Football Fans in Training (FFIT): a randomized controlled trial of a gender sensitised weight loss and healthy living programme delivered to men aged 35-65 by Scottish Premier League (SPL) football clubs

Timing of measurements

Outcomes were measured at baseline, 12 weeks and 12 months according to the measurement schedule shown in Table 3. Demographic characteristics were measured at baseline. Copies of the questionnaires are available on request.

The fieldwork team

Data were collected by teams of fieldworkers, educated at least to degree level. Each team in each measurement session had a designated team leader and a fieldwork nurse responsible for blood pressure measurement. Staff were trained to standard measurement protocols by experienced research and survey staff in the Medical Research Council (MRC)/CSO Social and Public Health Sciences Unit. Training took place over 2 days and emphasised strict adherence to protocol to minimise detection bias. Field staff wore T-shirts branded with FFIT research logos at all measurement sessions. Figure 1 illustrates the measurement team spirit that was encouraged.

FIGURE 1.

Fieldwork team arriving at a 12-month in-stadia measurement session.

Baseline data

All men who had registered an interest in FFIT prior to the baseline measures in their club (and whose self-reported BMI and date of birth suggested they were eligible to take part) were sent a letter of invitation to attend an appointment at an in-stadia measurement session at their club. They were asked to confirm or rearrange their appointment date and time by e-mail or telephone. Eligibility criteria were confirmed through objective measurement of height and weight.

Outcome measurement

Measurement protocols: objectively measured outcomes

Weight (kg) was recorded using electronic scales (Tanita HD 352™, Middlesex, UK) with participants wearing light clothing, no shoes and with empty pockets. Height (cm) was measured without shoes using a portable stadiometer (Seca Leicester™, Chino, CA, USA). Waist circumference was measured twice (three times, if the first two measurements differed by 5 mm or more) and the mean of all recorded measurements calculated. Resting blood pressure was measured using a digital blood pressure monitor (Omron HEM-705CP™, Buckinghamshire, UK) by a fieldwork nurse. All equipment was calibrated prior to fieldwork.

Measurement protocols: outcomes based on self-report

Participants completed self-administered questionnaires. Fieldworkers assisted any participant who appeared to have literacy problems and, whenever possible, checked questionnaires before the participant left the measurement session to minimise missing data.

Measurement of adverse events

An adverse event was defined as any injury or newly diagnosed health condition (e.g. high blood pressure, diabetes mellitus) that occurred while a man was registered on the FFIT programme, whether or not it was related to his participation in FFIT. A serious adverse event was defined as an adverse event that included at least one of the following: an event requiring hospitalisation or prolonged medical attention, an event that is immediately life-threatening (such as a cardiac arrest), a fatal event. Any serious adverse events were reported immediately to the chairperson or the Trial Steering Committee. A report of all adverse events was provided at every meeting of the Data Monitoring and Ethics Committee.

At the baseline and 12-week measurements, men were given a pre-paid postcard and details about how to report any adverse events. In addition, coaches (and the researchers who conducted the observations of the programmes) were also asked to report any adverse events that came to their attention. At the 12-month measurements, all participants were asked whether or not they had experienced any adverse events since their last contact with the research team.

All adverse events were categorised by a member of the research team according to their severity and whether or not they were related to participation in FFIT. When possible, serious adverse events and any adverse events for which relatedness to participation in FFIT was not clear were followed up by a telephone call to the participant. Adverse events that occurred before the baseline measurement period or after the August to December 2012 delivery of FFIT had started were not recorded.

Physical activity

Following standard procedures described in the IPAQ scoring protocol,70 we calculated and reported sedentary time, and metabolic equivalent (MET) minutes per week from self-reported walking, vigorous and moderate exercise and a measure of total MET minutes.

Diet

We used the adapted Dietary Instrument for Nutrition Education (DINE) questionnaire to collect data on self-reported frequency of intake of different food types and the dietary question referred to the last 7 days. The full DINE questionnaire can take a considerable time to complete and can be difficult for some participants. Recent evidence on dietary factors influencing weight gain highlights items not included in the tool (e.g. sugary drinks); therefore, we adapted the DINE questionnaire to reduce participant burden and capture information on additional relevant markers. From these data, we calculated a fatty food score, a fruit and vegetable score and a sugary food score.

Alcohol intake

Following Emslie et al. ,66 we converted responses to the 7-day recall diary for alcohol to standard units equivalent to 8 g of pure alcohol (half a pint of ordinary beer, lager or cider, one small glass of wine and one measure of spirits each contain 1 unit of alcohol). We calculated total number of units reported in the last week.

Psychological outcomes

Scores for both the RSE scale and the short form of the PANAS were normalised so that values could be calculated for participants who had missed one or two items contributing to each scale. The PANAS-normalised scale scores range from 1 to 5, with higher scores indicating higher negative affect and higher positive affect. Similarly, higher scores on the RSE scale (normalised range 0–3) indicate better self-esteem.

Scores on QoL using the SF-12 were summarised scores for mental and physical health following standard algorithms. 69

Resource use and costs

The cost calculation included the resources required to manage and run the programme (Table 16), as well as self-reported health-care resource use and GP-prescribed medications.

The principal part of the intervention cost is the £3544 cost of running the intervention in each club. This covers all the clubs costs involved in providing the intervention, including club-level management, staff time and venue hire and club-based recruitment activities. In addition, the SPL Trust management cost of £5000 per season covers the cost of training the coaches, the SPL-level management and co-ordination of the intervention across the clubs and marketing and additional recruitment. In addition to these costs, there are a number of resources required to provide the intervention. These include equipment to measure the height, weight, blood pressure and waist circumference of the participants, plus a display plate (Eatwell Plate)47 to illustrate the appropriate proportion of food stuffs to each from the five main food groups and portion sizes, and materials to deliver the intervention (including a pedometer and booklet for each participant and booklets for coaches). Each club was assumed to receive one complete set of equipment per year (with the exception of the waist measures of which each club was assumed to be provided with four sets per year), with the assumption that each club provided the intervention twice in each year. The materials were assumed to be provided per participant/coach, with the addition of a few spares. All resources required to deliver the intervention were costed according to the price paid to purchase them at the start of the trial (September 2011). Overall, the cost of providing the intervention in all SPL clubs was estimated to be £61,741, equivalent to £165 per FFIT participant.

In addition to the intervention costs, data were collected at each time point (baseline, 12 weeks and 12 months) from each participant relating to the number and type of any NHS resources used in the preceding 12-week period. This included visits to the GP, practice nurse or physiotherapist and any attendances at accident and emergency. Unit costs for each of these visits were taken from Personal Social Services Research Unit (PSSRU) 2011/12 (Table 17). 75

Data were also collected at each time point relating to any inpatient stays and outpatient appointments in the preceding 12-week period. Unit costs were taken from Information and Statistics Division Scotland tariffs for 2012 and, when necessary, NHS reference costs for 2011/12. 76–78

Finally, self-reported data were collected at each time point regarding GP prescriptions of antidepressants, painkillers, asthma, pain gels/creams, anti-inflammatories and sleeping tablets in the preceding 12 weeks. These medications were identified as the most likely to be affected by the intervention and were pre-specified on the advice of our clinical advisor; diabetes mellitus medication was not included in this list it was not expected to be affected by the intervention over the within-trial period. Other prescribed medications were also excluded from the analysis. In addition, because the analysis used an NHS and Personal Social Service perspective, we excluded over-the-counter medications. Medications were costed using unit costs for a typical prescription from the British National Formulary76 (Table 18).

In the economic evaluation, as in the main analyses, we did not take account of missing resource use data. For NHS resource use, the proportion of missing responses across all time points ranged from 1.3% to 2.3% across the different categories. The proportion of missing responses for medications was less than 2% across the different categories.

We used 12 weeks as the time frame over which participants were asked to recall their resource use, as longer periods have potentially been found to be subject to greater recall bias. 79

Table 19 shows that at baseline comparison group participants had higher inpatient costs.

Outcome measurement

The initial outcome measure for the within-trial analysis is the number of men achieving and maintaining the 5% weight reduction over 12 months, as measured at the 12-month follow-up.

In addition, self-report SF-12 data were collected at baseline, 12 weeks and 12 months. These values were converted into utility weights using the Short Form questionnaire-6 Dimensions algorithm. 75,80,81 Table 20 details the mean utility score associated with FFIT and no active intervention at each time point (baseline, 12 weeks and 12 months) with and without adjustment for missing data.

The area under the curve method was used to determine the overall utility for each participant over the trial period. 82 This provides a utility weighting, similar to a QALY, but measured over a 12-month period. Change from baseline has been used to account for differences in the average baseline values between the intervention and comparison groups, to give an estimate of the utility change over the year for each participant.

Analysis

The within-trial effectiveness is presented both in terms of the number of men achieving and maintaining a 5% weight reduction over 12 months, and QALYs gained over 12 months. The individual-level data on achieving and maintaining a 5% weight reduction are summed to provide the number attaining this outcome in each group, while the individual-level QALY data are averaged within each group (intervention, comparison). Differences in the average utility change between the intervention and comparison groups give an estimate of the QALYs gained from the intervention, assuming no differences beyond the 12-month follow-up period. Effect results are presented as mean values with CIs.

The cost associated with each individual is determined as the sum of the per participant intervention cost (for the FFIT intervention group), plus the cost of NHS resource use, plus any medication cost. The individual costs are averaged within each group to give an estimate of the average cost associated with the FFIT intervention and the comparison groups. The incremental cost associated with the FFIT intervention is the difference between the average cost of the FFIT intervention group and the average cost of the comparison group. Cost results are presented as mean values with CIs.

The incremental cost-effectiveness associated with the FFIT intervention is then presented in terms of incremental cost per additional individual achieving and maintaining the 5% weight reduction over 12 months and the incremental cost per QALY gained. Discounting of costs and outcomes is not required owing to the 12-month time frame of the within-trial analysis.

The uncertainty surrounding the estimates of incremental costs, incremental effects and cost-effectiveness was investigated through the use of bootstrapping with 10,000 iterations. The uncertainty surrounding the cost-effectiveness results are presented on the cost-effectiveness plane and summarised on a cost-effectiveness acceptability curve.

HELP model

The objective in developing HELP was to build a model capable of undertaking economic evaluation to inform Scotland’s approach to primary prevention (two unpublished articles by Lewsey JD, Lawson KD, Ford I, Fox K, Ritchie LD, Tunstall-Pedoe H, et al. , University of Glasgow, 2014). Predictions of life expectancy from the model closely match those published in national life tables (two unpublished articles by Lewsey JD, Lawson KD, Ford I, Fox K, Ritchie LD, Tunstall-Pedoe H, et al. , University of Glasgow, 2014). The structure of the state transition model is shown in Figure 7. Using the nine ASSIGN97 risk factors as parameter inputs, the HELP model predicts life-years gained, QALYs and lifetime costs.

FIGURE 7.

Structure of the state transition model. The numbers in brackets refer to Equations 1–7. CBVD, cerebrovascular disease.

The numbers in brackets in Figure 7 refer to the following equations:

Life expectancy

Individuals are assumed to be free from CVD at the point that they enter the model. Each individual is allocated a risk score based on their ASSIGN97 risk variables. These variables include age, gender, family history of CHD and stroke, postcode (linked to SIMD), diabetes mellitus, systolic blood pressure, number of cigarettes smoked per day, total and HDL cholesterol. It is this individual risk score that determines the risk of experiencing an initial event [non-fatal CHD, non-fatal cerebrovascular disease (CBVD), fatal CVD and fatal non-CVD] (see Equation 1). Individuals subsequently transit into one of four ‘competing’ events, non-fatal CHD hospitalisation, non-fatal CBVD hospitalisation, death from CVD and death from non-CVD causes. Survival analysis was used to model the cause-specific hazards of these competing first events. As not all SHHEC participants had experienced a first event by the end of follow-up, a parametric approach was used to extrapolate and provide estimates of the total remaining life expectancy. The predicted cumulative incidence of events was calculated from the cause-specific hazards and the probability of surviving from any of the competing events at a given time. Those individuals for whom the initial event is non-fatal will experience a fatal event at some point in the future, the risk of which is a determined by a combination of their age at initial event, family history and SIMD (see Equation 2; two unpublished articles by Lewsey JD, Lawson KD, Ford I, Fox K, Ritchie LD, Tunstall-Pedoe H, et al. , University of Glasgow, 2014). Each individual’s life expectancy is determined as the sum of the time to the initial event plus the time to the fatal event (for those whose initial event is not fatal).

Quality-of-life adjustment

Quality-of-life adjustment is made in three ways as an individual transits through the model to account for background morbidity (see Equation 3), impact of experiencing a first non-fatal CVD event (see Equation 4) and impact of experiencing subsequent non-fatal CVD events (see Equations 4 and 5). These are then combined to generate overall quality-adjusted life expectancy (two unpublished articles by Lewsey JD, Lawson KD, Ford I, Fox K, Ritchie LD, Tunstall-Pedoe H, et al. , University of Glasgow, 2014).

For background morbidity, Scottish Health Survey (SHeS) 200398 cross-sectional survey data were used to generate a preference-based weighted HRQoL score for each age group (Table 22). 75 These scores were used to weight survival probabilities in all arms of the model (two unpublished articles by Lewsey JD, Lawson KD, Ford I, Fox K, Ritchie LD, Tunstall-Pedoe H, et al. , University of Glasgow, 2014).

These utility scores were then adjusted to account for the experience of non-fatal events using utility decrements (Table 23) also estimated using data from SHeS 2003 (two unpublished articles by Lewsey JD, Lawson KD, Ford I, Fox K, Ritchie LD, Tunstall-Pedoe H, et al. , University of Glasgow, 2014).

Lifetime health service costs

Individuals accumulate health service costs as they transit through the model. These costs are a mixture of age-related costs (associated with increasing comorbidities) and costs associated with the experience of specific events. The linked SHHEC and SMRs data set provides information on all hospital episodes (two unpublished articles by Lewsey JD, Lawson KD, Ford I, Fox K, Ritchie LD, Tunstall-Pedoe H, et al. , University of Glasgow, 2014). These episodes were costed using method 1 in Geue et al. 99 to generate annual age-related health-care costs. Costs accumulate in the period prior to the initial event (see Equation 6) and following a non-fatal CVD event (see Equation 7).

More details on the HELP model are available on request.

Employing the HELP model for the longer-term analysis of Football Fans in Training

Within the longer-term analysis, the HELP model is used simply as a means to extrapolate the trial results. The model utilises individual sampling that enables us to generate estimates of long-term cost and outcomes for each individual within the trial population with which to supplement the trial data. This allows us to estimate the longer-term costs and outcomes associated with the FFIT intervention compared with no active intervention. As such, the model is populated with the 12-month data concerning the individual participants’ risk factors. These data are used to generate a post-intervention risk score from which the model generates a post-intervention estimate of life expectancy, a post-intervention estimate of QALYs as well as an estimate of cumulative lifetime hospital costs for each participant. The impact of the FFIT intervention is based on the differences between these estimates for the participants who received the FFIT intervention and those who were part of the waiting list comparison group.

It was necessary to make a number of assumptions and adjustments in order to use the HELP model within the longer-term FFIT analysis. All but three of the nine ASSIGN97 risk factors were collected for participants at baseline, 12 weeks and 12 months. The remaining three risk factors (family history of CHD/stroke, total cholesterol and HDL cholesterol) were not available for the participants. In order to generate an ASSIGN score these risk factors were imputed for each participant using information from other Scottish sources.

Family history of CHD/stroke is defined as an immediate family member (mother, father or sibling) being diagnosed with heart disease or stroke before the age of 60 years. 100 A participant may also be classed as having a family history if two or more of their aunts, uncles or cousins suffered CHD/stroke before age 60 years, despite not having a mother, father or sibling affected. The Midspan Family study101 is a cardiorespiratory investigation of two generations of a population based in the west of Scotland. The original Renfrew/Paisley study102 contained a cohort of 4064 married couples from 1972–6. In 1996, their offspring were traced and 2338 attended the cardiorespiratory examination and completed the survey questionnaire. From this data set we were able to find a proportion estimate of family history to apply to our study population (Professor Michaela Benzeval, University of Essex, 2013, personal communication). The proportion was based on men with at least one parent who experienced or died of CHD/stroke in our population of interest: men with a BMI ≥ 28 kg/m², aged 35–65 years. This proportion (121/313) was then applied randomly to our study population, resulting in 38% of both intervention and comparison groups having a family history CHD/stroke.

Using this approach to estimate family history has limitations. Generalisability is questionable as the Midspan population is specific to the offspring of a west of Scotland general population, whereas our sample is from all over Scotland. In addition, the definition of family history varied slightly from the ASSIGN risk score definition as information from the Midspan Family Study was only available on parents. Finally, the proportion with a family history is likely to be an underestimate, as it was based on self-reported data rather than hospital admissions data. However, as family history is not influenced by the intervention, these limitations should not impact the incremental analysis.

Data on total and HDL cholesterol for men aged 35–65 years with a BMI ≥ 28 kg/m² were available from the west of Scotland Twenty-07 study. 103 From these data, multivariate regression equations were estimated through discussion with clinical colleagues to relate total and HDL cholesterol to age, BMI, SIMD, education, diabetes mellitus and smoking status (Tables 24 and 25). The approach to estimate total and HDL cholesterol for each participant in this way was discussed and agreed with clinical colleagues, who suggested that activity, weight loss and diabetes mellitus would all effect HDL cholesterol more than total cholesterol. Note that we are not attempting to estimate the impact of behaviour change on cholesterol change, an approach which was deemed inappropriate by our clinical colleagues.

The equation for total cholesterol was based on a sample of 337 men, while the equation for HDL cholesterol was based on a sample of 317 men. Note that those with higher BMI were more likely to be on statins, lowering their cholesterol and, thus, explaining the negative coefficient in the results in Tables 24 and 25.

Analysis

The long-term effectiveness is presented in terms of both life-years gained and QALYs. These estimates are generated for each individual as the sum of the individual’s within-trial outcome (in terms of life-years or QALYs) and the individual’s estimate of life expectancy generated from the HELP model (in terms of life-years or QALYs).

The long-term cost associated with each individual is determined by the sum of the individual’s within-trial cost and the individual’s estimate from the HELP model.

The longer-term estimates of life expectancy, QALYs and costs were all discounted at a rate of 3.5% following guidance from the UK NICE. 104

The cost and effects of the FFIT intervention are calculated by averaging the costs and effects of the individual participants who received the FFIT intervention; the same process is undertaken for members of the waiting list comparison group to determine the costs and effects associated with no active intervention. The incremental cost associated with the FFIT intervention is the difference between the average cost of the FFIT intervention group and the average cost of the comparison group. The incremental effects associated with the FFIT intervention are taken as the difference in the average effects (in terms of life-years or QALYs) between the FFIT intervention group and the comparison group. The incremental cost-effectiveness associated with the FFIT intervention is then presented in terms of incremental cost per life-year gained and incremental cost per QALY gained.

Probabilistic analysis

In order to estimate the uncertainty in the model estimates, we undertook a probabilistic sensitivity analysis allowing for uncertainty in the estimation of all of the parameters within the model. Running this analysis required simulating 1000 draws from the probability distributions for each of the parameters and using each of these 1000 draws to estimate the life expectancy, QALYs and lifetime costs for each of the participants, generating an estimate of the average costs, life-years and QALYs for each group for each draw.

The resulting uncertainty in the incremental costs and effects associated with the intervention is plotted on the incremental cost-effectiveness plane. The cost-effectiveness acceptability curve presents the uncertainty surrounding the cost-effectiveness of the FFIT intervention compared with no active intervention.

Finally, the uncertainty surrounding the decision to implement the FFIT intervention was formally assessed, in terms of the associated costs and consequences, within a value of information (VOI) analysis. The expected value of perfect information (EVPI) provides a monetary valuation of the impact of the uncertainty surrounding the decision between FFIT and no active intervention every time that a decision is made. This per-decision amount is scaled up according to the frequency of the decision in order to provide a population-level value of the uncertainty. This valuation provides an estimate of the maximum return achievable, for the population, from reducing uncertainty through further research and can be used to determine whether or not it is potentially worthwhile undertaking further research around the effectiveness or cost-effectiveness of FFIT compared with no active intervention.

Within the VOI analysis of the FFIT intervention, the eligible population was specified as Scottish men aged 35–65 years identified over the next 3 years with a BMI ≥ 30 kg/m²; that is a population of 365,000 men.

Scenario analysis

Uncertainty about the long-term sustainability of behavioural change (structural uncertainty) is examined through a scenario analysis that limits the time frame for the risk reduction impact of the intervention. This was achieved by changing the hazard ratios utilised within the model 5 years after the intervention.

Data source 1: self-reports on online registration form and registration telephone calls

On registration, men were asked to provide their name, contact details, date of birth, the club they wished to attend and their self-reported trouser waist size, height and weight. When the research team telephoned men who had registered an initial interest in FFIT (either online or when approached at football games), 98% (1206/1231) were asked how they had heard about FFIT and a single response was recorded.

Data source 2: baseline questionnaire

The methods of data collection for the baseline questionnaire and measurements are reported in Chapter 2, Procedures and baseline characteristics of trial participants are reported in Chapter 3, Baseline data. In this chapter, we use age and objectively measured BMI and waist circumference to compare FFIT trial participants with men in the general population. Categories of waist circumference (‘low’ < 94 cm; ‘high’ ≥ 94 cm and < 102 cm; ‘very high’ ≥ 102 cm) and BMI (‘overweight’ BMI 28–29.99 kg/m²; ‘mild obesity’ BMI 30–34.99 kg/m²; ‘moderate obesity’ BMI 35–39.99 kg/m² and ‘extreme obesity’ BMI > 40 kg/m²) were used to assess risk of future ill health following Scottish Intercollegiate Guidelines Network (SIGN) guidelines. 43 Comparison figures for similarly aged men in the Scottish population were obtained from the SHeS 2011. 2

Data source 3: telephone interviews with men who opted out of Football Fans in Training

At 12 weeks, participants were contacted by the research team to arrange post-intervention measurements. At this point, 46 participants (12% of the original intervention group) informed the research team that they had left the intervention while it was still being delivered. During this telephone call, a brief structured exit survey was undertaken by telephone with any men who had opted out of FFIT (see Appendix 1). This asked about their reasons for joining, why they stopped attending, whether or not their attendance had changed them in any way and any suggestions for improvements to the programme (and whether or not this would have encouraged them to stay on the programme). It also invited them to make any additional comments not covered by these questions.

Data source 4: club coaches’ weekly attendance sheets

Club coaches were asked to keep a record of attendance at each of the 12 weekly sessions. Coaches for 12 of the 13 clubs (covering 356 of the 374 men allocated to the intervention arm) were able to provide these; one club (Club09) suffered a computer failure that resulted in the loss of their attendance record.

Data source 5: observations of programme deliveries

Three researchers were trained to conduct observations of the intervention delivery. Across the 13 clubs, 26 sessions were observed (observations were distributed so that each of the 12 sessions was observed at least twice and every club was observed twice). Table 28 details which sessions were observed in each of the clubs.

Researchers were introduced to the men by the coach at the beginning of each session. The researcher explained their role as observer, gave the men an opportunity to ask questions and asked for their consent to observe, take notes, audio-record the classroom session and video-record the physical activity session. They reassured participants that the researcher would leave the session if anyone did not wish to give their consent. Men in all sessions consented to be observed.

As soon as possible after observing the session, researchers wrote detailed notes using a proforma that focused on the extent to which coaches delivered key tasks for the session as specified in the programme delivery guide and identification of particularly good practice and/or any problems/issues with the delivery (see Appendix 2). Researchers listened to the audio-recording of the classroom session and watched the video of the physical activity session and supplemented their proforma notes with any relevant observations which had not already been captured. The key tasks for each session were designed to deliver core educational messages (see Table 1). In total, there were 42 key tasks to be delivered in 12 classroom sessions, as shown in Table 1. Observers rated whether or not key tasks had been ‘delivered’ or ‘not delivered’ and recorded reasons for their rating.

Data source 6: programme evaluation questionnaire

We asked men in the intervention group to complete a questionnaire to evaluate their experiences of the FFIT programme (the exit questionnaire is available from the authors on request). This was administered at 12-month measurement sessions after completion of all other measures. It was completed by 316 out of 333 men (95%) who attended the 12-month measurement sessions and 316 out of 374 men (84%) who were randomised to the intervention group. The questionnaire asked how useful they found key aspects of the programme including physical activity, diet, goal setting, weight loss, group interactions and support.

Data sources 7 and 8: participant focus group discussions

We conducted two sets of focus group discussions (FGDs), the first soon after the delivery of the intervention programme was completed (data source 7: 12-week FGDs) and the second after the 12-month follow-up measurements had been completed at each club (data source 8: 12-month FGDs). At each time point, one FGD was conducted at each of the 13 clubs.

For the 12-week FGDs, men who had consented to additional research-related contact and who had attended the programme for at least 6 weeks were approached to ask if they would be willing to take part in a group discussion on their views of the programme. Of 295 men contacted, 133 (45%) indicated interest in taking part. Up to six men per club were invited to take part in a 60-minute focus group. If men were not available or did not wish to attend at the chosen time, additional men were contacted from the list (if numbers permitted) until five or six men per club had confirmed they could take part. The 12-week FGDs covered how they had heard about FFIT and their reasons for taking part; perceptions of any impacts the programme had; which, if any, aspects of the programme had enabled them to make changes; any negative experiences; and any suggestions for changes that could be made to improve the programme (see Appendix 3). In total, 63 men participated in the 12-week FGDs across the 13 clubs (Table 29).

We wanted to ensure that the 12-month FGDs (which were conducted following final 12-month measurements) included a mix of men who had been variously successful in achieving and maintaining weight loss to 12 months. We e-mailed 280 men who had consented to additional research-related contact and 143 (51%) indicated that they were willing to take part. Again, up to six men per club were invited and if they were not available or did not wish to attend at the chosen time, additional men were contacted from the list (if numbers permitted) until five or six men per club had confirmed they could take part. In total, 68 men participated in the 12-month FGDs across the 13 clubs (see Table 29). The topic guide focused on what had helped and hindered men’s attempts to maintain weight loss, increased physical activity and a healthier diet (see Appendix 3).

With participants’ consent we audio- and video-recorded all FGDs. They were transcribed verbatim and checked for accuracy. As part of the consent procedure, men were assured that they could withdraw from the discussion at any time, they could choose not to answer any questions and their participation/lack of participation would not affect future participation in FFIT-related or other activities at their club. Participants were given a £20 club shop voucher to thank them for participation and offered reimbursement for any travel expenses incurred.

Data source 9: coach interviews

We conducted semistructured interviews with coaches who had delivered the programme at each club as soon as possible after the 2011 delivery was completed. At one club, all three coaches involved were interviewed together, at eight clubs two coaches were interviewed together, at one club both coaches were interviewed individually and at the remaining three clubs the main coach was interviewed individually.

As part of the consent procedure, coaches were assured that they could terminate the interview at any time or choose not to answer any question and that their participation/lack of participation would not affect future participation in FFIT.

The topic guide included questions about coaches’ experiences of delivering the programme, elements they thought were effective/less effective, aspects that were difficult to deliver and any changes they would like to suggest for future versions of the FFIT programme. Interviews were conducted at the clubs, lasted up to 1 hour, were audio-recorded, transcribed verbatim and checked for accuracy.

Qualitative data from focus group discussions, coach interviews and observational data

We used a structured, thematic, approach to analyse transcripts from FGDs, coach interviews and qualitative data from observations. 105–107 First, transcripts were repeatedly read and coded to broad themes reflecting the research questions covered in the process evaluation. For the 12-week focus group data, these broad themes were reasons for participating in FFIT, reasons for continuing with FFIT and satisfaction with/acceptability of FFIT. For the 12-month FGDs, themes relating to participant experiences of maintaining weight loss and lifestyle change were identified. For coach interview data, broad themes were experiences of delivering FFIT, satisfaction and acceptability of FFIT and any adaptations made during the delivery of FFIT.

Second, all data coded to these ‘broad themes’ were read independently by two researchers who noted all subthemes that were present, including both anticipated subthemes that related to the main research questions and any unanticipated themes or topics. 106 This mixed approach ensured that the full range of participants’ views was captured. 107 Third, the two researchers compared the themes they had identified and collectively agreed a coding framework based on these.

Fourth, each broad theme was recoded by one researcher to the agreed coding framework to ensure that all material of relevance to these analytical categories was captured. Finally, the same researcher produced an extended descriptive summary of each analytical category using data extracts to illustrate each point. This summary was read by the second researcher to double-check that all views were covered and then used to write this report.

In conducting our analysis we were particularly mindful of the capabilities, opportunities, motivation and behaviour (COM-B) model of behaviour change108 and the ROMEO logic model by Robertson et al. 10 The COM-B model argues that for behaviour change people need the right combination of capabilities, opportunities and motivation. The opportunity and motivation aspects of the COM-B model were especially useful for explaining data relating to reasons for participation. The ROMEO logic model describes the important influence of wider environments and culture and of family, friends and workplace interactions on individuals’ ‘weight loss journeys’; this was particularly useful in interpreting extrapersonal factors that drew men to the programme, why they engaged with FFIT and influenced the weight loss trajectories men followed after the programme finished. In conducting the analysis of men’s experiences of maintenance, we also drew on self-determination theory (SDT), which argues that maintenance of weight loss-related behaviours is associated with the satisfaction of three universal psychological needs: autonomy (volition), relatedness and competence. 109 Thus, men may be more likely to succeed in maintaining their weight loss, increased physical activity and healthier diet if they have developed internalised self-regulation and have integrated their new behaviours with other aspects of their personal identity; feel optimally challenged to perform the new behaviours; and feel meaningfully connected to others.

Quantitative data from the baseline questionnaire, the programme evaluation questionnaire and exit survey

Categories of waist circumference (‘low’, < 94 cm; ‘high’, ≥ 94 cm and < 102 cm; ‘very high’, ≥ 102 cm) and BMI (‘overweight’, 28–29.99 kg/m²; ‘mild obesity’, 30–34.99 kg/m²; ‘moderate obesity’, 35–39.99 kg/m^2; and ‘extreme obesity’, > 40 kg/m²) were used to assess risk of future ill health. Descriptive statistics were used to examine men’s satisfaction with the programme, as reported in the programme questionnaire at 12 months, and men’s reasons for dropping out of the programme, as recorded in the exit survey.

Reach

In order to attract sufficient numbers to the FFIT trial within a very constrained recruitment period, we needed multiple recruitment strategies (see Chapter 2, Recruitment strategies and contact with men and/or Chapter 3, Recruitment). Potential participants could therefore have been exposed to information on the upcoming FFIT programmes from multiple sources (e.g. leafleting at football matches, workplace fliers/e-mails, word of mouth) and we are unable to provide a clear denominator for any estimation of reach. Here then, we consider ‘reach’ in relation to the kinds of men who chose to participate in FFIT.

The baseline demographic characteristics of trial participants (see Table 6) demonstrate that FFIT was successful in reaching men from across the socioeconomic spectrum. However, in comparison with the general population, fewer participants were not in paid work (17.2% in FFIT compared with 22.4% of men aged 35–64 years in the Scottish population)110 and fewer were from non-white ethnic backgrounds (98.3% of FFIT participants described themselves as ‘white’ compared with 96.2% in the total Scottish population). 111

The FFIT succeeded in attracting men who were at high risk of ill health on the basis of their BMI, waist circumference and blood pressure. 34 As reported in Chapter 3, mean BMI was 35.3 kg/m² (SD 4.9 kg/m²). Over 90% of participants had a BMI ≥ 30 kg/m²; 44% were classed as mildly obese, 31% as moderately obese and 17% as extremely obese. Mean weight was 109.5 kg (SD 17.3 kg) and mean waist circumference was 118.4 cm (SD 11.7 cm); all but two men had a high (4%) or very high waist circumference (96%). Mean systolic and diastolic blood pressure readings were 140 mmHg and 89 mmHg, respectively. Table 30 compares FFIT RCT participants with male SHeS respondents of similar ages2 according to health risk category. 34 On the basis of their BMI and waist circumference, FFIT trial participants were at much higher risk of future ill health (type 2 diabetes mellitus, hypertension and CVD); around 10 times more men were classed as being at ‘extremely high’ risk (21%, 16% and 12% of FFIT participants aged 35–44 years, 45–54 years and 55–65 years, respectively, as compared with 2%, 2% and 1% of Scottish men of the same age). A further 223 out of 311 men (72%) aged 35–44 years, 212 out of 290 men (73%) aged 45–54 years and 116 out of 146 men (80%) aged 55–65 years were at ‘very high’ risk, compared with 25%, 25% and 32% of Scottish men, respectively.

Furthermore, despite being sufficiently concerned about their weight to register for the FFIT programme, only 3.6% had attended a commercial weight management programme and only 1.7% a primary care-based programme in the 3 months prior to undertaking FFIT. 34

Routes to recruitment

Men expressing an interest in FFIT reported hearing about the programme from a range of different sources. The most widely reported sources of information about the programme were match-day recruitment (reported by 327 men, 27% of the 1206 who were asked to identify what led them to join the programme). At least 13% (154/1206) of potential participants also reported hearing about the programme through club websites, articles or news pieces in the media (newspaper, radio and TV) and through word of mouth. Several other sources were mentioned by a small minority of men (< 10% of participants) including work-based advertisement (6%, 77/1206), posters at the clubs (5%, 55/1206), other club associations (4%, 45/1206), fans’ websites (3%, 40/1206) and GPs (1%, 9/1206).

Accounts from participants in the 12-week FGDs confirm findings from our feasibility study. 32 The most common account was of having heard or read about the programme from multiple sources. For example:

I’d actually, I had heard, coming to one of the home games, there was, like, folk out sort of talking to people periodically. We just happened to be walking past somebody when I heard – that was probably the first I heard of it, and then I’d picked it up in the work through someone in the work, who was actually sort of involved wi’ [with] the measuring side of it. So she’d kind of highlighted the fact that, you know, did I know fans [who would be interested]? I don’t know if it was a subtle hint!

Participant 1, Club12, 12-week FGD

This extract also points to the importance for some men of interactions with others in their decision-making about whether or not to engage with the programme. Other examples suggest some men were strongly encouraged to sign up by family members and some needed prompts from multiple sources before a final decision to sign up. Collectively, the data suggest that it is important to use multiple media outlets when advertising for recruitment and that each source can reinforce another and that making it as easy as possible for men to make the decision to participate is important.

Reasons for participation: personal motivations and the ‘draw’ of the football club

During the 12-week FGDs, participants were asked about their motivations for signing up for the FFIT programme. They offered multiple and overlapping explanations. This included a range of personal or family ‘push’ factors, such as wanting to regain a more youthful, better functioning or less compromised body. For example:

Well, I used to play football, [. . .] and when I had to chuck it, I kept playing fives [five-a-side], but I was kidding mysel’ on, and you’re no’ doing the same training but you continue to eat the same way you always did, and you continue to drink on the Saturday wi’ [with] your mates, the same way you did. And year on year, it [weight] just crept up to the point where I think I hit about sixteen stone, and I thought I need to dae [do] something aboot [about] it. And I did try to do something aboot [about] it, and it worked for a wee while, and then lapsed again, and then this came up through the work [advert about FFIT] and I thought, ‘I’m going to [Club12 ground],’ so my motivation was to lose the weight and get back fit again . . .

Participant 3, Club12, 12-week FGD

The opportunity to stave off or fight back health problems was frequently raised. One participant explained how when he was approached by a member of the recruitment team at a home game he connected his weight to his musculoskeletal health:

He said they were looking for fat bastards, and I’d had trouble wi’ [with] my knees because of the additional weight I’d been putting on. I knew I had to do something, so it just sort of fitted in.

Participant 5, Club13, 12-week FGD

Similarly, another participant noted that concerns about his high blood pressure prompted him to think about joining FFIT to lose weight.

I just wanted to lose weight. I mean, I’ve been on blood pressure tablets for, I dunno [don’t know] – three or four years. That’s something I’ve never particularly taken seriously, but you should take it seriously, obviously. It’s not a good thing. My doctor’s often said to me, ‘Lose that weight, you never know, you might come off that medication!’ Well, there’s a goal in itself, I suppose.

Participant 2, Club08, 12-week FGD

Another very commonly mentioned ‘push’ factor was a desire to ‘be there’ for family. This referred both to the present, what they wanted to be able to do now with or for family members, and to the future, through an expressed desire to survive long enough to support their families over coming decades and to see their children grow up. As one man put it, when describing why he took part in FFIT:

And plus the fact I’ve got a nine-year-old daughter, and she was beginning, it was beginning to tell when, if she was even swimming, I was swimming with her and I couldnae [couldn’t] keep up with her. She’s only nine, and that was the real, you know, sort of slap in the face, if you like, for me to say to myself, ‘well, I’ve really got to do something,’ because she’s getting fitter and fitter. She’s only nine, but what happens when she’s twelve and I can hardly run a hundred yards withoot [without], you know, breathing really heavy?

Participant 6, Club10, 12-week FGD

These push factors correspond to what the ROMEO model10 describes as history and personal motivations for weight loss.

At the same time, they were powerful ‘pull’ factors that drew the men to the programme. The most important of these were the programme’s delivery within the football club; being with people like them (men who were perceived to be like-minded and like-bodied); and the group format with opportunities to interact with other men. The football club setting was very important for most of the focus group participants and was frequently discussed as a very important ‘pull’ factor.

I think the big pull was you’re actually going to [Club12] to do it. So you’re going to a club where you’re spending a lot of time, anyway, coming to watch games and following the team. And, a bit like saying, well, like-minded [Club12] fans, and that’s really, I think that was the big pull in for me.

Participant 1, Club12, 12-week FGD

Equally important in many discussions was knowing that the programme would be for people like them: men who liked football and were of similar ages, sizes and levels of fitness. The following exchange is a good example:

I think the thing, also, about what we went through, as well, was, I mean, the common denominator is football. We all like football, you know? And that gets us all going.

Of course it does.

That was it.

The good thing, to me, is I didnae [didn’t] like going to a gym. I would prefer to go to a class, or have somebody telling you what to dae [do] and what not to dae [do]. It was kinda like, I don’t want to go to a gym and see all the younger ones, the fitter ones – and you got a kinda, you look roon [around] and you think they’re looking at ye [yourself]. ‘He’s that fat he cannae [can’t] even dae [do] that.’ And that was the kinda thing I liked. You come here, everybody was in the same boat – everybody was between a certain age and overweight, coz that’s how I got into it.

Club10, 12-week FGD

Linked to the importance of being in a group of like-minded (and like-bodied) men was the feeling that pursuing weight loss in a group setting would make the task easier:

Yeah, that was part of it as well, and as you says aboot being at [Club09 stadium] – that was another draw, being at your local club, being about the place. I just agree with what everybody’s saying – coz you’re doing it in a group, it’s so much easier. You’re encouraging each other and you’re happy to see other people getting on and losing weight – no’ just the losing weight.

Participant 3, Club09, 12-week FGD

These ‘pull’ factors correspond to what the ROMEO model10 describes as engagement. Men saw the programme as being in the right setting and circumstances to support them in losing weight and commonly articulated that the FFIT programme was an ‘ideal’ opportunity to translate an emerging or conscious desire to lose weight into action:

I’ve struggled with my weight since, maybe, early twenties and I’ve tried various diets, various things, and you seem to get to a stage where you’re successful, then you fall back out the way again. So, when I seen this advertised in the paper . . . the main thing that drew us to it was because it’s [Club07]. You’re going to be involved at [Club07], whether it just be at the ground, stadium . . . That was what really attracted me to it.

Participant 1, Club07, 12-week FGD

There were many similar examples of men discussing the synergy between their (developing or long-standing) motivation to lose weight or get fit (‘push’ factors) and the opportunity to take part in a programme in their club (‘pull factors’) and the ways in which this encouraged their initial engagement.

Figure 13 illustrates how the combination of ‘push’ and ‘pull’ factors, together with the increasing awareness of the opportunity to enrol for FFIT provided by the multifaceted recruitment strategy, were sufficient to encourage men to register their interest in the programme. Thus, in line with the COM-B model, the focus group data repeatedly provided accounts of men who wanted, and were motivated, to lose weight for whatever reason and for whom the FFIT programme was an appealing opportunity to engage.

FIGURE 13.

Factors attracting men to take part in FFIT: the power of the ‘draw’ of the football club for themselves and other like-minded/like-bodied men. Reprinted with permission from Hunt K, Gray C, Maclean A, Smillie S, Bunn C, Wyke S. Do weight management programmes delivered at professional football clubs attract and engage high risk men? A mixed-methods study. BMC Public Health 2014;14:50. 34

The powerful combination of ‘push’ and ‘pull’ factors is illustrated in some men’s accounts of overcoming deep-seated barriers to taking part in a weight management programme. For example, one man described how his experience of attending baseline measurement in his club’s grounds and discussion with the club coach afterwards had helped him to overcome long-held anxieties about tackling his weight problems:

I remember the first time . . . when you got weighed and all that sort of stuff [. . .] and I genuinely, I just didnae [don’t] want to be here. I felt very nervous aboot [about] the whole thing, . . . It was very embarrassing. It’s not now, but at the time, it was. At the time, I was like, ‘Oh, this is terrible,’ and aye, measuring my waist, and I came in here . . . That was the first time I met [Club07 Coach 1], and I genuinely thought, ‘After I get out [of] here, I’m just going in the car, ignore the phone calls, ignore the e-mails, I’m not daen [doing] that. That’s ridiculous.’ And I sat in here with [Coach 1], and he was telling us, ‘Right, you know, of course we train here, at [Club07’s stadium].’ And I thought, ‘That’s good. I wouldn’t mind training here at [Club07’s stadium] . . .’ And after that, he said, ‘Aye, ken [you know] what we’ll do, we’ll get you some training gear . . . you’ll be running aboot [about] in the training gear.’ And honestly, I couldnae [couldn’t] get the grin off my face. I was like a bairn [child]. I thought, ‘I want to be training at [Club07’s stadium],’ with the, you know, aye, with the kit.

Participant 4, Club07, 12-week FGD

Others expressed their worries about weight management in different ways, such as a fear of being so overweight, unwell or unfit that they might be rejected when they applied for FFIT.

Men’s very early experience of the programme reinforced their view that FFIT was the right programme for them and increased early engagement (see Figure 13). Men articulated this in relation to gaining privileged access to club facilities (e.g. home/away changing rooms, the tunnel, pitch side), as noted in the two examples below:

I’m a fan, and I think that helped a lot . . . the fact that I was coming to [Club05 stadium] and going into the changing room and stuff like that . . . I mean, it was just nice. And you felt kinda part of it . . .

The fact, walking about the stadium, up and doon [down] the stairs.

Club05, 12-week FGD

Just the enjoyment of coming along and being involved in the club . . . even walking round [Club04 stadium], to me, was an exciting part of the Monday night . . . walking up and down the terraces. You might only be restricted to one area when you come to a game, but, you know, the fact that you’ve got carte blanche, you can go wherever you like, other than the pitch.

Participant 1, Club04, 12-week FGD

Thus, FFIT was able to harness men’s initial desire to ‘do something’ about their weight, fitness and health with the deep symbolic and cultural attachments to the football clubs that many participants held. Many had supported their club since they were boys and the chance to take part in a weight management programme which gave them enhanced physical and symbolic access to that club, its coaches and like-minded fans was sufficiently powerful to overcome any reservations they may have felt about signing up for the programme (see Figure 13).

As discussed later, this powerful attachment to the club was also important in retaining men’s engagement with FFIT once they had started on the programme (see Process outcome 2: reasons for participating/opting out).

Attendance and opting out of Football Fans in Training

Across the 12 clubs for which we have data, attendance was high. Participants attended a mean of 8.7 (SD 3.7) sessions during the 12-week programme; 78.9% of men (281/356) attended at least six sessions; and 61.8% attended at least 10 sessions (Table 31).

However, although attendance at the main 12-week programme was high, attendance at the 9-month ‘reunion’ was quite poor; 72% (261/365) did not attend. This may have been because the sessions coincided with the Euro 2012 football championship or because they were held in the ‘closed’ season when we know men often switch off from football. However, it may also indicate less interest in the programme 6 months after the main sessions had been completed.

Some men did drop out of the programme. Examination of participant attendance week by week over the 12-week programme (Figure 14) demonstrated that there was an initial drop-in attendance between sessions 1 and 5, after which attendance remained relatively stable until the final two sessions, when a further small drop-off was observed.

FIGURE 14.

Number of participants attending FFIT by delivery session (of 356 for whom we have attendance data).

Table 32 shows the results from exit telephone interviews with the 46 ‘drop-outs’ whom we were able to contact. The most common reason cited for dropping out was changes to work patterns that meant they could no longer attend (19/46, 41% of ‘drop-outs’). Much less common were course-related issues, although seven men (15% of ‘drop-outs’) reported not being able to continue because of injury. Only one man said that he left FFIT because he did not like the classroom sessions and only two cited dislike of the physical activity sessions as their reason for dropping out. Of the 16 ‘other reasons’ cited, four men said that the course did not meet their expectations and one felt he was not making sufficient progress. Not only were programme-related reasons for leaving the course uncommon, but some men stressed in the exit survey that they felt that FFIT had had a positive effect on their lives or health: 20% (9/46) reported that they had lost weight; 43% (20/46) said they had improved their eating habits and 24% said they were doing more exercise (11/46).

Satisfaction and acceptability

Overall, both men expressed very high levels of satisfaction with the programme and found its content highly acceptable, as succinctly illustrated in one interchange at the end of a FGD when participants were asked for their final reflections on the programme as a whole:

I would just have said it was one of the best 12 weeks.

Aye, it was brilliant.

That’s one of the best things I’ve ever done in my life.

To me, it’s life changing. It was life changing, you know? Hopefully, you know, that you know, it will keep it up. I know I’m determined, I will keep it up.

Club02, 12-week FGD

Such spontaneous and enthusiastic praise was common, as one participant said:

I honestly can’t praise it enough. I thought it was great.

Club03, 12-week FGD, participant 6

A number of factors, which are considered in turn below, are particularly salient in explaining these high levels of satisfaction: (1) the football club setting, (2) the delivery of the programme by club coaches, (3) men’s enjoyment of interactions in the group and of being with men like themselves, (4) the content of the course and, (5) their experience of bodily changes over the 12-week programme.

The football club: branding and setting

We describe above how participants cited the location of the programme in the stadium and its close association with the football club as powerful ‘draws’ to the programme in the first place (see Reasons for participation: personal motivations and the ‘draw’ of the football club). These factors appeared to be equally important in men’s continued engagement with the programme and were elements that men consistently said they liked about FFIT. For example:

One of the things that I found, and it’s such a simple thing, [. . .] the booklet you got, first of all, from the club, with all the information on it – and I’m sure it’s identical in all the other clubs had it – but the fact that they did the [Club03] crest on it, then, you kind of felt as if, yeah, you were part of a bigger thing, doing it. I know it seems like a really small, stupid thing, but that really did kinda hook me.

You actually thought, at the end of the day, once you leave your group, you had your [Club03] jersey. You were actually doing it for [Club03], as well, not just yourself.

Aye, that’s right.

Club03, 12-week FGD

This exchange highlights the importance participants placed on symbolic representations of FFIT’s proximity to the club – the crests on the booklets and the team shirts – that were harnessed in the intervention (see Chapter 2, Gender sensitivity). Another group conceptualised the connection engendered with club in terms of being part of the ‘fans’ team’:

There’s an ownership wi’ [with] the club, or I suppose ‘ownership’ is probably not the right word, but you definitely feel a connection to the club that you maybe didn’t have before. Even just the T-shirts we all got.

Aye.

Aye, it’s like an identity. It’s almost as if it’s you become, I know this sounds crazy, but I had this in my head that it’s all like, you know, I’m part of the team, the fans’ team, you know? And it’s nothing to do with that, but there is a kind of psychological part of that, as well – but I think that was one of the things that kept me going, as well.

Club12, 12-week FGD

Thus, participation in the programme seemed to engage a new, enhanced, relationship to the club, symbolised through tangible markers or symbols. This enhanced closeness was also apparent in the way the men spoke of their enjoyment of being in the club grounds. For example:

I think the other good thing was it’s actually held here, in [Club08 stadium]. I remember, I think it was week 1 or week 2 and it was [FFIT participant] said, ‘You know, it’s unbelievable! We’re here and we’re in the stadium and, you know, we can go out to the park and things like that!’ And that was encouraging a lot more than anything else.

Yeah.

A couple of people said, in our group that, ‘Why did you not have it at [Club08 training ground]?’ And they says, ‘Well, we thought yous would all want to come here [stadium], rather than go to [training ground].’ He says, ‘Well, we could have went up to [training ground] one or two weeks of the course, like.’ And then most people said, ‘No, this is what we come for, to see this place [Club08 stadium].’

Club08, 12-week FGD

Other men expressed pleasure at getting access to parts of the stadium they would otherwise not see, such as the changing rooms or warm-up facilities. Thus, the physical setting of the stadium provided a direct, ongoing motivation for continuing with the programme. This shows that the physical, not just the cultural, connection to their clubs was important for galvanising participant attendance, that the setting was as important as the branding.

Taken together, the data on the importance of the football club as both setting and brand suggest that another angle of analysis could usefully be added to the micro level of the ROMEO model by Robertson et al. :10 the importance of objects. This resonates with Latour’s suggestion that inanimate objects play an active role in the social, acting as mediators of social relationships that are far more durable than transient interactions. 112 The fact that men cited the club-crested T-shirts and books that they received and the stadia in which the intervention took place as significant reasons for continuation and satisfaction suggests that this analytical approach holds value and should be carefully considered in the development and delivery of interventions; other health interventions might increase engagement if they are able to integrate objects that are symbolically valued by participants.

The delivery of the programme by club coaches

When talking about their experiences of FFIT, participants often spontaneously attributed their high level of commitment to FFIT to the positive interactions they had had with the coaches that led the sessions. For example,

And I think the two people that were running it were, you know, could have a laugh and, you know, there was wee jibes and jokes, so it was . . .

Yeah, it wasnae [wasn’t] somebody just up there rattling change in their pocket and talking at you.

Aye.

Club01, 12-week FGD

The importance of the genuine interest in the men that the coaches had shown was felt to set the tone for a sociable, enjoyable and motivational environment for participants; they had succeeded in promoting a very positive motivational climate in which the group could operate. Another aspect of the sessions that participants valued highly was the positive group interactions between participants on the programme and this too was something that was attributed to the coaches’ style of facilitation:

And I think the club coach was a big part of that, bonding everybody together and I think we’re lucky we got such a – he’s a good guy. He knows what, he’s very good at what he, at doing it and presenting it. So everybody felt quite comfortable as soon as he started on you.

Participant 5, Club07, 12-week FGD

Thus, coaches played a central role in the formation of the group and the fostering of group cultures. This was seen to be down to the engaging, knowledgeable and sociable approach they adopted while delivering the intervention, which really encouraged the building of relationships and to a genuine interest that they had in the participants.

Enjoyment of group interactions

Men’s active enjoyment of group interactions and the relationships they developed with each other while on the programme was also an important contributor to the very high levels of reported satisfaction with FFIT. There were three features to this: team spirit, the sociability of the group and a sense of solidarity deriving from being with men very much like themselves.

All groups made reference to the team spirit engendered among those that participated in FFIT. For example:

I think self-encouragement is, we’re there, because we’re part of a group, we were all encouraging each other. It’s not, you were no longer an individual. You were part of a team, and [. . .] I think it helped, and even although you had the book to start with, you could have flicked through the whole book yourself and worked it out yourself – I think you wanted the encouragement, as well, by going on to the next stage and having a wee bit of explanation. You can learn a lot from books, but the practical side, you learn a heck of a lot more from the practical side than you do from just the written word.

Participant 1, Club08, 12-week FGD

For this participant, the importance of working with others in maintaining commitment to and attendance at the programme was vital. As another participant put it:

There was a team spirit and you didnae [didn’t] want to let the team down, you know?

Participant 1, Club03, 12-week FGD

This was also reflected in responses to the programme evaluation questionnaire; 277/316 (88%) of respondents reported that it was ‘quite’ or ‘very’ useful to hear how other men were getting on during the course of the 12 weekly session highlighting the vicarious learning that is a feature of group-based interventions. 113,114

Related to team spirit was discussion of the sociable atmosphere in which the programme was delivered. The men joked, teased and supported one another and laughed together about incidents they related to each other, as illustrated by the next extract:

And the craic.

And the craic was great.

The biggest thing, I think, in life, is laughing because, you know, aw [all] the chemicals go off and you know . . .

[. . . discussion about a particular night].

But things like that was just, and like, wee bits of banter when we’re in the gym, or playing fitba [football] or that – you’d have a wee craic with somebody. And the laughter, when I played football – no’ at a great level, like – but I used to prefer the training bit to the actually going oot [out] and somebody trying to kick lumps out of you. And that was the environment we were working in. It was almost, coz we had training every week, you know?

And it was completely non-threatening.

Yeah.

Club02, 12-week FGD

Thus, within the football club setting, coaches and participants between them created a supportive, cohesive, non-threatening environment in which humour was experienced. This appeared to give meaning to the experience of taking part in FFIT that was said to be an important reason for continuing with the programme. For many, this was likened to other forms of sociality that they enjoyed in their day-to-day lives:

It was [like] going to the pub for the banter withoot [without] the drink.

Aye.

[Laughing.]

You know? That’s what it was.

Right enough, it just aboot [about] was.

Club13, 12-week FGD

The comparison of the atmosphere within the sessions to the geniality, comfort and sense of belonging that men might experience with their friends in the pub, points not just to men’s enjoyment of the sociality of the programme, but also to the ability of the programme to support group cohesion and demonstrates that its design successfully tapped into cultural frames that appeal to men.

Alongside enjoyment of the sociality and team spirit, participants often commented on the importance of the programme being aimed at people like themselves, in relation to age, love of football, love of their club and being aimed specifically at men only. For example:

I think it was quite good because your peers were people of possibly similar age, or within a reasonable age bracket of yourself. You were no gonna [going to], aye, you werenae [weren’t] gonna have your twenty-year-old who could, maybe is slightly overweight, who’ll find it easy to lose where, when you’re a wee bit older, it’s a lot harder.

Participant 1, Club08, 12-week FGD

The fact that the intervention was aimed at older men was often reported to be extremely important. Another perspective on commonality, a shared interest in the club, was frequently brought up:

The good thing was, straight from the start, we all had something in common with each other. Rather than being sixteen strangers, we’d all something in common, and that was the club and a love for it.

Two things in common. We were fat and we supported [Club03].

Sorry, we were cuddly and supported [Club03], and that was the big factor. So no matter, you met up the first few weeks, you didn’t know each other’s names, we immediately were able to converse with each other easily.

Club03, 12-week FGD

Thus, the combination of a shared passion and a shared problem allowed for the rapid consolidation of a group that they wanted to remain a part of and to high levels of cohesion. Others commented on another commonality, the fact that the programme was targeted at men, and contrasted FFIT to commercially available weight management programmes:

I think we were quite happy it was just men, to be honest. We spoke about going to Weight Watchers or that . . . but we were saying that, a lot of things are set up and it is mainly female – so it was good to see something that was just for male.

For guys.

[. . .]

That’s right. I think the majority felt that Weight Watchers was not for us. That was very much a women’s thing.

That’s a ladies’ thing.

Club08, 12-week FGD

Another group expressed these commonalities (and a humour typical of the groups) between participants very succinctly:

We’re all similar, old, fat gits.

Yeah, exactly.

You know? And that was it.

You could count five points we all have in common, right? One – age. One – weight, yeah? [Club03] supporters, yeah? I’ve ran oot [out] of ideas on that.

All want to lose weight, all want to get fit.

Uh huh.

Male.

Hair falling out.

Yeah.

No, mine’s fell out.

Every single one of us [over talking] has sort of, OK, I’ll say three, four, five things in common, and that’s the pulling thing for the whole lot.

Club03, 12-week FGD

The humour, facilitated through group interactions and the tone set early on by the coaches, not only contributed to men’s enjoyment of FFIT, but was seen as an important factor in enhancing participants’ engagement with the course content:

You know, outside what we did [i.e. activities to lose weight before FFIT], we’re doing it because we feel we have to do it, whereas, what we did here [on FFIT programme], we wanted to do it. It was a pleasure, it was enjoyable, and it was great meeting the guys.

No, they were. I think they were, there’s eh, you get a bit of a laugh with it, as well. It wasnae [wasn’t] all, you know – it was a kind of learning, a wee bit of fun and exercise with a bit of fun, as well. So, although there was a serious side to it, there was also the, there was a wee bit of [pause] I mean, [pause] at some points, it was laugh a minute.

Club12, 12-week FGD

For participants, behavioural changes encouraged by FFIT were transformed from an obligation – ‘we feel we have to do it’, to a desire – ‘ we wanted to do it’. Yet, this enjoyment enhanced, rather than detracted from, the ‘serious side’ of the programme: humour and fun were seen to facilitate learning and exercise, not impede them. It suggests that the high levels of group identity, which formed over the course of the programme, actually helped men to be even more committed to the changes they were making to their lifestyles. We turn now to men’s views of the course content.

The course content

The men (and coaches, see Process outcome 6: participants’ experiences of maintaining weight loss and lifestyle changes in the longer term) discussed how much they enjoyed and appreciated the actual content of the programme, in terms of classroom activities, physical activity sessions and ‘homework’ and skills they learnt on how to make behavioural changes. The content was seen as one of the reasons the programme ‘was so good’. Men commented on the style of delivery of the programme, which was non-didactic and based on adult learning techniques and on the value of graduated learning and the practicality of the skills learnt. They also valued the walking programme, the pedometers as tools for self-monitoring their progress with the walking programme, the self-monitoring of weight more generally and, to a lesser extent, the SMART goal setting. We discuss each of these in turn.

Men appeared to value the way in which the programme materials, supported by the style of delivery of these materials, encouraged them to build autonomy and take personal responsibility for their own behaviours. For example:

They’re giving us the tools – aye, but they’re not telling us what to do. They’re saying, ‘You can do this. This would be beneficial to you.’ They gave us that booklet and all the other tools and let us take them away.

It’s up to you.

And we’ve done what we’ve done with the basic information – and that’s what’s changed us all. It’s, you know what I mean? Yes, the course has helped, and all the work that they’ve done and everything else. They’ve given us the tools and the opportunity, and we’ve taken it away, and everybody’s nurtured it in a different way.

Club10, 12-week FGD

For participant 5 (Club10), then, the information was delivered in an empowering way as ‘tools’ to be used, not orders to be followed. The tools could be adapted and used in ways relevant and meaningful in the context of their own lives.

The modular, graduated, nature of the programme was also discussed in relation to building knowledge and skills over time. When one group was asked what it was about the programme that helped them make the positive changes they had just been discussing, a participant said:

I think coz it was in bite-sized chunks, you know? It was just like a week, every week was something different, so you could get stuck into it for a week, type thing. It wasnae [wasn’t] like overloading, trying to maybe do different things, coz that would probably switch me off, trying to change diet portion control, going shopping, trying to, you know, look at the labels, etc. It was bite-sized chunks with an education. It was like going through modules, for want of a better word, which was quite good for me.

Participant 5, Club08, 12-week FGD

By breaking down the programme’s educational content into ‘bite-sized chunks’, which were ‘like going through modules’, participant 5 (Club08) felt that the course facilitated positive change, a view endorsed by the coaches (see Process outcome 6: participants’ experiences of maintaining weight loss and lifestyle changes in the longer term). He appreciated being able to focus on one new aspect of lifestyle change at a time.

Responses to the programme evaluation questionnaire also suggested that the course’s educational content was important. The vast majority judged that the information about diet (302/316, 96%), food portion sizes (300/316, 95%), regular eating (291/316, 92%), daily calories and personal eating plans (296/316, 94%) was either ‘quite’ or ‘very’ useful. These judgements were supported by comments in the focus groups. The information on portion sizes and nutrition was particularly memorable for participants, as the following illustrates:

I got most of . . . the thing out the course I liked was the fact that I didnae [didn’t] know much aboot [about] food labels and nutrition and what to eat and portion sizes – so the whole start of the course, rather than the exercise – the whole nutrition and aw [all] that, getting aw that in was good, because then I could sit doon [down] and say, ‘Well, haud [hold] on. Looking at these Weight Watchers boxes and that, they arenae [aren’t] good for you because there’s still a lot of fat in them through cheese and aw [all] that,’ which I never knew about. And then it’s going home and educating my family to say, ‘Well, we need to, instead of having this, we need to have that because, even though it does say it’s good for you, it’s no’.’ So it was good to go back and educate my family, plus, then, empty oot [out] the cupboards and start again, and mair [more] fruit, and if I didn’t like certain fruit, put it in a smoothie, and then you could have it, rather than just say, ‘I cannae [can’t] eat that coz I don’t like it.’ Bung it in a smoothie. You can have it then, because you’re drinking it all in the one. So it was an education in food.

Participant 2, Club12, 12-week FGD

Thus, the information relating to portion sizes, nutritional values and food choice was a highly valued part of FFIT for many participants. They learnt to renegotiate their understanding of what an appropriate portion was for different foodstuffs and the course provided them with skills to scrutinise the content of the foods and to think about ways to include more nutritious foodstuffs into their daily diet.

More generally, participants commented on how useful they found the basic information and the very practical tips they discussed in the sessions, as illustrated in the following exchange:

It’s good stuff, aye. It’s good.

It is really basic stuff. Nobody ever really has told me that before.

It’s good quality information, wasn’t it? It was good quality information.

Aye. People think it’s going to be rocket science when you tell them what it is. You point to your pedometer, and then you say, ‘By the way, you watch your portion controls and, you know, naan breads, this. . .’. Remember the naan bread?

Aye. ‘Stop eating half the stuff that comes with curry!’. It’s, like you say, no’ rocket science at all.

Aye, and folk get surprised when you tell them.

Club02, 12-week FGD

Many participants expressed enthusiasm about the new information and understandings they had gained about diet and physical activity. They appreciated the way in which the programme was set out to explain the importance of balancing calorific input and output while also providing skills to make easy, practical, changes to achieve this. One participant suggested that this ‘scientific’ or ‘technical’ focus was one of the reasons the programme was so appealing to many men:

And the other, the part of the programme that helped, I think, again, for guys, there was a technical aspect to it, as well, you know? There was a scientific, technical background, and I think guys, especially, will react to stuff like that, when it’s put factual[ly] – it’s not airy-fairy and there it is.

Participant 2, Club01, 12-week FGD

This resonates with culturally prevalent perceptions of gender roles and interests, which tend to cast men as practical, device loving and scientific. While these norms have and should be questioned, it is noteworthy that men perceived the FFIT intervention to be sufficiently ‘scientific’ and ‘technical’, but yet accessible and credible, expressed by some men through references to ‘science’ but not ‘rocket science’.

We have previously demonstrated that men who took part in the pilot deliveries of FFIT responded extremely well to the walking programme as a first step towards regaining increased physical fitness and were enthusiastic about being able to monitor their progress with the pedometers provided. 31 In the FGDs presented here, men also repeatedly reinforced the views expressed by men on the earlier deliveries of FFIT and discussed how the walking programme supported them to build up their physical activity, typically from low levels of fitness, in a slow and graduated manner they felt suited them well. For example:

I think the pace of the course was good . . . if they put us in the gym the first week, most of us wouldn’t have came back in week two. I’d have been out.

Participant 4, Club13, 12-week FG

Walking is all I could have coped with, when I started out you know.

Yeah.

There’s no way I could have done anything else. I couldn’t have gone into a gym.

Yeah.

I certainly couldn’t have gone out running, jogging or anything.

Participant 6, Club05, 12-week FGD

The suggestion that the walking programme was a well-received component of FFIT was supported by responses to the programme evaluation questionnaire: 298 out of 316 (94%) of participants rated advice on walking either ‘quite’ or ‘very’ useful. In the FGDs, the pedometer was again seen as a key tool for monitoring and, thus, supporting achievement of their physical activity goals. It was seen as ‘the best thing’:

I think for me, personally, I started to think about what I’m putting in my mouth, now, and I started to think about an increase in exercise. The pedometer, for me, was brilliant because it made me go out and, I work in an office job, now – when I was a kid, I was very healthy, very active, played a lot of football, was super fit – but going into an office, you get out of the way of it. I was doing zilch exercise, and it [pedometer] gave you that incentive to go for a fifteen minute walk on my lunch break, and I started doing that, just to get my steps up – but it was for me. It made me change a lifestyle thing, change a habit into a good habit and then start doing more exercise.

Participant 3, Club13, 12-week FG

Thus, the pedometers provided participants with a tangible way of engaging with and adjusting their levels of physical activity. These data are again supported by the results from the programme evaluation questionnaire, which showed that 91% (288/316) found the pedometer either ‘very’ or ‘quite’ useful. The pedometer thus appeared to provide men with a concrete externalisation of their levels of activity that rendered an otherwise abstract and unmeasured aspect of their life visible and easy to manipulate.

One of the key BCTs known to be effective in weight management is goal setting and this is a key component of FFIT, in relation to both eating and physical activity. In response to direct questioning on how useful SMART goals were, some men discussed the difficulties they first had with setting SMART goals as well as how they used them effectively, at least in early parts of the course:

The first one [goal-setting exercise], when you first got to it, you didnae [didn’t] really ken [know] – then he sort of told you to change your goals to sort of exercise and try something different.

It was difficult. I mean, we had the first set of goals – and I can’t even remember what my first one was. Lose three pounds in one week or something. Don’t eat chocolate, I think, or something. And then, as the weeks went by, it was difficult to set yourself different goals – coz it was really the same thing you were doing every week, you know? The goals were the same goals, sort of thing.

Aye, you changed yoursel’ [yourself] right from the start, didn’t you? Coz everybody sort of said, well, I think it was after the portion size, I sort of looked at myself and thought, ‘Right, well, I’m really going to have to drastically change the way I’m going,’ you know what I mean? So from there it was like, well, what are my goals? Well, I’ll put another fifteen hundred steps on. Right, no problem. I’ll eat more veg. Well, I have been doing that. I’ll cut out another thing and I’ll cut out another – you know what I mean?

Club10, 12-week FGD

Although the SMART goals proved to be ‘difficult’, as participant 1 (Club10) notes, participant 5 was able to recount the processes that this technique led him through, demonstrating the impact it had on his thinking, from the initial realisation that he needed to change his lifestyle through to the tangible and incremental actions he identified to help him achieve this change.

However, success in identifying and implementing SMART goals was not uniform and not all men found them useful:

To be honest wi’ [with] you, I didnae [didn’t] buy into that part of it at all, because I knew what, I knew, myself, what I was wanting to achieve, and I didn’t – you know, I wrote them down, then thought, ‘Right, ok, we’ll try and do so many of these extra steps this week,’ you know? But eventually, I did, I ended up just chucking it, because I thought to myself, ‘If I keep to the step thing,’ you know, the increasing the steps, ‘and if I keep to the eating bit, I should be ok’, you know? I mean, for some, maybe some people found it helpful – I don’t know.

Participant 1, Club01, 12-week FGD

Thus, although the principle of goal setting is clearly important in the early stages of the programme, only some participants reported making use of SMART goal setting as the programme progressed, at least for eating goals. As Dombrowski et al. 58 suggest, different techniques may be more useful in the initiation rather than the maintenance phases of weight management.

Despite these mixed views of SMART goals, most participants found understanding their weight loss target to be useful, as reinforced by data from the programme evaluation questionnaire [in which 280 out of 316 (89%) participants reported it was ‘quite’ or ‘very’ useful to know their 5–10% weight loss target].

Experiencing successes

The experience of success, of progress, both individually and as a ‘team’, was reported to be highly motivating for participants. As one commented, when asked why the men kept coming back to the FFIT sessions:

It’s the success. Success, because it breeds success, doesn’t it, you know? If you’re doing well and you get off to a good start, you want to improve and to go on and lose weight, and then you’re, the sort of team thing comes in, where you’re part of a team and you want to go forward as part of the team, and to make sure that we all do the same things and we’re trying to encourage each other, as well.

Participant 3, Club08, 12-week FGD

Thus, the programme was seen to work, not just theoretically, but through, embodied, experiences:

I think also it works, or it certainly worked for the majority of people who went on it. I mean, I’ve done diets, etc. and not lost a jot, and the fact that, you know, you’re going on the scales every week and I was losing weight was incentive. I think, probably, halfway through, if I hadn’t been losing weight, I probably would have dropped out – but the fact that I was losing it, it was working, and it’s continued to do so very easily, you know? Obviously reducing your calorie intake slightly – I mean, I haven’t changed my life, eating-wise, hugely. Me breakfast, I certainly have, but other than that, I haven’t changed it. It’s actually the walking, and the walking has made the huge difference to me [. . .].

And what kept you coming back, week after week?

The fact it was working.

Aye.

Yeah.

Club05, 12-week FGD

For many, then, the achievements they realised each week led them to continue to attend the programme and fuelled their high levels of satisfaction with the programme overall. Many expressed a sense of personal achievement, particularly when they had tangible evidence (such as looser clothes) or external verification (such as others commenting on how they looked) of their successes:

I think one of the nicest things, when you lose your weight, if you’ve been successful, to put on a pair of trousers you’ve no’ had on for three or four years, and you know, just that nice feeling to think, ‘Oh my goodness me’ you know? Your notches on your belt and all the different signs that you track.

[. . .]

I think you get, I mean, when people, when somebody notices you get a wee bit, you feel a wee bit pleased, you know? If somebody hasn’t seen you for a wee while and they say to you, ‘Have you lost weight?’ And you think, ‘Well,’ you know, you know you have, coz you’ve got the letter telling you – I think you do get a wee bit, aye, you feel quite pleased and quite, and a wee bit proud, you know? Coz it’s not, nobody can do it for you. It’s all very much been your own efforts. I mean, it is a very personal achievement, and you do feel, you get a wee bit, aye, you feel quite proud and quite pleased when people are noticing. [. . .] And I think when people are telling you you’re looking better, it’s a circular thing, you know? Just self-perpetuates, that’s really what I’d say.

Club08, 12-week FGD

Further discussion of the importance of tangible markers of success emerged when participants and coaches commented on the use of physical representations of weight loss in session 7 of the programme:

Yeah, I couldnae [couldn’t] believe it, when you were handed the [sand]bag and [coach 2] said, ‘Feel that weight!’ Because we didn’t know [at first] what it was all about. ‘That’s what you’ve lost in the last . . .’ what was it, 6 weeks, about week 6 or something, wasn’t it?

I’d lost eight bags of it [physical representation of actual weight loss], yeah, which was quite incredible, yeah.

Yeah, could not believe it!

That was the thing, when you seen the bags lying, you thought one was for every person that was there, but they gave you four. You’re saying, ‘No, no, that’s not for me!’

The other thing that amazed me was that lump of rubber which represented the fat.

Club08, 12-week FGD

Thus, the sandbags and other physical objects (e.g. replica lumps of fat in week 11), which were used to render weight loss visible and tangible, were another successful component of the programme. Men’s recollections of seeing and handling these objects convey some of the excitement they felt at the time – ‘I couldnae believe it’ (participant1, Club08,12-week FGD) and ‘it was amazing’ (participant 3 Club08_12-week FGD).

When we explicitly asked about unexpected outcomes, the only ones mentioned, usually partly in jest, were the need to buy new clothes:

Do you know the only thing, it’s costing me a fortune!

On clothes.

In clothes.

Club10, 12-week FGD

In summary, men recounted a strong experience of enjoyment while taking part in the programme and expressed very high levels of satisfaction with, and acceptability of, the programme. Several factors were repeatedly raised in discussions about what motivated them to keep coming along to the programme: the positive atmosphere fostered by coaches, the physical environment of the football club setting, feeling a part of and closer to the club (symbolised by the T-shirts and other branded physical objects), the enjoyment of the group interactions and feeling part of a ‘team’ indicating high levels of group cohesion and the satisfaction of learning tips and techniques for behaviour change for themselves and for others. Together these built to deliver tangible experiences of success in reaching their weight and physical activity goals, which kept the vast majority of men engaged throughout the 12-week programme.

Factors that facilitated weight loss maintenance

During the FFIT programme, the coaches had provided clear, easy-to-follow advice about how to lose weight by adopting healthier eating habits. The men were shown practical examples of how to reduce portion sizes and how to make better food choices (by swapping energy-dense foods for nutrition-dense foods) and learned about the benefits of regular mealtimes. This learning was reinforced through group discussion about adapting this information for their personal situations and the use of goal setting and action planning. At 12 months, members of the FGDs who had successfully maintained weight loss described following the lessons learnt on eating in ways that best suited their own lifestyle:

We stick to the Eatwell Plate, we’ve got that up in the kitchen which is good, it’s a good reminder, you know, when you’re doing the shopping we check out all the, you know, the various fat content, sugar, salt, things like that.

Participant 5, Club02, 12-month FGD

Instead of eating at 11, 12 o’clock at night when I come home from work (having a big plate of food), stopping suppertime, 5, 6 o’clock, no matter what I’m doing, and having a meal. I’ve managed to do that. I’ve had breakfast in the morning, dinner and I have a supper at night. And it’s just maintaining that, and then that stops all form of binge eating, grabbing what you can sorta stuff, you know? It’s just certainly giving you a structure for eating like that.

Participant 1, Club06, 12-month FGD

My eating habits have totally changed and that’s since I’ve started the programme to now, and I don’t think I’ll ever go back to where I was. I mean, even things like, it’s just a small thing, but I got a tub of Mackie’s ice-cream, you know, the two litre, and before, I was sitting with that and eat it, maybe not eat it all obviously, but you know, I’d eat part of it. And now what I’ve learnt is, because what [coach 1] was saying . . . I put it into a bowl, I put the ice cream away, so that I’m only eating that specific amount, rather than eating a whole lot.

Participant 6, Club07, 12-month FGD

These extracts illustrate how being able to make autonomous choices about how to change their eating habits had helped the men sustain the improvements in the longer term.

Another way that FFIT had tried to support weight loss maintenance was by promoting the ongoing use of self-monitoring, which has been shown to be associated with weight loss maintenance. 58 Towards the end of the active phase, the men were encouraged to continue to weigh themselves regularly and to use their pedometers to monitor and record their physical activity levels as part of their weight loss maintenance strategy. Many (but not all) men had found this advice helpful:

I find that the pedometer, even now it’s my conscience. If I can look back 7 days and say, ‘Phew, I’m only averaging about 7000. I usually should be doing eight or nine’, it’ll make me go for a longer walk some time later in the week.

Participant 2, Club10, 12-month FGD

[Weighing myself] it’s my motivation. It’s the fact ‘Shit I’ve put on four pounds here in a fortnight!’ So it motivates me to do a bit more, eat a bit better so that’s my own self-monitoring motivator and that’s what I’ve always stuck to myself. ‘Cause if I didn’t do it then I just would not bother my shirt, you know.

Participant 3, Club09, 12-month FGD

Once again, the FGDs provided evidence of how men had made their own choices over how to apply advice around ongoing self-monitoring: some continued to use their pedometer, others to weigh themselves regularly, while one man described using internalised somatic and psychological cues to regulate his eating and physical activity. For some participants, maintaining weight loss remained effortful and while there was little evidence that men had continued to use SMART goal setting and review, some had found the action planning they had learned to use during FFIT was helpful in maintaining behavioural change:

I think the thing for me is actually the planning of stuff because you tend to need to plan a bit more about your activity. You know about how, if you want tae walk you’re gonna have to plan about ‘When am I gonna walk?’ An’ also I quite often end up staying at hotels or whatever for work, an’ you have to know, ‘What am I gonna eat? Where am I gonna eat?’ So you have to do a bit more planning about how you do that. [. . .] You have to sort of try an’ work something out there so you don’t end up goin’ to [a bakery] or whatever.

You have to plan your [food] shop as well.

Yeah (nodding).

Club05, 12-month FGD

A clear message that was emphasised during FFIT was the importance of men feeling comfortable with the changes they made to their eating habits and not feeling they had to totally deprive themselves of foods they really enjoyed. Many of the men who had been successful in maintaining their weight loss had adopted a flexible approach (e.g. allowing themselves to eat unhealthy foods on occasion). Men who had tried to follow a more rigid eating regimen during the active phase had found this more difficult to sustain afterwards:

My diet changed a wee bit because I wasn’t sorta eating healthily or as much as I was when I was involved in the twelve-week programme. I don’t know if that was me, just, I don’t know, it’s, just found it quite difficult to stick to the eating plan because, you know, you had, for that twelve-week period, I done so well losing so much weight and I don’t know if I found it, did I find it boring or some of the things that? I know I’ve gotta try and eat five bits of fruit every single day, and I just found or, you know, your veg as well, sometime I just couldn’t do it.

Participant 1, Club08, 12-month FGD

Finally, following the active phase of FFIT, the coaches sent participants e-mail prompts every 6–8 weeks that were designed to support the maintenance of weight loss, physical activity and healthy eating and the men were invited back to attend the 9-month reunion meeting at their club. There was some confusion in the FGDs over the 9-month meeting. Some men appeared unclear whether they had attended it or not and, as we saw under Attendance and opting out of Football Fans in Training, very few had attended the sessions. The utility of the e-mail prompts was also the subject of some debate:

The prompts have been good from [Club02 coach] and some of his prompts about getting through yourselves as well, just to say, ‘Look, you know, how are you doing?’ and that type of thing. You felt, still feel part of it even though [. . .] no I found them, you know, they’re very good, you know, ‘cause it gets you thinking again, you know, right okay, you know. And there’s this, you know, we’re doing this and we’re doing that. That type of thing.

Participant 5, Club02, 12-month FGD

I just got the impression these were e-mails that had been sent by the people at [Club01] so they can fulfil the criteria required to get to do this Football Fans in Training. ‘We did what we had to do, we had to send out an e-mail periodically.’ It didn’t seem that it was anything really in it. It was just a case of, ‘Right we’ve now met every criteria we’ve to complete the thing.’ That’s all I felt it was. I didn’t get anything from that, to be honest wi’ [with] you.

Participant 1, Club01, 12-month FGD

It therefore appears that few of the men had found the ‘light-touch’ components of the weight maintenance phase of FFIT particularly useful. They preferred to select the tools and BCTs that were most salient to them and which best suited their lifestyles as they tried to maintain their weight loss, physical activity and healthy eating.

Self-determination theory also argues that people who feel intrinsically motivated (e.g. who do something because they find it interesting or beneficial) are more likely to sustain a behaviour than those who are extrinsically motivated109 (e.g. who do something because someone else has told them to, such as eating smaller portions because the FFIT coach has suggested you do it). The contributions within the FGDs of men who had successfully maintained weight loss were certainly congruent with SDT as we show below.

Deci and Ryan109 describe three stages in the internalisation of regulation. The first stage is ‘introjection’, when a person manages to regulate his or her own behaviours, but this is driven by external values. The result is that positive (e.g. pride in personal achievement) and negative emotions and external factors become important sources of motivation. There was evidence of this in the FGDs:

I think the information you got has increased the guilt conscience more. There’s a bit o’ [of] that in there to be honest. There’s a bit o’[of] that that said ‘Jeez, I suppose I better do something!’ Not the driving factor, but certainly in there.

Participant 1, Club09, 12-month FGD

Something that was never mentioned when we did all this course was we were talking, we don’t buy crisps now, we don’t buy chocolate things. I reckon I probably spend ten quid a week less ‘cos I’m not buying the rubbish that I was eating before in the evening.

Participant 2, Club02, 12-month FGD

Although introjected regulation of behaviour is more likely to persist than external regulation, it remains relatively unstable. Recognition that a healthier lifestyle can save money may be an example of introjected behaviour, but it also shows some elements of the second stage of internalisation, ‘identification’, when people recognise and accept the value of a behaviour for them. Deci and Ryan109 argue that as identification is associated with greater regulatory stability, it should be more effective than introjection in supporting behavioural persistence. Many of the FGD participants described their appreciation of how much better their positive lifestyle had made feel in themselves:

I would start to eat more greens, more – what I call wet food, you know. The vegetables, you know, the stuff that’s carrying more water and towards the end of it, it clears out my system, it allows you to breathe, you feel fitter [. . .] you feel healthier, you feel more able to function.

Participant 3, Club01, 12-month FGD

We all know once you’ve done the exercise how you get a buzz out of it – endocrines is it or . . .?

Participant 2, Club10, 12-month FGD

Endorphins?

Endorphins, aye. But, you start to – I wouldnae [wouldn’t] say you start to be a junkie on them, but your day does feel different if you’ve done that, and I now have that discipline.

Participant 2, Club10, 12-month FGD

The third stage of the internalisation process, ‘integration’, occurs when people fully assimilate their new behaviours with other aspects of their personal values and identity. The result is complete self-regulation, which is the most stable form of regulation and is most likely to support long-term maintenance of weight loss-related behaviours. A few of the men who had been successful in maintaining their weight loss appeared to have achieved a new, coherent sense of self:

I used to, when I was out in the car look at people runnin’ out in the street thinkin’, ‘God, they’re really keen, they’re [pause] look at that idiot!’ But that’s now me [points thumb at self]. So it’s . . . I dunno, it’s just a perception, I couldn’t have done it before. An’ even things like runnin’ across the road to the shop when it’s rainin’ an’ runnin’ back to the office. I’m not outta [out of] breath when I come back in an’. . . you realise that and you remind yourself how much better you’ve become because of it.

Participant 3, Club03, 12-month FGD

However, a FGD among men who had experienced mixed success in weight loss at 12 months suggested they had been less successful in internalising their new behaviours:

I don’t feel that, I don’t feel I’ve changed at all but I feel that, you know, that my habits have changed and, you know, eating habits.

As I was saying, I’m wi’ [with] you on that, it’s like I think I’m the same person, but I know a lot of my habits have changed. I mean, is changing your habits changing the person? I don’t really think so.

Club07, 12-month FGD

Taking part in FFIT therefore helped some men internalise extrinsic motivation and develop different degrees of self-regulation of their new weight loss-related behaviours. Many appeared to have moved beyond ‘introjection’ to ‘identification’ and a few appeared to have developed the highly stable ‘integrated’ self-regulation that SDT suggests is most likely to be associated with long-term maintenance of behaviour change.

Self-determination theory suggests that for fully integrated motivation (regulation), two other universal needs are necessary – feelings of relatedness and of competence. Again, there is evidence of increasing experiences of each of these as facilitators of maintenance of weight loss.

We have seen how much men enjoyed interacting with one another in the 12-week programme (see Enjoyment of group interactions). In some clubs, men had continued to meet up to exercise together regularly after the 12 weekly active phase of FFIT had ended suggesting very high levels of group cohesion and social identification. Some of these ongoing groups were organised by the FFIT coaches and a couple were held at the clubs; others were organised by the men themselves and took place at local community venues. FGD participants appreciated these opportunities to keep meeting up, irrespective of how well they were doing in maintaining their weight loss:

I was still struggling, but the coach organising the Monday night thing was a Godsend to me ‘cause I coulda [could have] easily have just slipped into bad habits again.

Participant 4, Club13, 12-month FGD

Aye, it’s really like . . . I mean, the physical activities, I wouldn’t say almost are a by-product of it, but, you know, we go round there and everybody’s sorta common goals or aims; and, like I say, we’ve got common setbacks a lot of us, you know, and things like that. And you, and like you say, it’s like a support group, as such, ‘cause we’re all in there, everybody’s there for the same reason sorta thing, so it’s a good sorta almost like a, what’s the word I’m looking for? . . . Safety valve almost, you know?

Participant 5, Club07, 12-month FGD

Some men were not able to make these meetings; others had taken part in FFIT at a club where ongoing groups had not been set up. They described experiencing a real sense of loss when the active phase of FFIT had ended:

I would like tae have seen it [the active phase] just a wee bit longer . . . Even if it had went doon [down] from every week to know, maybe once a month or something like that? I think it would still have gave everybody the wee incentive to go along, share their experiences an’ things like that. Pass on like the good habits, the bad habits – the good an’ bad times an’ things like that . . .

Participant 1, Club05, 12-month FGD

For other men, leading a healthier, more active lifestyle had helped them to become more involved in family life. For them, this was a really positive benefit that helped them maintain the changes they had made:

I must admit my kids have kept me goin’ an’ a lot of the—an’ they’re now startin’ to drag their mother out as well when they’re wantin’ to go oot [out] for runs on their bikes an’ things, an’ that’s made a big difference [touches nose] to keepin’ you goin’ when you get . . . If you’re havin’ a – you want tae [to] have . . . or feel like being lazy or tired, I’ve got one [child] at five an’ one at ten an’ they just want to be goin’ all the time. So it does give you a good feelin’ when they’ll come tae [to] me if they want to go an’ do somethin’ that involves either runnin’ aboot [about] or cyclin’ aboot [about] an’ the mum gets left, so . . .

Participant 6, Club03, 12-month FGD

For many men, feeling meaningfully connected to other people, both their peers from the programme and family members, was a valued outcome from taking part in FFIT and this continued to be an important factor for many in the period after the active phase. However, as the extracts demonstrate, satisfaction of relatedness was not necessarily associated with autonomy and increased well-being and, for some men, it was particularly important when things were not going well.

People are more likely to engage in healthy lifestyle behaviours when they have the necessary skills to perform them, and find them interesting and optimally challenging. 108 FFIT provided the men with a range of skills and knowledge about how to lose weight by improving their eating habits and becoming more active and the coaches were trained to further support the development of a feeling of competence through providing positive feedback about the men’s efforts and achievements. Men who had done well in maintaining their weight loss spoke with confidence about applying what that had learnt from participation in FFIT:

I feel I’m more knowledgeable about things as well. I mean obviously those were the main things, but I mean for instance food advertising and what they put on the labelling is a disgrace. It wouldn’t be allowed in other fields, and yet you know they can get away with it. They’re misleading, it’s pretty bad actually, it’s pretty bad and I’m aware of that now . . . it’s changed the way I look at things.

Participant 2, Club13, 12-month FGD

So, I mean, I went out and bought a slow cooker and started cooking things like that, just using fresh vegetables putting things like that in it, meat joi— getting proper big meat joints and actually cooking them off and doing things like that.

Participant 3, Club11, 12-month FGD

Practice theory describes how ‘novices’ learn experientially and assimilate new behaviours into their routinised practice to become ‘full practitioners’. 115,116 The FGD participants’ narratives revealed a trajectory of increasing competence, confidence and habit formation.

I think now right the exercise . . . is a part of your way of life . . . used to be your work, sleep, up again, work, sleep . . . Now you make time, either once a day or at least a couple of times a week, to go and do that wee bit [of] exercise. Now it’s, it just pushes you right on.

Participant 2, Club10, 12-month FGD

As their feeling of competence and expertise increased, men described how they and others viewed themselves differently. Some changed from ‘novice learner’ to fully practising ‘carriers of practice’ who took pleasure in sharing their new knowledge with their family and friends:

Everything about my life – and my children – even my children, you know what I mean . . . We’ll walk to the shops, you know what I mean? Or they’ll take their bikes. Any chance they’ve got to come out wi’ [with] me they’ll do it, so they’ve started tae [to] get more exercise, they’ve started to watch what they’re eating, they’ll not have chocolate cereal in the morning, they’ll have normal cereal or they’ll have porridge or that so . . . It’s not just my aspect on life, it’s theirs as well that’s sorta benefited from twelve weeks.

Participant 1, Club10, 12-month FGD

The racquetball has been a revelation . . . Absolutely love it [participant 1 agrees]. And, you know, I’ve got to the point where I’m trying to sort of get of some of my workmates involved in playing as well now and I’m back down south next week and I phoned up my brother-in-law and said ‘Do you fancy a game of racquetball?’, sort of thing, so he’s gonna give it a go.

Practice theory 4, Club08, 12-month FGD

The preceding sections have shown that men made autonomous choices over which tools and techniques they continued to use to maintain their weight loss and positive lifestyle changes after the active phase of FFIT. Many succeeded in developing some degree of internalised self-regulation and those who were successful in maintaining their weight loss and lifestyle changes spoke with confidence about applying their new knowledge both in their own lives and to influence other people. However, although continuing to meet up with other men they perceived as being ‘like them’ was important for many FGD participants, this was not always associated with weight loss maintenance nor the development of self-regulation; men who found it difficult to maintain their weight loss and lifestyle changes also valued the continuing camaraderie and social support from their peers. Many of the men reported facing a number of challenges in maintaining the changes they had made after the active phase of FFIT ended. The next section examines these problems.

Factors that hindered weight loss maintenance

As we have seen in Chapter 3, although there was a large difference in outcomes between the intervention and control group, less than half of the intervention group maintained at least a 5% weight loss at 12 months. Participants in the 12-month focus groups described a range of difficulties and issues they had encountered in trying to maintain their weight loss and positive lifestyle changes in the longer term, including specific events and more generalised barriers.

Most men reported some degree of success in maintaining increased physical activity levels after the end of the 12 weekly sessions. However, the most commonly reported barrier to remaining physically active was injury, which often occurred as a result of men’s increased activity levels:

Couple of times wi’ [with] me, I reckon I picked up [. . .] injury after injury at five-a-sides, and it was really frustrating ‘cos I really enjoy it . . . I can hardly do anything for . . . I mean, I can hardly get oot [out] o’ bed. So that’s the thing that kinda puts me, sort of puts me back a bit. But that’s . . . I maybe go back down tae [to] just doing walking and cycling and just doing stuff that’s no’ gonna have much impact in terms of your muscles and your bones so, and I could probably get by with that.

Practice theory 4, Club12, 12-month FGD

A number of men reported that changes at work had played a major role on their ability to maintain their physical activity levels after the active phase of FFIT. Sometimes these changes had a positive effect (e.g. starting new job and standing up all day), but more often the impact was negative:

I’m less active now ‘cos I’ve moved offices. I used to park my car in near the [Local Bridge] and walk to my office. But, my office moved to the other side of the city centre, and it’s now half an hour walk instead of fifteen minute walk. But I can’t really afford an hour of my day walking to and from my car, and plus trying to get home and everything. So, I now get the underground, so that’s less walking.

Practice theory 1, Club01, 12-month FGD

Three reported how health problems had limited the amount of physical activity they were able to do, as illustrated here:

Sadly after the course finished, I put on a couple of pounds over Christmas and New Year, which I wasn’t too concerned about – got back on track in January – and I suffered much more serious haemorrhaging in my right eye, which I was very, very disappointed with because I’d got my blood sugar down and I’d lost a couple of stone in weight, and that really put me on the back foot. For six months I couldn’t exercise, or I probably could have if I’d gone to a gym, but I had been doing all my work outside, walking and running in the streets. I couldn’t drive at night, so that restricted me as well.

Practice theory 3, Club12, 12-month FGD

Taken together, these extracts suggest that adopting a flexible approach (finding different activities to suit different circumstances) is important for overcoming specific barriers to remaining physically active in the long term.

Most of the men had also experienced challenges to maintaining healthy eating presented by holidays and other special occasions (e.g. Christmas, weddings). A common response (as had been emphasised in the course material) was to view these events as temporary lapses that could be overcome by using the techniques and strategies they had learnt on FFIT:

Everything noo [now] is great. I was on holiday for the last fortnight there, I was in Florida, and I did put two or three pound on. But I came back on Monday there, and this is now Friday, and I’ve lost a pound again. Just because eating salads and stuff and goin’ tae [to] the gym again.

Practice theory 2, Club12, 12-month FGD

However, occasionally, major events in men’s personal lives had totally undermined their efforts to maintain change:

My brother passed away, which is one o’ the difficult things. My dad became unwell, and so that was, that, a lot o’ [of] that’s kinda impinged in, you know . . . when my brother died, basically he died in his early fifties, so it’s young. But it was his heart that caused problems, so you think that well that kinda would inspire you. But to a certain extent that was probably one of the worst times where, you know, things were going wrong, and it was just, you know, feeling bad and eating.

Practice theory 5, Club09, 12-month FGD

In addition to the challenges posed by specific events, the men reported a number of other, more generalised, problems they had encountered in trying to maintain their weight loss and positive lifestyle changes. These included not being able to find enough time to be physically active:

But I think this last year for me has been kinda busy, and the bits that you don’t need tae [to] do get kinda left behind. So it will, so I think when you’re that busy, sometimes when you get in at night and you think, ‘Right, I need tae go for a walk’, and you’re thinking, ‘Do you know, just no’ got the energy’.

Well, it’s winter time isn’t it . . .

And it’s just, there’s no’ enough time in the day. Then tae just, you know, sit back and gather your thoughts and things.

Club09, 12-month FGD

Despite discussion of strategies to overcome the negative influence Scotland’s weather could have on people’s motivation to be physically active during the active phase of FFIT, a number of participants still reported they struggled to keep active when the weather was bad:

Weather’s the worst one, absolutely by a mile, because you would go, I would be, I’d be out playing golf and I’d gone for a walk. See when I’m on holiday, guaranteed, absolutely guaranteed, when I’m on holiday, other when I was on a cruise to be fair, but normally after dinner her [wife] and I’ll go, and we can walk for Britain – literally hours on end, walk. And it’s great, pleasure walking at night, cool breeze, all that – lovely. Come hame [home] that’s . . . it’s pissing from the heavens, an’ I think, ‘Nah, we’ll no’ bother’ [participant 2 nods], just sit in.

Practice theory 1, Club09, 12-month FGD

For some men, the cost of healthy food and access to exercise facilities were significant obstacles to maintaining a healthy lifestyle:

Well, I find it’s price of the stuff, prices you oot [out] o’ [of] the market. See, I’m the oldest here. Now I’m a pensioner now, so it’s difficult when you, when you’re on the State Pension, especially when you’re trying to pay for electricity, gas and stuff like that. And I’ve got my, gotta keep my car running.

P6, Club08, 12-month FGD

I find it’s quite disappointing that sort of like [local public leisure facilities] are probably one of the most expensive ones in, you know, sort of, in Scotland. If you look at the prices of, you know, municipal leisure centres and all that around the rest of the country, [local public leisure facility]’s really quite poor in terms of what they charge.

P4, Club08, 12-month FGD

Finally, while other people were an important source of support for many men, their influence was not always positive or helpful:

My brother split up wi’ [with] his missus, come doon [down], ‘Would you like a glass o’ water?’ ‘No! I’ve just spilt up wi’ [with] my missus!’ ‘Right, have a beer then.’ (Laughter.) I don’t want a beer, you know? So there is a sorta wee daft things that go on. I can’t believe his missus has left – that’s really inconsiderate of her! Now I’ve got tae [to] drink one beer . . . (laughter). ‘Have you any crisps?’ Oh, he’s only wantin’ crisps as well! (laughter). I’m on a diet here!

Participant 1, Club05, 12-month FGD

In summary, although many of the men who took part in the 12-month FGDs appeared to be doing well in maintaining their weight loss and lifestyle changes, most had faced some challenges in the period since the active phase of FFIT ended. These included specific events such as injuries, changes at work, holidays, ill health and bereavement, and more generalised issues such as time and financial pressures, the weather and negative social influences. However, some of the men also reported how they had overcome these challenges through taking a flexible approach to being active and using the relapse prevention strategies (regular self-monitoring and recording of weight and/or physical activity, SMART goal setting) they had learnt on FFIT.