The intervention process in the European Fans in Training (EuroFIT) trial: a mixed method protocol for evaluation

How the Plants for Joints multidisciplinary lifestyle intervention achieved its effects: a mixed methods process evaluation

BACKGROUND

Plants for Joints (PFJ) is a multidisciplinary intervention centered around a whole-food plant-based diet, physical activity, and sleep and stress management. The PFJ intervention successfully improved disease activity and symptoms in people with rheumatoid arthritis (RA) or osteoarthritis (OA), respectively, and metabolic health. To investigate how these effects were achieved a mixed methods process evaluation was conducted to understand the context, implementation, and mechanism of impact of the PFJ intervention. Also, the relationship between degree of implementation and lifestyle changes was explored.

METHODS

Quantitative and qualitative data were collected across the evaluation domains context (i.e. reach), implementation (i.e. recruitment and delivery), and mechanism of impact (i.e. responsiveness) of both the participants and coaches (incl. dietitians, sport coaches) according to the UK MRC guidelines for process evaluations. Data was collected from the participants via focus groups and questionnaires after the intervention, and interviews with coaches. Qualitative data were analyzed thematically, and quantitative data were assessed with descriptive statistics and linear regression analyses. Degree of implementation was quantified using a theory-driven implementation index score composed of different process evaluation constructs.

RESULTS

Of the 155 participants who participated in the PFJ intervention, 106 (68%) took part in the questionnaire and 34 (22%) attended a focus group. Participants felt the intervention was complete, coherent, and would recommend the intervention to others (mean score 9.2 (SD 1.4) out of 10). Participants felt heard and empowered to take control of their lifestyle and health outcomes. Components perceived as most useful were self-monitoring, social support, practical and theoretical information, and (individual) guidance by the multidisciplinary team. Participants perceived the intervention as feasible, and many indicated it effectively improved their health outcomes. In an explorative analysis there was no significant difference in healthy lifestyle changes across implementation index score groups.

CONCLUSION

This process evaluation offers important insights into why the PFJ intervention works and how the intervention can be optimized for future implementation. Results indicating the intervention's high satisfaction, feasibility, and perceived effectiveness, further support the use of plant-based lifestyle interventions as an additional treatment option for patients with RA, OA, or other chronic diseases.

TRIAL REGISTRATION

International Clinical Trial Registry Platform numbers: NL7800, NL7801, and NL7802, all registered 17-06-2019.

Long-Term Effect of Weight Regain Following Behavioral Weight Management Programs on Cardiometabolic Disease Incidence and Risk: Systematic Review and Meta-Analysis

BACKGROUND

Behavioral weight management programs (BWMPs) enhance weight loss in the short term, but longer term cardiometabolic effects are uncertain as weight is commonly regained. We assessed the impact of weight regain after BWMPs on cardiovascular risk factors, diabetes, and cardiovascular disease.

METHODS

Trial registries, 11 databases, and forward-citation searching (latest search, December 19) were used to identify articles published in English, from any geographical region. Randomized trials of BWMPs in adults with overweight/obesity reporting cardiometabolic outcomes at ≥12 months at and after program end were included. Differences between more intensive interventions and comparator groups were synthesized using mixed-effects, meta-regression, and time-to-event models to assess the impact of weight regain on cardiovascular disease incidence and risk.

RESULTS

One hundred twenty-four trials reporting on ≥1 cardiometabolic outcomes with a median follow-up of 28 (range, 11-360) months after program end were included. Median baseline participant body mass index was 33 kg/m2; median age was 51 years. Eight and 15 study arms (7889 and 4202 participants, respectively) examined the incidence of cardiovascular disease and type 2 diabetes, respectively, with imprecise evidence of a lower incidence for at least 5 years. Weight regain in BWMPs relative to comparators reduced these differences. One and 5 years after program end, total cholesterol/HDL (high-density lipoprotein) ratio was 1.5 points lower at both times (82 studies; 19 003 participants), systolic blood pressure was 1.5 mm mercury and 0.4 mm lower (84 studies; 30 836 participants), and HbA1c (%) 0.38 lower at both times (94 studies; 28 083 participants). Of the included studies, 22% were judged at high risk of bias; removing these did not meaningfully change results.

CONCLUSIONS

Despite weight regain, BWMPs reduce cardiometabolic risk factors with effects lasting at least 5 years after program end and dwindling with weight regain. Evidence that they reduce the incidence of cardiovascular disease or diabetes is less certain. Few studies followed participants for ≥5 years.

REGISTRATION

URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42018105744.

How European Fans in Training (EuroFIT), a lifestyle change program for men delivered in football clubs, achieved its effect: a mixed methods process evaluation embedded in a randomised controlled trial

BACKGROUND

A randomised trial of European Fans in Training (EuroFIT), a 12-week healthy lifestyle program delivered in 15 professional football clubs in the Netherlands, Norway, Portugal, and the United Kingdom, successfully increased physical activity and improved diet but did not reduce sedentary time. To guide future implementation, this paper investigates how those effects were achieved. We ask: 1) how was EuroFIT implemented? 2) what were the processes through which outcomes were achieved?

METHODS

We analysed qualitative data implementation notes, observations of 29 of 180 weekly EuroFIT deliveries, semi-structured interviews with 16 coaches and 15 club representatives, and 30 focus group discussions with participants (15 post-program and 15 after 12 months). We descriptively analysed quantitative data on recruitment, attendance at sessions and logs of use of the technologies and survey data on the views of participants at baseline, post program and after 12 months. We used a triangulation protocol to investigate agreement between data from difference sources, organised around meeting 15 objectives within the two research questions.

RESULTS

We successfully recruited clubs, coaches and men to EuroFIT though the draw of the football club seemed stronger in the UK and Portugal. Advertising that emphasized getting fitter, club-based deliveries, and not 'standing out' worked and attendance and fidelity were good, so that coaches in all countries were able to deliver EuroFIT flexibly as intended. Coaches in all 15 clubs facilitated the use of behaviour change techniques and interaction between men, which together enhanced motivation. Participants found it harder to change sedentary time than physical activity and diet. Fitting changes into daily routines, planning for setbacks and recognising the personal benefit of behaviour change were important to maintain changes. Bespoke technologies were valued, but technological hitches frustrated participants.

CONCLUSION

EuroFIT was delivered as planned by trained club coaches working flexibly in all countries. It worked as expected to attract men and support initiation and maintenance of changes in physical activity and diet but the use of bespoke, unstable, technologies was frustrating. Future deliveries should eliminate the focus on sedentary time and should use only proven technologies to support self-monitoring and social interaction.

TRIAL REGISTRATION

ISRCTN81935608, registered 16/06/2015.

Factors influencing the implementation of the EuroFIT lifestyle change program in professional football clubs in Europe: a qualitative study in four European countries

This paper investigated facilitators and barriers to implementing the European Football Fans in Training program (EuroFIT) in professional sports clubs in England, the Netherlands, Norway, and Portugal. We analyzed qualitative data collected at clubs that delivered EuroFIT, based on semi-structured interviews with coordinating staff (n = 15), coaches (n = 16), and focus group interviews with participants (n = 108), as well as data from clubs that considered delivering EuroFIT in the future, based on interviews with staff (n = 7) and stakeholders (n = 8). Facilitators for implementation related to the content and structure of the program, its evidence-base, and the context for delivery in the football stadia. Financial and human resources were both facilitators and barriers. Further barriers were mostly practical, relating to human resources and infrastructure. Major differences between countries related to experience and commitment to running community projects, and differences in infrastructure, financing, and human resources. Professional football clubs' ability to support health promotion efforts depended on their ethos and the financial and human resources available to them. Overall, the EuroFIT program was well received by clubs, coaches, participants, and stakeholders, which was reflected by the many facilitators supporting sustained implementation. For sustainable implementation, it is crucial that clubs and their stakeholders engage fully with the EuroFIT program and understand that for an adequate program delivery their views (ethos) and ways of working influence the implementation and thereby the effectiveness of EuroFIT. An important prerequisite for future roll out of EuroFIT would be a strong EuroFIT delivery partner organization to ensure financial and human resources while overseeing and guiding the quality of delivery in clubs.

Mixed-methods process evaluation of the Dynamic Work study: A multicomponent intervention for office workers to reduce sitting time

Previously, we observed no significant reductions in sitting time of the multicomponent Dynamic Work (DW) intervention among office workers. In this study we used mixed-method data to understand context, implementation (i.e. recruitment and delivery) and mechanism of impact (i.e. experiences) of the DW intervention and to explore whether an higher implementation index score led to larger changes in participants' outcomes. We found considerable variation across departments regarding context (i.e. different size and work tasks) and implementation (i.e. delivery varied). Satisfaction with the DW intervention was high. An higher implementation index score was associated with lower overall sitting time, lower occupational sitting time, higher number of steps/day and steps/day at work at 4-months, which was maintained at 8-month for occupational sitting time. These findings provide an understanding that implementation was affected by a lack of availability of intervention components, department policy, work tasks, positioning and work location. TRIAL REGISTRATION: Clinicaltrials.gov, registration number:NCT03115645. Registered February 17, 2017 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03115645.

Identifying essential implementation strategies: a mixed methods process evaluation of a multi-strategy policy implementation intervention for schools

BACKGROUND

Physically Active Children in Education (PACE) is composed of eight implementation strategies that improves schools' implementation of a government physical activity policy. A greater understanding of each discrete implementation strategy could inform improvements to PACE for delivery at-scale. This study aimed to: (A) measure the dose delivered, fidelity, adoption and acceptability of each strategy using quantitative data; (B) identify implementation barriers and facilitators using qualitative data; and (C) explore the importance of each strategy by integrating both data sets (mixed methods).

METHODS

This study used data from a cluster randomised noninferiority trial comparing PACE with an adapted version (Adapted PACE) that was delivered with reduced in-person external support to reduce costs and increase scalability. Data were collected from both trials arms for between-group comparison. Descriptive statistics were produced using surveys of principals, in-school champions and teachers; and project records maintained by PACE project officers (objective A). Thematic analysis was performed using in-school champion and project officer interviews (objective B). Both data sets were integrated via a triangulation protocol and findings synthesized in the form of meta-inferences (objective C).

RESULTS

Eleven in-school champions and six project officers completed interviews; 33 principals, 51 in-school champions and 260 teachers completed surveys. Regardless of group allocation, implementation indicators were high for at least one component of each strategy: dose delivered =100%, fidelity ≥95%, adoption ≥83%, acceptability ≥50%; and several implementation barriers and facilitators were identified within three broad categories: external policy landscape, inner organizational structure/context of schools, and intervention characteristics and processes. All strategies were considered important as use varied by school, however support from a school executive and in-school champions' interest were suggested as especially important for optimal implementation.

CONCLUSION

This study highlights the importance of both executive support and in-school champions for successful implementation of school physical activity policies. In particular, identifying and supporting an in-school champion to have high power and high interest is recommended for future implementation strategies. This may reduce the need for intensive external support, thus improving intervention scalability.

Process and Outcome Evaluations of Interventions to Promote Voluntary Exercise Training Among South Korean Firefighters

The main aim of the present study is to evaluate reach, dose, fidelity, and outcomes of the interventions for promoting voluntary exercise training among South Korean firefighters. Four interventions for promoting voluntary exercise training among firefighters (i.e., virtual reality exercise system intervention, poster intervention, monitor intervention, and wearable health device intervention) were performed in a fire station located in Seoul, South Korea. To evaluate reach and dose received related to each intervention, participants were asked to answer several simple questions. Three process evaluators completed a 20-item survey to share their impressions related to the quality of intervention delivery. Paired t test was used to examine mean changes in primary (i.e., mean minutes of exercise training per week) and secondary outcomes (i.e., beliefs and intention) between pre- and postinterventions. More than 60% of participants experienced monitor and wearable health device interventions. Process evaluators tend not to agree with a statement saying that the number of the virtual reality exercise equipment was appropriate. Among firefighters who participated in exercise training less than 150 min per week at 1-month follow-up, mean minutes of exercise training per week increased by 67.95 min after interventions. Future studies need to examine whether the monitor and wearable health device interventions effectively increase exercise training participation among firefighters in other fire stations located in Seoul, South Korea.

Electrical stimulation to prevent recurring pressure ulcers in individuals with a spinal cord injury compared to usual care: the Spinal Cord Injury PREssure VOLTage (SCI PREVOLT) study protocol

BACKGROUND

Pressure ulcers (PUs) on the buttocks are among the most common secondary complications in individuals with chronic spinal cord injury (SCI). PUs can result from sitting for extended periods, disuse atrophy, increased sitting pressure and reduced circulation. Compared with usual care, activation of paralysed muscles using electrical stimulation (ES) has been shown to markedly increase paralysed muscle mass, improve circulation of skin and muscle and improve sitting pressure distribution. ES might therefore be a useful method to reduce PU incidence.

METHODS

A multicentre randomized controlled trial (SCI PREVOLT) will be conducted with an economic and process evaluation alongside. One hundred participants with a SCI in the chronic phase and a minimal incidence of 1 PU in the last 5 years will be recruited from rehabilitation centres across the Netherlands. Participants will be stratified by centre and age and randomized to the intervention or control group. The intervention group will use ES at least 1 h/day during at least 4 times a week for 1 year next to usual care. The control group will only receive usual care. The primary outcome is the incidence of PUs, measured by a blinded person assessing the presence or absence of a PU on the buttocks on a photo made by the participant or his/her caregiver. The incidence of a PU will be evaluated every 2 weeks. Secondary outcomes include interface pressure distribution, blood flow in the profunda femoris artery, muscle thickness of the hamstrings and gluteal muscles and questionnaires about different dimensions of life, e.g. participation and quality of life. Secondary outcomes will be measured at baseline and 3, 6, 9 and 12 months after randomization.

DISCUSSION

This study will assess if electrical stimulation is a (cost-)effective method to prevent PUs and reduce the risk factors of getting PUs. If ES is effective and cost-effective compared with usual care, ES could be implemented in daily treatment of individuals with a SCI.

TRIAL REGISTRATION

Netherlands Trials Register NTR NL9469 . Registered on 26 May 2021.

Contributions of changes in physical activity, sedentary time, diet and body weight to changes in cardiometabolic risk

Background

Increased physical activity (PA), reduced time spent sedentary (SED), healthier diet and reduced body weight may all have a positive impact on cardiometabolic risk. The relative importance of change in each of these variables on cardiometabolic risk, however, is unclear. We therefore sought to investigate the relative contributions of changes in PA, SED, diet and body weight on cardiometabolic risk.

Methods

This is a secondary analysis of data collected from the EuroFIT randomised controlled trial, which was a 12-week group-based lifestyle intervention for overweight middle-aged men delivered by coaches in football club stadia aiming to improve PA, SED, diet, and body weight. PA and SED were assessed by accelerometry, diet using the Dietary Instrument for Nutrition Education (DINE). An overall cardiometabolic risk score was derived from combining z-scores for glucose, HbA1c, insulin, lipids and blood pressure. In total, 707 men (from the overall cohort of 1113) with complete data for these variables at baseline and 12-month follow-up were included in the multivariable linear regression analyses.

Results

In multivariable analyses, change in number of steps (explaining 5.1% of R²) and dietary factors (less alcohol, fatty and sugary food, and more fruit and vegetables) (together explaining 4.5% of R²), but not changes in standing time or SED, were significantly associated with change in body weight. Changes in number of steps (R² = 1.7%), fatty food score (R² = 2.4%), and sugary food score (R² = 0.4%) were significantly associated with change in cardiometabolic risk score in univariable models. However, in multivariable models which included changes in weight as well as changes in steps and dietary variables, change in weight explained a substantially larger proportion of the change in cardiometabolic risk score, explaining 14.1% of R² (out of an overall model R² of 19.0%). When baseline (as well as change) values were also included in the model, 38.8% of R² for change in cardiometabolic risk score was explained overall, with 14.1% of R² still explained by change in weight.

Conclusion

Change in body weight, together with baseline cardiometabolic risk explained most of the change in cardiometabolic risk. Thus, the benefits of increasing physical activity and improving diet on cardiometabolic risk appear to act largely via an effect on changes in body weight.

Trial registration

International Standard Randomised Controlled Trials, ISRCTN-81935608. Registered 06052015. https://www.isrctn.com/ISRCTN81935608?q=&filters=recruitmentCountry:Portugal&sort=&offset=7&totalResults=92&page=1&pageSize=10&searchType=basic-search

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-021-01237-1.

The importance of standard operating procedures in physical fitness assessment: a brief review

Background

Physical fitness status is a key aspect of health and, consequently, it is important to create and adopt appropriate interventions to maintain or improve it, and assess it using valid measures. While in other testing contexts, standard operating procedures (SOPs) are commonly and widely adopted, in physical fitness testing, a variety of unstandardized testing protocols are proposed.

Aims

The topic of this review was to evaluate the existing literature on SOPs in physical fitness assessment and to provide guidelines on how SOPs could be created and adopted.

Method

The electronic databases PubMed, Web of Science and Scopus were screened and original, peer-reviewed studies that included SOPs, related to physical fitness, were recorded.

Results

After the inclusion and exclusion criteria screening, a total of six studies were included and these were critically and narratively analyzed.

Conclusions

Standard operating procedures are rarely adopted in the field of physical fitness and a step by step guide has been provided in this manuscript. In the future, it is suggested to follow protocols as a routine, because this is the only way to generalize and contextualize findings.

Exploring the provision and motives behind the adoption of health-promotion programmes in professional football clubs across four European countries

This study mapped existing health-promotion provisions targeting adults in professional football clubs across England, the Netherlands, Norway, and Portugal, and explored motives behind the clubs’ adoption of the European Fans in Training (EuroFIT) programme. We surveyed top-tier football clubs in the four countries and interviewed representatives from football clubs and the clubs’ charitable foundation who delivered EuroFIT. The findings showed large between-country differences, with football clubs in England reporting far greater healthy lifestyle provision than other countries. Relatively few health-promotion programmes targeted adults, particularly in the Netherlands, Portugal, and Norway. Club representatives reported that the motives for adopting the EuroFIT programme often involved adhering to both the social objectives of the football club or club’s foundation and business-related objectives. They viewed the scientific evidence and evaluation underpinning EuroFIT as helpful in demonstrating the value and potential future impact of both the programme and the clubs’ wider corporate social responsibility provision.

A school-based, peer-led programme to increase physical activity among 13- to 14-year-old adolescents: the GoActive cluster RCT

Background

Adolescent physical activity levels are low and are associated with rising disease risk and social disadvantage. The Get Others Active (GoActive) intervention was co-designed with adolescents and teachers to increase physical activity in adolescents.

Objective

To assess the effectiveness and cost-effectiveness of the school-based GoActive programme in increasing adolescents’ moderate-to-vigorous physical activity.

Design

A cluster randomised controlled trial with an embedded mixed-methods process evaluation.

Setting

Non-fee-paying schools in Cambridgeshire and Essex, UK (n = 16). Schools were computer randomised and stratified by socioeconomic position and county.

Participants

A total of 2862 Year 9 students (aged 13–14 years; 84% of eligible students).

Intervention

The iteratively developed feasibility-tested refined 12-week intervention trained older adolescents (mentors) and in-class peer leaders to encourage classes to undertake two new weekly activities. Mentors met with classes weekly. Students and classes gained points and rewards for activity in and out of school.

Main outcome measures

The primary outcome was average daily minutes of accelerometer-assessed moderate-to-vigorous physical activity at 10 months post intervention. Secondary outcomes included accelerometer-assessed activity during school, after school and at weekends; self-reported physical activity and psychosocial outcomes; cost-effectiveness; well-being and a mixed-methods process evaluation. Measurement staff were blinded to allocation.

Results

Of 2862 recruited participants, 2167 (76%) attended 10-month follow-up measurements and we analysed the primary outcome for 1874 (65.5%) participants. At 10 months, there was a mean decrease in moderate-to-vigorous physical activity of 8.3 (standard deviation 19.3) minutes in control participants and 10.4 (standard deviation 22.7) minutes in intervention participants (baseline-adjusted difference –1.91 minutes, 95% confidence interval –5.53 to 1.70 minutes; p = 0.316). The programme cost £13 per student compared with control. Therefore, it was not cost-effective. Non-significant indications of differential impacts suggested detrimental effects among boys (boys –3.44, 95% confidence interval –7.42 to 0.54; girls –0.20, 95% confidence interval –3.56 to 3.16), but favoured adolescents from lower socioeconomic backgrounds (medium/low 4.25, 95% confidence interval –0.66 to 9.16; high –2.72, 95% confidence interval –6.33 to 0.89). Mediation analysis did not support the use of any included intervention components to increase physical activity. Some may have potential for improving well-being. Students, teachers and mentors mostly reported enjoying the GoActive intervention (56%, 87% and 50%, respectively), but struggled to conceptualise their roles. Facilitators of implementation included school support, embedding a routine, and mentor and tutor support. Challenges to implementation included having limited school space for activities, time, and uncertainty of teacher and mentor roles.

Limitations

Retention on the primary outcome at 10-month follow-up was low (65.5%), but we achieved our intended sample size, with retention comparable to similar trials.

Conclusions

A rigorously developed school-based intervention (i.e. GoActive) was not effective in countering the age-related decline in adolescent physical activity. Overall, this mixed-methods evaluation provides transferable insights for future intervention development, implementation and evaluation.

Future work

Interdisciplinary research is required to understand educational setting-specific implementation challenges. School leaders and authorities should be realistic about expectations of the effect of school-based physical activity promotion strategies implemented at scale.

Trial registration

Current Controlled Trials ISRCTN31583496.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 9, No. 6. See the NIHR Journals Library website for further project information. This work was additionally supported by the Medical Research Council (London, UK) (Unit Programme number MC_UU_12015/7) and undertaken under the auspices of the Centre for Diet and Activity Research (Cambridge, UK), a UK Clinical Research Collaboration Public Health Research Centre of Excellence. Funding from the British Heart Foundation (London, UK), Cancer Research UK (London, UK), Economic and Social Research Council (Swindon, UK), Medical Research Council, the National Institute for Health Research (Southampton, UK) and the Wellcome Trust (London, UK), under the auspices of the UK Clinical Research Collaboration, is gratefully acknowledged (087636/Z/08/Z; ES/G007462/1; MR/K023187/1). GoActive facilitator costs were borne by Essex and Cambridgeshire County Councils.

Interventions outside the workplace for reducing sedentary behaviour in adults under 60 years of age

BACKGROUND

Adults spend a majority of their time outside the workplace being sedentary. Large amounts of sedentary behaviour increase the risk of type 2 diabetes, cardiovascular disease, and both all-cause and cardiovascular disease mortality.

OBJECTIVES

Primary • To assess effects on sedentary time of non-occupational interventions for reducing sedentary behaviour in adults under 60 years of age Secondary • To describe other health effects and adverse events or unintended consequences of these interventions • To determine whether specific components of interventions are associated with changes in sedentary behaviour • To identify if there are any differential effects of interventions based on health inequalities (e.g. age, sex, income, employment) SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, Cochrane Database of Systematic Reviews, CINAHL, PsycINFO, SportDiscus, and ClinicalTrials.gov on 14 April 2020. We checked references of included studies, conducted forward citation searching, and contacted authors in the field to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster RCTs of interventions outside the workplace for community-dwelling adults aged 18 to 59 years. We included studies only when the intervention had a specific aim or component to change sedentary behaviour.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles/abstracts and full-text articles for study eligibility. Two review authors independently extracted data and assessed risk of bias. We contacted trial authors for additional information or data when required. We examined the following primary outcomes: device-measured sedentary time, self-report sitting time, self-report TV viewing time, and breaks in sedentary time.

MAIN RESULTS

We included 13 trials involving 1770 participants, all undertaken in high-income countries. Ten were RCTs and three were cluster RCTs. The mean age of study participants ranged from 20 to 41 years. A majority of participants were female. All interventions were delivered at the individual level. Intervention components included personal monitoring devices, information or education, counselling, and prompts to reduce sedentary behaviour. We judged no study to be at low risk of bias across all domains. Seven studies were at high risk of bias for blinding of outcome assessment due to use of self-report outcomes measures. Primary outcomes Interventions outside the workplace probably show little or no difference in device-measured sedentary time in the short term (mean difference (MD) -8.36 min/d, 95% confidence interval (CI) -27.12 to 10.40; 4 studies; I² = 0%; moderate-certainty evidence). We are uncertain whether interventions reduce device-measured sedentary time in the medium term (MD -51.37 min/d, 95% CI -126.34 to 23.59; 3 studies; I² = 84%; very low-certainty evidence) We are uncertain whether interventions outside the workplace reduce self-report sitting time in the short term (MD -64.12 min/d, 95% CI -260.91 to 132.67; I² = 86%; very low-certainty evidence). Interventions outside the workplace may show little or no difference in self-report TV viewing time in the medium term (MD -12.45 min/d, 95% CI -50.40 to 25.49; 2 studies; I² = 86%; low-certainty evidence) or in the long term (MD 0.30 min/d, 95% CI -0.63 to 1.23; 2 studies; I² = 0%; low-certainty evidence). It was not possible to pool the five studies that reported breaks in sedentary time given the variation in definitions used. Secondary outcomes Interventions outside the workplace probably have little or no difference on body mass index in the medium term (MD -0.25 kg/m², 95% CI -0.48 to -0.01; 3 studies; I² = 0%; moderate-certainty evidence). Interventions may have little or no difference in waist circumference in the medium term (MD -2.04 cm, 95% CI -9.06 to 4.98; 2 studies; I² = 65%; low-certainty evidence). Interventions probably have little or no difference on glucose in the short term (MD -0.18 mmol/L, 95% CI -0.30 to -0.06; 2 studies; I² = 0%; moderate-certainty evidence) and medium term (MD -0.08 mmol/L, 95% CI -0.21 to 0.05; 2 studies, I² = 0%; moderate-certainty evidence) Interventions outside the workplace may have little or no difference in device-measured MVPA in the short term (MD 1.99 min/d, 95% CI -4.27 to 8.25; 4 studies; I² = 23%; low-certainty evidence). We are uncertain whether interventions improve device-measured MVPA in the medium term (MD 6.59 min/d, 95% CI -7.35 to 20.53; 3 studies; I² = 70%; very low-certainty evidence). We are uncertain whether interventions outside the workplace improve self-reported light-intensity PA in the short-term (MD 156.32 min/d, 95% CI 34.34 to 278.31; 2 studies; I² = 79%; very low-certainty evidence). Interventions may have little or no difference on step count in the short-term (MD 226.90 steps/day, 95% CI -519.78 to 973.59; 3 studies; I² = 0%; low-certainty evidence) No data on adverse events or symptoms were reported in the included studies.

AUTHORS' CONCLUSIONS

Interventions outside the workplace to reduce sedentary behaviour probably lead to little or no difference in device-measured sedentary time in the short term, and we are uncertain if they reduce device-measured sedentary time in the medium term. We are uncertain whether interventions outside the workplace reduce self-reported sitting time in the short term. Interventions outside the workplace may result in little or no difference in self-report TV viewing time in the medium or long term. The certainty of evidence is moderate to very low, mainly due to concerns about risk of bias, inconsistent findings, and imprecise results. Future studies should be of longer duration; should recruit participants from varying age, socioeconomic, or ethnic groups; and should gather quality of life, cost-effectiveness, and adverse event data. We strongly recommend that standard methods of data preparation and analysis are adopted to allow comparison of the effects of interventions to reduce sedentary behaviour.

Five-year cost-effectiveness analysis of the European Fans in Training (EuroFIT) physical activity intervention for men versus no intervention

Objectives

Increasing physical activity reduces the risk of chronic illness including Type 2 diabetes, cardiovascular disease and certain types of cancer. Lifestyle interventions can increase physical activity but few successfully engage men. This study aims to investigate the 5 year cost-effectiveness of EuroFIT, a program to improve physical activity tailored specifically for male football (soccer) fans compared to a no intervention comparison group.

Methods

We developed a Markov cohort model in which the impact of improving physical activity on five chronic health conditions (colorectal cancer, Type 2 diabetes, coronary heart disease, stroke and depression) and mortality was modelled. We estimated costs from a societal perspective and expressed benefits as quality adjusted life years (QALYs). We obtained data from a 4-country (England, Netherlands, Portugal and Norway) pragmatic randomised controlled trial evaluating EuroFIT, epidemiological and cohort studies, and meta-analyses. We performed deterministic and probabilistic sensitivity analyses to assess the impact of uncertainty in the model’s parameter values on the cost-effectiveness results. We used Monte Carlo simulations to estimate uncertainty and presented this using cost-effectiveness acceptability curves (CEACs). We tested the robustness of the base case analysis using five scenario analyses.

Results

Average costs over 5 years per person receiving EuroFIT were €14,663 and per person receiving no intervention €14,598. Mean QALYs over 5 years were 4.05 per person for EuroFIT and 4.04 for no intervention. Thus, the average incremental cost per person receiving EuroFIT was €65 compared to no intervention, while the average QALY gain was 0.01. This resulted in an ICER of €5206 per QALY gained. CEACs show that the probability of EuroFIT being cost-effective compared to no intervention is 0.53, 0.56 and 0.58 at thresholds of €10,000, €22,000 and €34,000 per QALY gained, respectively. When using a time horizon of 10 years, the results suggest that EuroFIT is more effective and less expensive compared to (i.e. dominant over) no intervention with a probability of cost-effectiveness of 0.63 at a threshold of €22,000 per QALY gained.

Conclusions

We conclude the EuroFIT intervention is not cost-effective compared to no intervention over a period of 5 years from a societal perspective, but is more effective and less expensive (i.e. dominant) after 10 years. We thus suggest that EuroFIT can potentially improve public health in a cost-effective manner in the long term.

Rugby Fans in Training New Zealand (RUFIT-NZ): protocol for a randomized controlled trial to assess the effectiveness and cost-effectiveness of a healthy lifestyle program for overweight men delivered through professional rugby clubs in New Zealand

Background

A healthy lifestyle program that appeals to, and supports, obese New Zealand (NZ) European, Māori (indigenous) and Pasifika men to achieve weight loss is urgently needed. In Scotland, Football Fans in Training (FFIT), a weight management and healthy lifestyle program for overweight and obese men aged 35–65 years , delivered by community coaching staff at professional football clubs, has been shown to be beneficial and cost-effective. A pilot program inspired by FFIT but delivered by professional rugby clubs in NZ (n = 96) was shown to be effective in weight loss, improved physiological outcomes, and adherence to healthy lifestyle behaviors in overweight and obese men. The objective of this trial is to determine the effectiveness and cost-effectiveness of the Rugby Fans in Training New Zealand (RUFIT-NZ) program.

Methods

A pragmatic, two-arm, multi-center, randomized controlled trial involving 308 overweight and obese men aged 30–65 years, randomized to either an intervention group (n = 154) or a wait-list control group (n = 154). The intervention-group participated in the 12-week RUFIT-NZ program, a gender-sensitized, healthy lifestyle intervention adapted to the environment and cultural diversity of NZ and delivered through professional rugby clubs. Participants in the intervention group undergo physical training sessions, in addition to workshop-based sessions to learn about nutrition, physical activity, sleep, sedentary behavior, and a range of behavior-change strategies for sustaining a healthier lifestyle. The control group receives the program after 52 weeks. The primary outcome is change in body weight from baseline to 52 weeks. Secondary outcomes include change in body weight at 12 weeks; waist circumference, blood pressure, fitness, and lifestyle behaviors at 12 and 52 weeks; and cost-effectiveness. A process evaluation informed by the RE-AIM framework will evaluate potential implementation of RUFIT-NZ as an ongoing program in NZ after the trial.

Discussion

This trial will investigate the effectiveness and cost-effectiveness of the RUFIT-NZ program in overweight and obese NZ men.

Trial registration

Australia New Zealand Clinical Trials Registry, ACTRN12619000069156. Registered on 18 January 2019, according to the World Health Organization Trial Registration Data Set. Universal Trial Number, U1111-1245-0645.

Scale-Up and Scale-Out of a Gender-Sensitized Weight Management and Healthy Living Program Delivered to Overweight Men via Professional Sports Clubs: The Wider Implementation of Football Fans in Training (FFIT)

Increasing prevalence of obesity poses challenges for public health. Men have been under-served by weight management programs, highlighting a need for gender-sensitized programs that can be embedded into routine practice or adapted for new settings/populations, to accelerate the process of implementing programs that are successful and cost-effective under research conditions. To address gaps in examples of how to bridge the research to practice gap, we describe the scale-up and scale-out of Football Fans in Training (FFIT), a weight management and healthy living program in relation to two implementation frameworks. The paper presents: the development, evaluation and scale-up of FFIT, mapped onto the PRACTIS guide; outcomes in scale-up deliveries; and the scale-out of FFIT through programs delivered in other contexts (other countries, professional sports, target groups, public health focus). FFIT has been scaled-up through a single-license franchise model in over 40 UK professional football clubs to 2019 (and 30 more from 2020) and scaled-out into football and other sporting contexts in Australia, Canada, New Zealand, England and other European countries. The successful scale-up and scale-out of FFIT demonstrates that, with attention to cultural constructions of masculinity, public health interventions can appeal to men and support them in sustainable lifestyle change.

The effect of a programme to improve men's sedentary time and physical activity: The European Fans in Training (EuroFIT) randomised controlled trial

BACKGROUND

Reducing sitting time as well as increasing physical activity in inactive people is beneficial for their health. This paper investigates the effectiveness of the European Fans in Training (EuroFIT) programme to improve physical activity and sedentary time in male football fans, delivered through the professional football setting.

METHODS AND FINDINGS

A total of 1,113 men aged 30-65 with self-reported body mass index (BMI) ≥27 kg/m2 took part in a randomised controlled trial in 15 professional football clubs in England, the Netherlands, Norway, and Portugal. Recruitment was between September 19, 2015, and February 2, 2016. Participants consented to study procedures and provided usable activity monitor baseline data. They were randomised, stratified by club, to either the EuroFIT intervention or a 12-month waiting list comparison group. Follow-up measurement was post-programme and 12 months after baseline. EuroFIT is a 12-week, group-based programme delivered by coaches in football club stadia in 12 weekly 90-minute sessions. Weekly sessions aimed to improve physical activity, sedentary time, and diet and maintain changes long term. A pocket-worn device (SitFIT) allowed self-monitoring of sedentary time and daily steps, and a game-based app (MatchFIT) encouraged between-session social support. Primary outcome (objectively measured sedentary time and physical activity) measurements were obtained for 83% and 85% of intervention and comparison participants. Intention-to-treat analyses showed a baseline-adjusted mean difference in sedentary time at 12 months of -1.6 minutes/day (97.5% confidence interval [CI], -14.3-11.0; p = 0.77) and in step counts of 678 steps/day (97.5% CI, 309-1.048; p < 0.001) in favor of the intervention. There were significant improvements in diet, weight, well-being, self-esteem, vitality, and biomarkers of cardiometabolic health in favor of the intervention group, but not in quality of life. There was a 0.95 probability of EuroFIT being cost-effective compared with the comparison group if society is willing to pay £1.50 per extra step/day, a maximum probability of 0.61 if society is willing to pay £1,800 per minute less sedentary time/day, and 0.13 probability if society is willing to pay £30,000 per quality-adjusted life-year (QALY). It was not possible to blind participants to group allocation. Men attracted to the programme already had quite high levels of physical activity at baseline (8,372 steps/day), which may have limited room for improvement. Although participants came from across the socioeconomic spectrum, a majority were well educated and in paid work. There was an increase in recent injuries and in upper and lower joint pain scores post-programme. In addition, although the five-level EuroQoL questionnaire (EQ-5D-5L) is now the preferred measure for cost-effectiveness analyses across Europe, baseline scores were high (0.93), suggesting a ceiling effect for QALYs.

CONCLUSION

Participation in EuroFIT led to improvements in physical activity, diet, body weight, and biomarkers of cardiometabolic health, but not in sedentary time at 12 months. Within-trial analysis suggests it is not cost-effective in the short term for QALYs due to a ceiling effect in quality of life. Nevertheless, decision-makers may consider the incremental cost for increase in steps worth the investment.

TRIAL REGISTRATION

International Standard Randomised Controlled Trials, ISRCTN-81935608.

Protocol for a gender-sensitised weight loss and healthy living programme for overweight and obese men delivered in Australian football league settings (Aussie-FIT): A feasibility and pilot randomised controlled trial

INTRODUCTION

Overweight and obesity are highly prevalent among Australian men. Professional sports settings can act as a powerful 'hook' to engage men in weight loss programmes; the Football Fans in Training programme delivered in professional UK soccer clubs was successful and cost-effective in helping men lose weight. The Australian Football League (AFL) is a potentially attractive setting to engage men in a weight loss programme. We aim to develop, pilot and evaluate the feasibility of a weight loss intervention for overweight/obese middle-aged men, delivered in AFL settings, to promote weight loss and healthier lifestyles and determine its suitability for a future randomised control trial.

METHODS AND ANALYSIS

120 overweight/obese male fans will complete baseline physical and psychological health measures and objective measures of physical activity (PA), weight, waist size and blood pressure prior to randomisation into the intervention or waitlist comparison group. The intervention group will receive 12 weekly 90 min workshops incorporating PA, nutrition education, behaviour change techniques and principles of effective motivation. Four community coaches will be trained to deliver Aussie-FIT at two AFL clubs in Western Australia. Measurements will be repeated in both groups at 3 months (post-intervention) and 6 months (follow-up). Outcomes will include programme uptake, attendance, changes in lifestyle and weight variables to inform power calculations for a future definitive trial, fidelity of programme delivery, acceptability, satisfaction with the programme and perceptions of effectiveness. We will also determine trial feasibility and potential to gather cost-effectiveness data.

ETHICS AND DISSEMINATION

Ethics approval was granted by Curtin University's Human Research Ethics Committee (HREC2017-0458). Results will be disseminated via peer-reviewed publications, conference presentations and reports. A multicomponent dissemination strategy will include targeted translation and stakeholder engagement events to establish strategies for sustainability and policy change.

TRIAL REGISTRATION NUMBER

ACTRN12617000515392; Pre-results.

GoActive: a protocol for the mixed methods process evaluation of a school-based physical activity promotion programme for 13-14year old adolescents

BACKGROUND

Process evaluations are critical for interpreting and understanding outcome trial results. By understanding how interventions function across different settings, process evaluations have the capacity to inform future dissemination of interventions. The complexity of Get others Active (GoActive), a 12-week, school-based physical activity intervention implemented in eight schools, highlights the need to investigate how implementation is achieved across a variety of school settings. This paper describes the mixed methods GoActive process evaluation protocol that is embedded within the outcome evaluation. In this detailed process evaluation protocol, we describe the flexible and pragmatic methods that will be used for capturing the process evaluation data.

METHODS

A mixed methods design will be used for the process evaluation, including quantitative data collected in both the control and intervention arms of the GoActive trial, and qualitative data collected in the intervention arm. Data collection methods will include purposively sampled, semi-structured interviews and focus group interviews, direct observation, and participant questionnaires (completed by students, teachers, older adolescent mentors, and local authority-funded facilitators). Data will be analysed thematically within and across datasets. Overall synthesis of findings will address the process of GoActive implementation, and through which this process affects outcomes, with careful attention to the context of the school environment.

DISCUSSION

This process evaluation will explore the experience of participating in GoActive from the perspectives of key groups, providing a greater understanding of the acceptability and process of implementation of the intervention across the eight intervention schools. This will allow for appraisal of the intervention's conceptual base, inform potential dissemination, and help optimise post-trial sustainability. The process evaluation will also assist in contextualising the trial effectiveness results with respect to how the intervention may or may not have worked and, if it was found to be effective, what might be required for it to be sustained in the 'real world'. Furthermore, it will offer suggestions for the development and implementation of future initiatives to promote physical activity within schools.

TRIAL REGISTRATION

ISRCTN, ISRCTN31583496 . Registered on 18 February 2014.