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.

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.

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.

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

[This corrects the article DOI: 10.1371/journal.pmed.1002736.].

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.

Who are the high achievers at work? Perceived motivational climate, goal orientation profiles, and work performance.

The purpose of this study was to respond to the call for research on goal orientation (mastery and performance orientation) profiles in work contexts. Among 8,282 engineers and technologists, Latent profile analyses indicated that four different goal orientation profiles existed - primarily mastery oriented, indifferent, moderate multiple goals, and success oriented. Both success oriented employees and employees who are primarily mastery oriented indicated the highest individual work performance. Further, mastery and performance climates were found to be relevant antecedents of employees' goal orientation profiles. Supplementary analyses suggested that a primarily mastery oriented profile seems to be more beneficial for the facilitation of employee well-being. The practical implications of these findings and directions for future research are presented.

Study protocol of European Fans in Training (EuroFIT): a four-country randomised controlled trial of a lifestyle program for men delivered in elite football clubs.

BACKGROUND: Lifestyle interventions targeting physical activity, sedentary time and dietary behaviours have the potential to initiate and support behavioural change and result in public health gain. Although men have often been reluctant to engage in such lifestyle programs, many are at high risk of several chronic conditions. We have developed an evidence and theory-based, gender sensitised, health and lifestyle program (European Fans in Training (EuroFIT)), which is designed to attract men through the loyalty they feel to the football club they support. This paper describes the study protocol to evaluate the effectiveness and cost-effectiveness of the EuroFIT program in supporting men to improve their level of physical activity and reduce sedentary behaviour over 12 months. METHODS: The EuroFIT study is a pragmatic, two-arm, randomised controlled trial conducted in 15 football clubs in the Netherlands, Norway, Portugal and the UK (England). One-thousand men, aged 30 to 65 years, with a self-reported Body Mass Index (BMI) ≥27 kg/m(2) will be recruited and individually randomised. The primary outcomes are objectively-assessed changes in total physical activity (steps per day) and total sedentary time (minutes per day) at 12 months after baseline assessment. Secondary outcomes are weight, BMI, waist circumference, resting systolic and diastolic blood pressure, cardio-metabolic blood biomarkers, food intake, self-reported physical activity and sedentary time, wellbeing, self-esteem, vitality and quality of life. Cost-effectiveness will be assessed and a process evaluation conducted. The EuroFIT program will be delivered over 12 weekly, 90-minute sessions that combine classroom discussion with graded physical activity in the setting of the football club. Classroom sessions provide participants with a toolbox of behaviour change techniques to initiate and sustain long-term lifestyle changes. The coaches will receive two days of training to enable them to create a positive social environment that supports men in engaging in sustained behaviour change. DISCUSSION: The EuroFIT trial will provide evidence on the effectiveness and cost-effectiveness of the EuroFIT program delivered by football clubs to their male fans, and will offer insight into factors associated with success in making sustained changes to physical activity, sedentary behaviour, and secondary outcomes, such as diet. ISRCTN: 81935608 . Registered 16 June 2015.

Associations between health problems and athlete burnout: a cohort study in 210 adolescent elite athletes.

Objectives: We studied associations between the burden of health problems and athlete burnout in a population of athletes from Norwegian Sport Academy High Schools. Methods: This is a mixed prospective/retrospective cohort study. We included 210 athletes, 135 boys and 75 girls, from endurance, technical and team sports. We used the Oslo Sports Trauma Centres Questionnaire for Health Problems to collect 124 weeks of health data. During the first 26 weeks, athletes reported the health data prospectively using a smartphone app. For the following 98 weeks, we collected health data by interviewing athletes at the end of their third year in Sport Academy High School. At the time of the interview, the athletes also completed a web-based questionnaire, including the Athlete Burnout Questionnaire and covering social relations in sports and school, coach relations and living conditions. Results: A greater burden of health problems was associated with a higher score for athlete burnout (B: 0.16, 95% CI 0.09 to 0.22, p<0.001). In a multivariable model, this was true for both illnesses (B: 0.21, 95% CI 0.10 to 0.32, p<0.001), acute injuries (B: 0.16, 95% CI 0.04 to 0.27, p=0.007) and overuse injuries (B: 0.10, 95% CI 0.002 to 0.18, p=0.011). This was also true in gender and sports category subgroups. The coach having a high influence on training week was associated with a lower score for athlete burnout. Conclusion: A greater burden of health problems was associated with greater symptoms of athlete burnout in athletes attending Sport Academy High Schools.

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.

The European Football Fans in Training program (EuroFIT) led to health improvements in male football fans delivered through professional sports clubs in England, the Netherlands, Norway, and Portugal. This study looked at what factors influenced the implementation of the program. 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 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. Yet, an important prerequisite for the 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.

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.

Perceived Motivational Climates and Employee Energy: The Mediating Role of Basic Psychological Needs.

This study draws on achievement goal theory and self-determination theory to examine the associations among two motivational climates (i.e., mastery and performance) and two indicators of energy at work (i.e., vigor and emotional exhaustion), as well as the mediating role of basic psychological need satisfaction (i.e., autonomy, relatedness, and competence). A two-wave longitudinal study was conducted collecting data from 1,081 engineers and technologists. We applied previously validated instruments to assess the variables of interest. Structural equation modeling analyses were conducted to test the hypotheses. Our findings show that mastery climate is positively and significantly related to each of the three basic needs, whereas a performance climate is negatively and significantly related to each of the three basic needs. Further, the results indicate that the basic needs are significantly associated with both measures of energy, negatively with emotional exhaustion and positively with vigor. This pattern of results suggests that basic psychological need satisfaction mediates the relationship between motivational climates and energy at work.

Clarifying Misconceptions and Misrepresentations in Achievement Goal Research in Sport: A Response to Harwood, Hardy, and Swain.

In a recent article, Harwood, Hardy, and Swain (2000) presented what they termed a critical analysis of the conceptualization and measurement of achievement goals in sport. The purpose of the present article is to challenge their interpretation of achievement goal theory and to question many of their subsequent recommendations. Specifically, the present response will focus on Harwood et al.'s (a) interpretation of Nicholls' personal theories of achievement; (b) their contention that task involvement cannot exist in competitive sport; (c) the proposed tripartite conceptualization of goal involvement states; (d) their understanding of the relationship between the way an individual conceptualizes ability and the foundation of dispositional goal orientations; and (e) their criticisms of the way dispositional goal orientations have been measured in sport. Theoretical frameworks are always a work in progress. To this end, we concur with the spirit of Harwood et al.'s article which implies that our conceptual models should be continuously questioned, tested, and extended. However, we believe their interpretation and recommendations do little to enhance our conceptual understanding of achievement goal theory in sport.

Parental and coach support or pressure on psychosocial outcomes of pediatric athletes in soccer.

OBJECTIVE: The purpose of this article was to examine supportive and/or pressuring influences of parents and coaches on young athletes' maladaptive perfectionist tendencies, relationships to friends, and competency perceptions in soccer. Previous research has revealed that parents and coaches may give rise to both enjoyable and stressful sport experiences for the pediatric athlete and that parents and coaches are thus able to influence whether young people decide to quit sport or continue participating. Less is known about the relation of supportive versus pressuring parental and coach behaviors on the quality of athletes' achievement striving, relationships to friends in sport, and their competence perceptions. Such knowledge may help create a better psychological sport experience for pediatric athletes. DATA SOURCES/SYNTHESIS: A questionnaire-based cross-sectional field study was carried out among 677 young Norwegian soccer players (aged 10 to 14 years; 504 boys, 173 girls; mean age: boys = 11.9 years, SD = 2.9; girls = 11.2 years, SD = 2.1) taking part in the Norway Cup international youth soccer tournament in 2001. Multivariate analysis of variance (MANOVA) with follow-up canonical correlation was used to examine multivariate relationships between supportive and pressuring behavior and athletes' psychosocial experiences. RESULTS: Joint pressuring behaviors from parents and coaches related positively to maladaptive achievement striving, as indicated by overconcern for mistakes, doubt about one's soccer actions, and lowered perceptions of soccer competence. Mirroring these findings, predominantly supportive coach-created psychological climates were related to a linear pattern of psychological outcomes comprising high-quality friendships, positive competency perceptions, and the absence of specific worries related to achievement striving. CONCLUSIONS: Supportive, mastery-oriented coach influence seems beneficial for constructive psychosocial outcomes in pediatric athletes, and athletes experiencing a joint social pressure to excel from coaches and parents may benefit less psychosocially through sport.

Peer relationships in adolescent competitive soccer: associations to perceived motivational climate, achievement goals and perfectionism.

The aim of this study was to examine the relationship between the perceived motivational climate, achievement goals, perfectionism and indices of peer relationships in a sample of young male and female Norwegian soccer players. The sample consisted of 1719 experienced soccer players (1231 males, 488 females) aged 12-19 years (mean = 14.9 years) participating in the Norway Cup international youth soccer competition. The players responded to a questionnaire measuring perceived peer acceptance and quality of friendship in soccer, perceived motivational climate, achievement goals and perfectionism in soccer. Canonical correlation analyses revealed that young female players who perceived the motivational climate as predominantly mastery oriented, and who were moderately task oriented and scored negatively on maladaptive perfectionism, reported better relations with their peers in soccer. Constructive peer relations were evident in that they scored positively on companionship with their best friend in soccer; they perceived this friend as being loyal and allowing of free discussion, and they reported being socially accepted by their peers in soccer. Mirroring these findings, young male players who perceived the motivational climate as predominantly performance oriented, who had a moderately negative score on task orientation but a quite strong positive score on maladaptive perfectionism, reported negative relationships with peers in terms of these aspects. They also reported being in conflict with their best soccer friend. The findings suggest that the qualities of motivation have a systematic relationship with peer acceptance and the quality of friendship in male and female youth soccer.

Effect of motivational climate on sportspersonship among competitive youth male and female football players.

The purpose of this study was to investigate the influence of perceived motivational climate and gender on sportspersonship behavior of competitive youth football players. Participants were 512 boy and 202 girl Norwegian youth football players (12-14 years old) competing in an international football tournament. A 2 x 2 x 2 (gender, mastery climate high and low, performance climate high and low) MANOVA produced no multivariate or interaction effects, but main effects for gender, performance climate, and mastery climate did emerge. Post hoc analyses of the simple main effects found that boys and girls were different in sportspersonship, but only in that boys were more sportspersonlike than girls on one of the four sportspersonship dimensions. Players perceiving a high mastery climate endorsed sportspersonship more than those players perceiving a low mastery climate, and players perceiving a high performance climate were less likely to endorse sportspersonship than players perceiving a low performance climate. Canonical correlation analysis revealed that a strong mastery climate was positively associated with commitment, respect for social conventions, and respect for rules and officials. A strong performance climate was negatively associated with respect and concern for social conventions and respect for rules and officials, while a positive association emerged for respect and concern for the opponent. The results of our study suggest that both boys and girls may well perceive the coach emphasizing similar criteria of success and failure and thereby a similar culture of sportspersonship, while in general a strong mastery climate leads to a higher sportspersonship orientation.