Multi-country collaborative citizen science projects to co-design cardiovascular disease prevention strategies and advocacy: findings from Ethiopia, Malawi, Rwanda, and South Africa.

BACKGROUND: Cardiovascular diseases (CVD) were responsible for 20.5 million annual deaths globally in 2021, with a disproportionally high burden in sub-Saharan Africa (SSA). There is growing evidence of the use of citizen science and co-design approaches in developing interventions in different fields, but less so in the context of CVD prevention interventions in SSA. This paper reports on the collaborative multi-country project that employed citizen science and a co-design approach to (i) explore CVD risk perceptions, (ii) develop tailored prevention strategies, and (iii) support advocacy in different low-income settings in SSA. METHODS: This is a participatory citizen science study with a co-design component. Data was collected from 205 participants aged 18 to 75 years in rural and urban communities in Malawi, Ethiopia and Rwanda, and urban South Africa. Fifty-one trained citizen scientists used a mobile app-based (EpiCollect) semi-structured survey questionnaire to collect data on CVD risk perceptions from participants purposively selected from two communities per country. Data collected per community included 100-150 photographs and 150-240 voice recordings on CVD risk perceptions, communication and health-seeking intentions. Thematic and comparative analysis were undertaken with the citizen scientists and the results were used to support citizen scientists-led stakeholder advocacy workshops. Findings are presented using bubble graphs based on weighted proportions of key risk factors indicated. RESULTS: Nearly three in every five of the participants interviewed reported having a relative with CVD. The main perceived causes of CVD in all communities were substance use, food-related factors, and litter, followed by physical inactivity, emotional factors, poverty, crime, and violence. The perceived positive factors for cardiovascular health were nutrition, physical activity, green space, and clean/peaceful communities. Multi-level stakeholders (45-84 persons/country) including key decision makers participated in advocacy workshops and supported the identification and prioritization of community-specific CVD prevention strategies and implementation actions. Citizen science-informed CVD risk screening and referral to care interventions were piloted in six communities in three countries with about 4795 adults screened and those at risk referred for care. Health sector stakeholders indicated their support for utilising a citizen-engaged approach in national NCDs prevention programmes. The citizen scientists were excited by the opportunity to lead research and advocacy. CONCLUSION: The collaborative engagement, participatory learning, and co-designing activities enhanced active engagement between citizen scientists, researchers, and stakeholders. This, in turn, provided context-specific insights on CVD prevention in the different SSA settings.

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.

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.

Integrating care: the work of diabetes care technicians in an integrated care initiative.

BACKGROUND: As diabetes prevalence rises world-wide, the arrangement of clinics and care packages is increasingly debated by health care professionals (HCPs), health service researchers, patient groups and policy makers. 'Integrated care', while representing a range of approaches, has been positioned as a promising solution with potential to benefit patients and health systems. This is particularly the case in rural populations which are often removed from centres of specialist care. The social arrangements within diabetes integrated care initiatives are understudied but are of particular importance to those implementing such initiatives. In this paper we explore the 'work' of integration through an analysis of the role played by Health Care Assistants (HCAs) who were specially trained in aspects of diabetes care and given the title 'Diabetes Care Technician' (DCT). METHODS: Using thematic analysis of interview (n = 55) and observation data (n = 40), we look at: how the role of DCTs was understood by patients and other HCPs, as well as the DCTs; and explore what DCTs did within the integrated care initiative. RESULTS: Our findings suggested that the DCTs saw their role as part of a hierarchy, providing links between members of the integrated team, and explaining and validating clinical decisions. Patients characterised DCTs as friends and advisors who provided continuity. Other HCPs perceived the DCTs as supportive, providing long-term monitoring and doing a different job to conventional HCAs. We found that DCTs had to navigate local terrain (social, ethical and physical), engage in significant conversation and negotiate treatment plans created through integrated care. The analysis suggests that relationships between patients and the DCTs were strong, had the quality of friendship and mitigated loneliness. CONCLUSIONS: DCTs played multidimensional roles in the integrated care initiative that required great social and emotional skill. Building friendships with patients was central to their work, which mitigated loneliness and facilitated the care they provided.

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.

Commercial determinants of health: advertising of alcohol and unhealthy foods during sporting events.

Tobacco, alcohol and foods that are high in fat, salt and sugar generate much of the global burden of noncommunicable diseases. We therefore need a better understanding of how these products are promoted.The promotion of tobacco products through sporting events has largely disappeared over the last two decades, but advertising and sponsorship continues bycompanies selling alcohol, unhealthy food and sugar-sweetened beverage. The sponsorship of sporting events such as the Olympic Games, the men's FIFA World Cup and the men's European Football Championships in 2016, has received some attention in recent years in the public health literature. Meanwhile, British football and the English Premier League have become global events with which transnational companies are keen to be associated, to promote their brands to international markets. Despite its reach, the English Premier League marketing and sponsorship portfolio has received very little scrutiny from public health advocates. We call for policy-makers and the public health community to formulate an approach to the sponsorship of sporting events, one that accounts for public health concerns.

Le tabac, l'alcool et les aliments riches en graisse, en sel et en sucre génèrent la plus large partie de la charge mondiale des maladies non transmissibles. Il est donc nécessaire de mieux comprendre la manière dont ces produits sont promus. La promotion des produits du tabac dans le cadre d'événements sportifs a largement disparu au cours des vingt dernières années, mais la publicité et le sponsoring par des entreprises qui vendent de l'alcool, des produits alimentaires peu sains et des boissons sucrées sont encore d'actualité. Depuis quelques années, la littérature sur la santé publique commence à porter son attention sur le sponsoring d'événements sportifs, tels que les Jeux olympiques, la Coupe du monde masculine de la FIFA ou encore le Championnat d'Europe de football masculin de 2016. Mais dans le même temps, le football britannique et la Premier League anglaise sont devenus des événements mondiaux auxquels les multinationales aiment être associées pour promouvoir leurs marques auprès de marchés internationaux. Malgré leur portée, le marketing et le sponsoring de la Premier League anglaise semblent négligés par les défenseurs de la santé publique. Nous appelons les décideurs politiques et la communauté de santé publique à élaborer une approche pour le sponsoring d'événements sportifs qui réponde aux enjeux de santé publique.

El tabaco, el alcohol y los alimentos que son ricos en grasa, como la sal y el azúcar, generan gran parte de la carga mundial de enfermedades no contagiosas. Por tanto, necesitamos una mejor comprensión de la forma en que se promueven estos productos. La promoción de los productos del tabaco a través de eventos deportivos ha desaparecido en gran medida en las últimas dos décadas, pero la publicidad y el patrocinio continúan por parte de las empresas que venden alcohol, alimentos poco saludables y bebidas azucaradas. El patrocinio de eventos deportivos como los Juegos Olímpicos, la Copa Mundial de la FIFA masculina y el Campeonato de Fútbol Europeo del 2016 ha recibido cierta atención en los últimos años en la bibliografía sobre salud pública. Mientras tanto, el fútbol británico y la Premier League inglesa se han convertido en eventos globales con los que las empresas transnacionales están dispuestas a asociarse, para promocionar sus marcas ante los mercados internacionales. A pesar de su alcance, la cartera de comercialización y patrocinio de la Premier League inglesa apenas han sido objeto de escrutinio por parte de los defensores de la salud pública. Pedimos a los responsables de la formulación de políticas y a la comunidad de la salud pública que formulen un enfoque para el patrocinio de eventos deportivos, que tenga en cuenta estas preocupaciones sobre la salud pública.

Exploring the relationship between Big Food corporations and professional sports clubs: a scoping review.

OBJECTIVE: Professional sport occupies a prominent cultural position in societies across the globe and commercial organisations make use of this to promote their products. The present scoping review explores existing academic literature on the relationship between professional sports clubs and food and drink marketing and considers how this relationship may impact upon the public's health. DESIGN: The scoping review searched six databases. Experts were also consulted. Records written in languages other than English were excluded. We also excluded records relating to mega events (e.g. Olympics, Football World Cup) and alcohol marketing, because of the attention already given to these. SETTING: Professional sports clubs. RESULTS: We identified 18 166 titles, reviewed 163 abstracts and read twenty-six full texts. We included six papers in the review. Four were from Australia and New Zealand. The Australasian literature focused largely on the marketing of foods and beverages to children and the potential impact on consumption. Single papers from researchers in Turkey and the USA were identified. The Turkish paper analysed shirt sponsorship in football leagues internationally and showed food and beverage (including alcohol) companies were the most common sponsors. The US paper examined a mixed reaction to a football team named after an energy drink. CONCLUSIONS: Commercial relationships between professional sports clubs and Big Food corporations have largely eluded scrutiny in much of the world. The current review highlights the lack of public health research on these relationships. Research exploring the interdependent commercial practices of food and drink companies and professional sports clubs is urgently needed.

Long-term weight loss trajectories following participation in a randomised controlled trial of a weight management programme for men delivered through professional football clubs: a longitudinal cohort study and economic evaluation.

BACKGROUND: Obesity is a major public health concern requiring innovative interventions that support people to lose weight and keep it off long term. However, weight loss maintenance remains a challenge and is under-researched, particularly in men. The Football Fans in Training (FFIT) programme engages men in weight management through their interest in football, and encourages them to incorporate small, incremental physical activity and dietary changes into daily life to support long-term weight loss maintenance. In 2011/12, a randomised controlled trial (RCT) of FFIT demonstrated effectiveness and cost-effectiveness at 12 months. The current study aimed to investigate long-term maintenance of weight loss, behavioural outcomes and lifetime cost-effectiveness following FFIT. METHODS: A longitudinal cohort study comprised 3.5-year follow-up of the 747 FFIT RCT participants. Men aged 35-65 years, BMI ≥ 28 kg/m2 at RCT baseline who consented to long-term follow-up (n = 665) were invited to participate: those in the FFIT Follow Up Intervention group (FFIT-FU-I) undertook FFIT in 2011 during the RCT; the FFIT Follow Up Comparison group (FFIT-FU-C) undertook FFIT in 2012 under routine (non-research) conditions. The primary outcome was objectively-measured weight loss (from baseline) at 3.5 years. Secondary outcomes included changes in self-reported physical activity and diet at 3.5 years. Cost-effectiveness was estimated at 3.5 years and over participants' lifetime. RESULTS: Of 665 men invited, 488 (73%; 65% of the 747 RCT participants) attended 3.5-year measurements. The FFIT-FU-I group sustained a mean weight loss of 2.90 kg (95% CI 1.78, 4.02; p < 0.001) 3.5 years after starting FFIT; 32.2% (75/233) weighed ≥5% less than baseline. The FFIT-FU-C group had lost 2.71 kg (1.65, 3.77; p < 0.001) at the 3.5-year measurements (2.5 years after starting FFIT); 31.8% (81/255) weighed ≥5% less than baseline. There were significant sustained improvements in self-reported physical activity and diet in both groups. The estimated incremental cost-effectiveness of FFIT was £10,700-£15,300 per QALY gained at 3.5 years, and £1790-£2200 over participants' lifetime. CONCLUSIONS: Participation in FFIT under research and routine conditions leads to long-term weight loss and improvements in physical activity and diet. Investment in FFIT is likely to be cost-effective as part of obesity management strategies in countries where football is popular. TRIAL REGISTRATION: ISRCTN32677491 , 20 October 2011.

Can professional football clubs deliver a weight management programme for women: a feasibility study.

BACKGROUND: Levels of obesity remain high in the UK. The Football Fans in Training (FFIT) randomised controlled trial (RCT) demonstrated that a 12-week, gender-sensitised weight management, physical activity and healthy eating group programme delivered through professional football clubs helped men aged 35-65 years with BMI at least 28 kg/m2 lose a clinically-significant amount of weight. We aimed to test the feasibility of a minimally-adapted FFIT programme for delivery to women by assessing recruitment and completion rates; determining if the programme content and delivery required further refinement; and evaluating the potential of FFIT for Women to deliver improvements in weight and other clinical, behavioural and psychological outcomes. METHODS: A feasibility study of the FFIT for Women programme including before-and-after measurements of clinical (weight, waist, body mass index [BMI], blood pressure) behavioural (self-reported physical activity, food and alcohol intake) and psychological (self-esteem, positive and negative affect, physical and mental HRQoL) outcomes at five professional football clubs. Post-programme focus groups assessed acceptability of the programme format, content and style of delivery for women. RESULTS: Recruitment across the five clubs resulted in 123 women aged 35-65 years with BMI at least 28 kg/m2 taking part in the study. The mean weight (95.3 kg) and BMI (36.6 kg/m2) of the cohort were both suggestive of high risk of future disease. Of 123 women who started the programme, 94 (76%) completed it; 72 (58.5%) returned for 12-week follow-up measurements. Participants compared FFIT for Women favourably to commercial weight loss programmes and emphasised the importance of the programme's physical activity content. They also spoke positively about group dynamics, suggested that the approach to food was less restrictive than in other weight loss approaches, and broadly enjoyed the football setting. Mean weight loss was 2.87 kg (95% CI 2.09, 3.65, p ≤ 0.001). Mean waist reduction was 3.84 cm (2.92, 4.77, p ≤ 0.001). CONCLUSION: In this evaluation, FFIT for Women was feasible, acceptable and demonstrated potential as a weight loss programme. Our findings suggest the programme has the potential to produce outcomes that are on a par with existing commercial and state-funded offerings.

Optimization of the Hockey Fans in Training (Hockey FIT) weight loss and healthy lifestyle program for male hockey fans.

BACKGROUND: The health outcomes of men continue to be poorer than women globally. Challenges in addressing this problem include difficulties engaging men in weight loss programs as they tend to view these programs as contrary to the masculine narrative of independence and self-reliance. Researchers have been turning towards sports fans to engage men in health promotion programs as sports fans are typically male, and tend to have poor health habits. METHODS: Developed from the highly successful gender-sensitized Football Fans in Training program, Hockey Fans in Training (Hockey FIT) recruited 80 male hockey fans of the London Knights and Sarnia Sting who were overweight or obese into a weekly, 90-minute classroom education and group exercise program held over 12 weeks; a 40-week minimally-supported phase followed. A process evaluation of the Hockey FIT program was completed alongside a pragmatic randomized controlled trial and outcome evaluation in order to fully explore the acceptability of the Hockey FIT program from the perspectives of coaches delivering and participants engaged in the program. Data sources included attendance records, participant focus groups, coach interviews, assessment of fidelity (program observations and post-session coach reflections), and 12-month participant interviews. RESULTS: Coaches enjoyed delivering the program and found it simple to deliver. Men valued being among others of similar body shape and similar weight loss goals, and found the knowledge they gained through the program helped them to make and maintain health behaviour changes. Suggested improvements include having more hockey-related information and activities, greater flexibility with timing of program delivery, and greater promotion of technology support tools. CONCLUSIONS: We confirmed Hockey FIT was an acceptable "gender-sensitized" health promotion program for male hockey fans who were overweight or obese. Minor changes were required for optimization, which will be evaluated in a future definitive trial. TRIAL REGISTRATION: NCT02396524 (Clinicaltrials.gov). Date of registration: Feb 26, 2015.

Hockey Fans in Training (Hockey FIT) pilot study protocol: a gender-sensitized weight loss and healthy lifestyle program for overweight and obese male hockey fans.

BACKGROUND: Effective approaches that engage men in weight loss and lifestyle change are important because of worldwide increases, including in Canada, in obesity and chronic diseases. Football Fans in Training (FFIT), developed in Scotland, successfully tackled these problems by engaging overweight/obese male football fans in sustained weight loss and positive health behaviours, through program deliveries at professional football stadia. METHODS: Aims: 1) Adapt FFIT to hockey within the Canadian context and integrate with HealtheSteps™ (evidence-based lifestyle program) to develop Hockey Fans in Training (Hockey FIT); 2) Explore potential for Hockey FIT to help overweight/obese men lose weight and improve other outcomes by 12 weeks, and retain these improvements to 12 months; 3) Evaluate feasibility of recruiting and retaining overweight/obese men; 4) Evaluate acceptability of Hockey FIT; and 5) Conduct program optimization via a process evaluation. We conducted a two-arm pilot pragmatic randomized controlled trial (pRCT) whereby 80 overweight/obese male hockey fans (35-65 years; body-mass index ≥28 kg/m2) were recruited through their connection to two junior A hockey teams (London and Sarnia, ON) and randomized to Intervention (Hockey FIT) or Comparator (Wait-List Control). Hockey FIT includes a 12-week Active Phase (classroom instruction and exercise sessions delivered weekly by trained coaches) and a 40-week Maintenance Phase. Data collected at baseline and 12 weeks (both groups), and 12 months (Intervention only), will inform evaluation of the potential of Hockey FIT to help men lose weight and improve other health outcomes. Feasibility and acceptability will be assessed using data from self-reports at screening and baseline, program fidelity (program observations and coach reflections), participant focus group discussions, coach interviews, as well as program questionnaires and interviews with participants. This information will be analyzed to inform program optimization. DISCUSSION: Hockey FIT is a gender-sensitive program designed to engage overweight/obese male hockey fans to improve physical activity and healthy eating choices, thereby leading to weight loss and other positive changes in health outcomes. We expect this study to provide evidence for a full-scale confirmatory pRCT. TRIAL REGISTRATION: NCT02396524 (Clinicaltrials.gov). Date of registration: Feb 26, 2015.

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.

'Coz football is what we all have': masculinities, practice, performance and effervescence in a gender-sensitised weight-loss and healthy living programme for men.

In this paper we use a social practice approach to explore men's experience of Football Fans in Training (FFIT), a group-based weight management programme for men that harnesses men's symbolic attachment to professional football clubs to engage them in lifestyle change. FFIT is delivered by community coaches in clubs' stadia and is gender-sensitised in relation to context, content and style of delivery. Using a 'toolkit' of concepts from the work of Bourdieu, Goffman and Durkheim we analysed data from 13 focus group discussions with participants, and fieldwork notes from programme observations to investigate the appeal and success of FFIT, and how it worked to support change. Our analysis builds on our work on the importance of shared symbolic commitment to the football club and being with 'men like me' to understand how the interaction context facilitated 'effervescent' experiences. These experiences encouraged men to make changes to their diet and physical activity, talk about them, practice performing them and implement them in their lives. Thus a social practice approach illuminated the social processes through which lifestyle change was achieved, and we argue that it can deepen and enrich both intervention design and evaluation.

A gender-sensitised weight loss and healthy living programme for overweight and obese men delivered by Scottish Premier League football clubs (FFIT): a pragmatic randomised controlled trial.

BACKGROUND: The prevalence of male obesity is increasing but few men take part in weight loss programmes. We assessed the effect of a weight loss and healthy living programme on weight loss in football (soccer) fans. METHODS: We did a two-group, pragmatic, randomised controlled trial of 747 male football fans aged 35-65 years with a body-mass index (BMI) of 28 kg/m(2) or higher from 13 Scottish professional football clubs. Participants were randomly assigned with SAS (version 9·2, block size 2-9) in a 1:1 ratio, stratified by club, to a weight loss programme delivered by community coaching staff in 12 sessions held every week. The intervention group started a weight loss programme within 3 weeks, and the comparison group were put on a 12 month waiting list. All participants received a weight management booklet. Primary outcome was mean difference in weight loss between groups at 12 months, expressed as absolute weight and a percentage of their baseline weight. Primary outcome assessment was masked. Analyses were based on intention to treat. The trial is registered with Current Controlled Trials, number ISRCTN32677491. FINDINGS: 374 men were allocated to the intervention group and 374 to the comparison group. 333 (89%) of the intervention group and 355 (95%) of the comparison group completed 12 month assessments. At 12 months the mean difference in weight loss between groups, adjusted for baseline weight and club, was 4·94 kg (95% CI 3·95-5·94) and percentage weight loss, similarly adjusted, was 4·36% (3·64-5·08), both in favour of the intervention (p<0·0001). Eight serious adverse events were reported, five in the intervention group (lost consciousness due to drugs for pre-existing angina, gallbladder removal, hospital admission with suspected heart attack, ruptured gut, and ruptured Achilles tendon) and three in the comparison group (transient ischaemic attack, and two deaths). Of these, two adverse events were reported as related to participation in the programme (gallbladder removal and ruptured Achilles tendon). INTERPRETATION: The FFIT programme can help a large proportion of men to lose a clinically important amount of weight; it offers one effective strategy to challenge male obesity. FUNDING: Scottish Government and The UK Football Pools funded delivery of the programme through a grant to the Scottish Premier League Trust. The National Institute for Health Research Public Health Research Programme funded the assessment (09/3010/06).

Challenges in the Ethical Review of Peer Support Interventions.

PURPOSE: Ethical review processes have become increasingly complex. We have examined how 8 collaborating diabetes peer-support clinical trials were assessed by ethics committees. METHODS: The ethical reviews from the 8 peer-support studies were collated and subjected to a thematic analysis. We mapped the recommendations of local Institutional Review Boards and ethics committees onto the "4+1 ethical framework" (autonomy, beneficence, non-maleficence, and justice, along with concern for their scope of application). RESULTS: Ethics committees did not consistently focus on tasks within the 4+1 framework: many conducted reviews of scientific, organizational, and administrative activities. Of the 20 themes identified across the ethical reviews, only 4 fell within the scope of the 4+1 framework. Variation in processes and requirements for ethics committees were particularly evident between study countries. Some of the consent processes mandated by ethical review boards were disproportionate for peer support, increased participant burden, and reduced the practicality of testing an ethical intervention. Across the 8 studies, ethics committees' reviews included the required elements to ensure participant safety; however, they created a range of hurdles that in some cases delayed the research and required consent processes that could hinder the spontaneity and/or empathy of peer support. CONCLUSION: Ethics committees should avoid repeating the work of other trusted agencies and consider the ethical validity of "light touch" consent procedures for peer-support interventions. The investigators propose an ethical framework for research on peer support.

Do weight management programmes delivered at professional football clubs attract and engage high risk men? A mixed-methods study.

BACKGROUND: The prevalence of obesity in men in the UK is amongst the highest in Europe but men are less likely than women to use existing weight loss programmes. Developing weight management programmes which are appealing and acceptable to men is a public health priority. Football Fans in Training (FFIT), a men-only weight management programme delivered to groups of men at top professional football clubs, encourages men to lose weight by working with, not against, cultural ideals of masculinity. To inform further development of interventions in football club settings, the current study explored who is attracted to FFIT and why overweight/obese men choose to take part. METHODS: A mixed-methods study analysing baseline data on 747 men aged 35-65 years with BMI ≥ 28 kg/m2 who were participants in a randomised controlled trial of FFIT, and data from 13 focus group discussions with 63 men who had attended the programme. RESULTS: Objectively-measured mean body mass index was 35.3 kg/m2 (sd 4.9). Overall over 90% of participants were at very high or extremely high risk of future ill-health. Around three-quarters of participants in all age groups were at 'very high' risk of type 2 diabetes, hypertension and cardiovascular disease (72%, 73% and 80% of men aged 35-44, 45-54 and 55-64 years respectively). A further 21%, 16% and 13% were at 'extremely high' risk. Qualitative data revealed that the powerful 'draw' of the football club attracted men otherwise reluctant to attend existing weight management programmes. The location and style of delivery of early FFIT sessions fostered team spirit; men appreciated being with others 'like them' and the opportunity to undertake weight management in circumstances that enhanced physical and symbolic proximity to something they valued highly, the football club. CONCLUSIONS: The delivery of a weight management intervention via professional football clubs attracted men at high risk of ill-health. The setting enabled men to join a weight management programme in circumstances that felt 'right' rather than threatening to themselves as men. FFIT is an example of how to facilitate health promotion activities in a way that is consistent with, rather than challenging to, common ideals of masculinity.

Transient post-reperfusion left bundle branch block and accelerated idioventricular rhythm with paradoxical QRS narrowing.

Accelerated idioventricular rhythm (AIVR) commonly follows coronary reperfusion and has been called a "reperfusion arrhythmia". Transient left bundle branch block (LBBB) is only rarely seen after interventional reperfusion and is usually considered a procedural complication. We report herein electrocardiograms (ECGs) in a case of acute lateral myocardial infarction which demonstrate both post-perfusion AIVR and a simultaneous transient LBBB with fusion complexes causing paradoxical QRS narrowing.

Rapid ethnographic appraisal of community concepts of and responses to joint pain in Kilimanjaro, Tanzania.

INTRODUCTION: Musculoskeletal disorders, experienced as joint pain, are a significant global health problem, but little is known about how joint pain is categorised and understood in Tanzania. Understanding existing conceptualisations of and responses to joint pain is important to ensure both research and interventions are equitable and avoid biomedical imposition. METHODS: Rapid ethnographic appraisal was conducted in a periurban and rural community in Kilimanjaro, documenting language used to describe joint pain, ideas about causes, understandings of who experiences such pain, the impacts pain has and how people respond to it. We conducted 66 interviews with community leaders, traditional healers, community members and pharmacists.Photographs were taken and included in fieldnotes to supplement the interview data and develop thick descriptions. Data were analysed by constant comparison using QDA Miner software. RESULTS: Across the sample, dominant concepts of joint pain were named ugonjwa wa baridi, cold disease; ugonjwa wa uzee, old age disease; rimatizim, disease of the joints; and gauti, gout. Causes mentioned included exposure to the cold, old age, alcohol and red meat consumption, witchcraft, demons and injuries/falls. Age, gender and occupation were seen as important factors for developing joint pain. Perceived impacts of joint pain included loss of mobility, economic and family problems, developing new health conditions, death, reduction in sexual functioning and negative self-perceptions. Responses to joint pain blended biomedical treatments, herbal remedies, consultations with traditional healers and religious rituals. CONCLUSIONS: Conceptualisations of and responses to joint pain in the two communities were syncretic, mixing folk and biomedical practices. Narratives about who is affected by joint pain mirror emerging epidemiological findings, suggesting a strong 'lay epidemiology' in these communities. Anthropological methods can support the decolonisation of global health by decentring the imposition of English language biomedicine and pursuing synthetic, dignified languages of care.

Policies for type 2 diabetes and non-communicable disease management during the COVID-19 pandemic in Kenya and Tanzania: a desk review and views of decision-makers.

BACKGROUND: The COVID-19 pandemic caused disruptions in care that adversely affected the management of non-communicable diseases (NCDs) globally. Countries have responded in various ways to support people with NCDs during the pandemic. This study aimed to identify policy gaps, if any, in the management of NCDs, particularly diabetes, during COVID-19 in Kenya and Tanzania to inform recommendations for priority actions for NCD management during any future similar crises. METHODS: We undertook a desk review of pre-existing and newly developed national frameworks, policy models and guidelines for addressing NCDs including type 2 diabetes. This was followed by 13 key informant interviews with stakeholders involved in NCD decision-making: six in Kenya and seven in Tanzania. Thematic analysis was used to analyse the documents. RESULTS: Seventeen guidance documents were identified (Kenya=10; Tanzania=7). These included pre-existing and/or updated policies/strategic plans, guidelines, a letter, a policy brief and a report. Neither country had comprehensive policies/guidelines to ensure continuity of NCD care before the COVID-19 pandemic. However, efforts were made to update pre-existing documents and several more were developed during the pandemic to guide NCD care. Some measures were put in place during the COVID-19 period to ensure continuity of care for patients with NCDs such as longer supply of medicines. Inadequate attention was given to monitoring and evaluation and implementation issues. CONCLUSION: Kenya and Tanzania developed and updated some policies/guidelines to include continuity of care in emergencies. However, there were gaps in the documents and between policy/guideline documents and practice. Health systems need to establish disaster preparedness plans that integrate attention to NCD care to enable them to better handle severe disruptions caused by emergencies such as pandemics. Such guidance needs to include contingency planning to enable adequate resources for NCD care and must also address evaluation of implementation effectiveness.