27 months of project signposting activity, the value of reduced allied health professionals

appointments equates to £47,218 per year in direct saving to NHS services. It is anticipated that

there will be much more additional savings to the NHS in the future that could not be captured at

this stage of the HDSP. Increased physical activity greatly reduces the risk of developing over 25

health conditions and chronic diseases (Booth et al., 2012), and improves mental health and

wellbeing (WHO, 2010). The impact of these benefits to NHS services may not be seen for many

years, and assessing the impact may not be possible.

A common theme found amongst a number of the disabled children participating in the SROI was

that they were no longer victims of bullying since being signposted via the HDSP. The three children

had physical impairments and attend mainstream education. Research indicates that children in

mainstream and special school education indicated that disabled children were 2 to 4 times more

likely to be bullied than non-disabled children (Hartley et al, 2015). Being bullied as a child has been

shown to have potential long-term implications for victims (Gladstone et al., 2006; Vanderbilt and

Augustyn, 2010; Wolke et al., 2013). Victims of childhood bullying are at increased risk of poorer

health and wellbeing, reduced wealth, and worse social relationships in adulthood (Wolke et al.,

2013). Victims of bullying in childhood were also shown to have greater risks of mental health

problems, including increased levels of depression, anxiety, and aggressive behaviours over the life

span (Gladstone et al., 2006; Vanderbilt and Augustyn, 2010; Wolke et al., 2013). Victims of bullying

in childhood have been reported to result in increased criminal offences in adulthood, and increased

levels of drug and alcohol abuse (Ttofi et al., 2012), and higher incidence of self-harm and suicide

(Wolke et al., 2013). The SROI has demonstrated that involvement in physical activity (including

sport) can be a positive intervention to stop bullying in disabled children, and help disabled children

make friends, potentially having a significant positive impact on their futures

26

For additional discussion on the social values created by the HDPS and a review of the literature

please see additional document.

Discussion.docx

5.1 Limitations The researcher works in the role of the Health Disability Sport Officer (HDSO) for the HDSP. The role

of the HDSO is to lead on the HDSP work within BCUHB, including delivering the up-skilling training

to health professionals. The researcher has a vested interest in the HDSP and seeks to gain from

potential future employment if the HDSP is shown to be an effective model that could be rolled out

to other health boards (Finlay, 2002). It is recognised that this introduces a conflict of interest and

risk of bias (Corbin and Strauss, 2014). However, the HDSO has not been directly involved in the

pathway of any of the disabled people who have been signposted from Health to physical activity

(including sport) opportunities; there has only been previous engagement with the three talented

athletes as they attended a Ministerial event in BCUHB in 2015. The stakeholders who were involved

in the interviews were therefore unaware of the HDSO role in the HDSP, and were unaware of the

future implications of the research for the researcher.

Ten participants (disabled people) (participants 1-10), and the three talented athletes took part in

the interviews. There was no representation for people who are Deaf/hard of hearing in the

participants who were interviewed. The number of people who are Deaf/hard of hearing in the

HDSP population who engaged in physical activity (including sport) was small (n=5). Engagement was

sought from people who are Deaf/hard of hearing, however participation in the interviews was

declined by the participants. As no people who are Deaf/hard of hearing were included in this SROI,

and the potential differences they experience in motor skills and health related quality of life, it may

not be appropriate to generalise the outcomes and the social value (or present value per participant)

to somebody who is Deaf/hard of hearing, as the outcomes that they may experience may differ to

those involved in this study. Future studies should look to include people who are Deaf/hard of

hearing. Due to the limitation of time, the sample size was small (n=10 + n= 3 talented athletes).

Using a larger sample size would increase the internal validity of the results by increasing the

likelihood that the sample is reflective of the population being studied; this SROI is therefore limited

by the small sample size. Future studies should look to examine a larger proportion of the

population to strengthen to reliability and validity of the results.

27

A number of stakeholders were omitted from the SROI due to capacity (Appendix 3). Excluded

stakeholders included LA’s, NGB’s, the National Exercise Referral Scheme, sport clubs/session, and

3rd sector partners. The outcome of increased brand awareness for DSW was also excluded during

the study due to the complex nature of valuing this outcome. By excluding a number of stakeholders

a number of outcomes of the HDSP may have potentially been missed, and the impact of the HDSP,

including the SROI ratio, may have been underrepresented. Future studies could investigate the

impact of the HDSP on the excluded stakeholders.

5.3 Recommendations Future study of the HDSP should include longitudinal data, evaluating participants from the initial

point of signposting, evaluate how outcomes change for them over time, and establishing drop-out

rates. Standardised outcome measures could also be used to evaluate health and well-being

outcomes, additional to the interviews which remain important for capturing what outcomes are

important to the stakeholder. For future studies the reliability would also be strengthened with

larger participant numbers, seeking to include disabled people from all impairment groups. To

improve the accuracy of investment value, DSW development officers should record the amount of

time they spend delivering work for the HDSP. Future studies should also look to examine the impact

on other stakeholders, such as LAs, NGBs and third sector partners to expand the evidence of the

impact of the HDSP.

This SROI only included disabled people who had actively engaged in physical activity (including

sport) secondary to being signposted via the Heath Disability Sport Pathway. Future studies could

include disabled people who failed to engage, or only partially engaged, as these groups could

provide important information to improve future projects. Including disabled people who failed to

engage, or only partially engaged, in physical activity (including sport) after being signposted via the

Health Disability Sport Pathway, could help identify why disabled people fail to engage in physical

activity (including sport), as well as identifying potential strategies to reduce the barriers to

engagement.

28

6.0 Conclusion

The Health Disability Sport Partnership (HDSP) is a joint project between Betsi Cadwaladr University

Health Board (BCUHB) and Disability Sport Wales (DSW), supported by a Sport Wales grant. The

HDSP is the first project in the UK with a Health Board and a sport body working in partnership.

Through a process of up-skilling health professionals, and supporting them to signpost disabled

people towards physical activity (including sport) opportunities in the community, the aim of the

HDSP is to improve the health and wellbeing of disabled people in North Wales.

Two-hundred and eighty-two disabled people have been signposted from Health to (disability) sport

and activity engaged in physical activity (including sport) opportunities. Engaging in physical activity

(including sport) has improved the physical and mental health and wellbeing of disabled people.

Disabled people have reported outcomes including increased confidence, increased social

interaction and inclusion, and feeling happier. Some disabled children report no longer being bullied

since doing well in sport. Improvements in health and wellbeing have resulted in some disabled

people reducing the amount of contact they have with allied health professionals, including

physiotherapists and dieticians. Some family members of the disabled children have report

improvements in their own levels of physical activity secondary to their family members’

involvement, resulting in improvements in their own health and wellbeing.

Investing in the HDSP, a partnership intervention that supports health professionals in promoting

physical activity (including sport) to disabled people and signposting them to opportunities in their

local communities, is cost effective, as every £1 invested has resulted in £124 of added social value.

Social value has been created through improvements in the physical and mental health and

wellbeing of disabled people, and at times that of their family members. The HDSP has

demonstrated that Health and (disability) sport can successfully and cost-effectively work in

partnership to improve the health and well-being of disabled people through increased physically

activate (including sport). Health and (disability) sport working in partnership offers a cost effective

model to contribute to reducing the physical inactivity burden.

29

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31

Appendix 1: Impact (participants 1-10)

32

Appendix 2: Impact map (talented athletes, participants 11-13)

33

Appendix 3: Stakeholders and their reason for inclusion/ exclusion in the SROI

Stakeholder Reason for inclusion

Sport Wales Provided the £150,000 grant investment in the HDSP making them a key stakeholder without whom the project may not have been realised.

Disability Sport Wales (DSW) Joint lead on delivering the project alongside BCUHB. The HDSP aims are synonymous with the mission of DSW, to get everyone disabled person hooked on sport for life (DSW, 2014). DSW are a key stakeholder in supporting disabled people through the Health Disability Sport Pathway and supporting inclusive physical activity/ sport opportunities in the community. Without the involvement of DSW the HDSP could not continue.

Betsi Cadwaladr University Health Board BCUHB)

Joint lead on delivering the project alongside DSW. The aim of the HDSP is to develop a strong and sustainable relationship between BCUHB and DSW through a process of up-skilling health professionals. The outcome of this new relationship is to be an increase in the number of physically active disabled people across North Wales following signposting from Health towards community opportunities. BCUHB are therefore a key stakeholder without whom the change would not occur.

Disabled people The aim of the HDSP is to increase the number of physically active disabled people in North Wales. Disabled people are therefore a key stakeholder and those expected to experience most change as a result of the project.

Family/friends/carers of disabled people

Families/ friends/ carers of disabled people play an important role in the HDSP. Family/friends/carers may provide a vital role in supporting a disabled person to access physical activity/ sport opportunities. Families/ friends/ carers are also anticipated to potentially experience change themselves as a result of disabled people becoming physically active/ playing sport. Due to the important role of family/friends/carers they are to be included in the study.

Excluded Stakeholder Reason for exclusion

Local Authorities (LAs)

Local authorities are responsible for supporting, providing and developing physical activity and sport opportunities in their communities, creating an environment that encourages healthy active lifestyles (Welsh Local Government Association, no date). The Sport Development Officers (identified on the Health Disability Sport Pathway, figure 1.1) are located within each Local Authorities’ Sport Development Team (or similar). The Sport Development Officers play a vital role in the HDSP, providing the information and support to disabled people to make the transition from Health to physical activity/ sport opportunities in the community.

34

Excluded Stakeholder Reason for exclusion

Local Authorities (LAs) (continued)

Local Authorities are an important stakeholder in the HDSP and it is anticipated that they will experience a number of outcomes secondary to the HDSP. Outcomes include increased membership in leisure centres, development of additional opportunities and supporting the embedding of inclusion messages. Due to the large and varied set ups of LAs it is anticipated that this analysis is outside of the score of this SROI due to the limited resources. A number of the anticipated outcomes will be captured in other areas, such as the health and wellbeing of communities.

National Governing Bodies (NGBs)

National Governing Bodies are a key stakeholder for DSW in relation to the DSW Insport programme and vision for disability sport in Wales. Nation Governing Bodies will be impacted by the HDSP though increased membership and supporting in the development of opportunities as latent demand is identified. The impact of the HDSP is expected to be relatively small in the scale of the NGBs work, and examining the impact would be challenging due to the large number of NGS, they are therefore excluded from this SROI due to capacity.

Sport/ PA clubs/ sessions The aim of the partnership is to increase the number of physically active disabled people in North Wales. Via the Health Disability Sport Pathway disabled people will be signposted to physical activity/ sport opportunities in the community, in the form of clubs, sessions and leisure facilities. It is evident that membership will increase secondary to the HDSP, however this is on a relatively small scale compared with the overall active population in North Wales at this stage. Membership increases in some clubs/ sessions is anticipated to be greater than in others, and therefore the impact on individual clubs/ sessions will vary significantly. Assessing the impact on all clubs/ sessions/ leisure centres would be a large task with potentially small scale social values and has therefore been excluded from this study due to capacity.

National Exercise Referral Scheme (NERS)

The National Exercise Referral Scheme (NERS) is a Welsh Assembly Government (WAG) funded scheme aimed at improving the lives of people across who are sedentary and experiences a chronic health condition through physical activity (Welsh Local Government Association, no date b). The National Exercise Referral scheme links with the HDSP as both offer opportunities for disabled people to be physically active. The relationship with NERS is shown in the pathway (figure 1.1). The impact for NERS in working alongside the HDSP is deemed to be small in the scale of their activities and they have therefore been excluded from the SROI.

3rd sector groups A wide range of 3rd sector groups are considered to be stakeholders of the HDSP. Third sector stakeholders include charities and organisations that work with disabled people. There are a large number of 3rd sector stakeholder, and the impact of the HDSP is deemed to be small in the scale of their activities.

35

Appendix 4: Outcomes for each participant 1= The outcome occurred; 0= The outcomes did not occur. For the outcomes of fewer appointments with health professionals, the number recorded is the reduction in appointments over a 1-year period based on the participant’s previous level of contact with the health professional.

36

Appendix 5: Attribution Participant Attribution (%

attributed to other factors)

Rationale

Participant 1 10% Minimal participation in physical activity/ sport prior to HDSP; no previous participation outside of school in any active hobbies. Would participate in some level of physical education (PE) in school, however not fully included.

Participant 2 30% Participating in physical activity/ sport in PE and within physiotherapy rehabilitation programmes since ages 10. Since signposting to the HDSP has taken up a number of sports and begun competitive opportunities.

Participant 3 10% Minimal participation in physical activity/ sport prior to HDSP. Had attended a few sport sessions, however inconsistently and reported not enjoying the opportunities prior to HDSP.

Participant 4 0% No participation in physical activity/ sport prior to HDSP. Participant 5 50% Participating in a number of physical activity/ sport and other community opportunities prior to HDSP. Since

signposting has begun a range of additional physical activity/ sport opportunities and reports these have made a difference to their outcomes.

Participant 6 0% No participation in physical activity/ sport prior to HDSP. Reports being socially withdrawn prior to HDSP. Participant 7 60% Participating in physical activity/ sport and other community opportunities prior to HDSP through involvement with 3rd

sector partner. Since signposting has begun additional physical activity/ sport opportunities. Participant 8 60% Participating in physical activity/ sport opportunities prior to HDSP. Since signposting has begun two new physical

activity/ sport opportunities and reports these have made a difference to their outcomes. Participant 9 0% Not participating in physical activity/ sport prior to HDSP. Participant 10 10% Minimal participation in physical activity/ sport prior to HDSP. Participation in swimming with family prior to HDSP,

however Mum identifies the outcomes in relation to swimming lessons following HDSP signposting. Participant 11 10% Minimal participation in physical activity/ sport prior to HDSP; no previous participation outside of school in any active

hobbies. Would participate in some level of physical education (PE) in school, however not fully included. Participant 12 10% Minimal participation in physical activity/ sport prior to HDSP; no previous participation outside of school in any active

hobbies. Would participate in some level of physical education (PE) in school, however not fully included. Participant 13 10% Minimal participation in physical activity/ sport prior to HDSP; no previous participation outside of school in any active

hobbies. Would participate in some level of physical education (PE) in school, however not fully included. Total = 260%. Divided by 13 participants = 20% average attribution