T0
T1
T2
Objectively measured by fieldwork staff
✓
✓
✓
Height (T0 only), weight, body mass index, waist circumference, body composition (% fat)
Health and well-being
✓
✓
✓
Self-assessed health and fitness; self-esteem; positive and negative affect; health service and medication use
Joint pain; past and recent injuries affecting ability to do physical activity
✓
Health behaviours
✓
✓
✓
Diet; physical activity; alcohol consumption; smoking
Social and other characteristics
✓
✓
✓
Marital status; employment status; education
Ethnicity; quintile of deprivation of area of residence; housing tenure; orientation to masculine norms
✓
Football
✓
✓
✓
Frequency of attending matches at home and away games; frequency of viewing football at home and in the pub; football-associated alcohol consumption
All objective baseline physical measures (weight, height, waist circumference, blood pressure, percentage body fat) were taken in the clubs by fieldworkers trained to standard protocols (see Hunt et al. [21, 27] for more details). As part of the process evaluation of FFIT, men who had attended at least six sessions in August–December 2011 (85 % of intervention group) were invited to a discussion about their experiences of FFIT at the end of the 12 weekly FFIT sessions; 63 men participated in 13 focus groups. These discussions were audio-recorded with consent, transcribed verbatim, and transcripts checked for accuracy against recordings. Men were asked about their experience of taking part both in the FFIT programme and in the research evaluating its effectiveness. We were able to achieve very high levels of follow-up of the participants in the trial at both 12 weeks (88 % intervention group, 93 % of waitlist comparison group) and 12 months (89 % intervention group, 95 % of waitlist comparison group).
The results of the RCT are reported in detail elsewhere and have shown that participation in FFIT enables men to lose weight (the primary outcome of the trial was the difference in weight loss between the intervention and comparison groups 12 months after baseline) and gain other benefits to their health and well-being, and that the programme provides a cost-effective use of resources [21]. In brief, the trial succeeded in attracting high-risk men from a range of socioeconomic backgrounds; at baseline 92 % were classed as ‘obese’, mean body-mass index was 35.3 kg/m2, and over 90 % were at very high or extremely high risk of future ill-health on the basis of their combined BMI and waist circumference. Men who had done the FFIT programme weighed, on average, 5.6 kg less 12 months after baseline (compared with 0.6 kg in the waitlist comparison group). Put another way, 12 months after starting the programme, FFIT participants had lost over nine times more weight than men who had not done the programme. There were significant differences in the changes in the secondary outcomes post-programme (weight loss at 12 weeks, waist circumference, BMI, percent body fat, systolic and diastolic blood pressure, total MET-minutes/week expended in physical activity, fatty food score, fruit and vegetable score, sugary food score, amount of alcohol consumed, self-esteem, positive affect and negative affect), all of which showed greater health improvements in the intervention than the waitlist comparison group. At 12 months, these differences were still apparent, although sometimes the differences between the two groups had lessened.
The health economic assessment showed that FFIT was relatively inexpensive to deliver (including the cost of club-branded t-shirts, programme materials for coaches and participants, a pedometer for each man, club community coaches’ time for training and for delivering the sessions), and was judged to be cost-effective (for a cost-effectiveness threshold of £20,000 per quality-adjusted life year gained (QALY) , the probability that FFIT is cost-effective compared to no intervention is 0.72, and this probability rises to 0.89 for a cost-effectiveness threshold of £30,000) [21].
Our qualitative research has demonstrated the popularity of FFIT with its participants [16, 20, 23].
Future Work
Further funding for the FFIT programme has been provided by the Scottish Government for deliveries in the football seasons 2013–2014, and 2014–2015. The coordination of these deliveries is provided by SPFL Trust . Further projects have developed from FFIT, including a feasibility study of delivery of a similar programme in the rugby clubs setting (RUFIT ), a study of using a FFIT-based programme to address inactivity and sedentary behaviour in professional football clubs in four European countries (EuroFIT), and work testing the use of the football metaphor and form in other settings, including prisons .
Lessons Learnt
The football club setting proved very successful in attracting high-risk men from a wide range of social backgrounds to a weight management and healthy living programme
Professional sports clubs , and specifically professional football clubs in the United Kingdom, are increasingly seen as settings that can attract men to health-promoting activities [28, 29]; Pringle and colleagues suggest that ‘the product (i.e. football/EPL [English Premier League]) … , the place (club stadia and facilities), people (players and management) and processes (including communication, marketing and the product delivery infrastructure)’ all contribute to their appeal [29, p. 412]. The mean weight of the participants in the FFIT RCT was 109.5 kg (sd 17.3) and mean BMI was 35.3 kg/m2 (sd 4.9). Over 90 % of participants had a BMI > 30; 44 % were classed as ‘mildly obese’, 31 % as ‘moderately obese’, and 17 % as ‘extremely obese’. Over 95 % were classed as at ‘extremely high’ or ‘very high’ risk of developing Type-2 diabetes, hypertension and cardiovascular disease on the basis of their objectively measured body mass index and waist. The qualitative data revealed the powerful ‘draw’ of the football club setting in attracting men who were otherwise reluctant to attend existing weight management programmes [27]. The opportunity to undertake the FFIT programme in circumstances that enhanced physical and symbolic proximity to something they valued highly, i.e. the football club, was crucial in overcoming other apprehensions about enrolling in a group-based weight management programme. Although these men were sufficiently concerned about their weight to enrol for FFIT, less than 4 % had attended a commercial or NHS weight loss programme or clinic in the previous 3 months. Many of the men appreciated being able to work together in a male-only group, with ‘men like them’ (both in terms of shared interests and perceived similarities in body shape and fitness). The feeling that FFIT was ‘right’ for them was reinforced by what men said that FFIT was not: i.e. FFIT was not for women, not Weight Watchers or Scottish Slimmers, not a diet club and so on [27].
Participants’ ‘insider’ experiences of the club, i.e. the greater physical and symbolic proximity to the club that they felt they gained whilst on the programme, fostered a strong and supportive group identity which encouraged men in achieving their individual weight loss and other goals.
The FFIT programme can be delivered in other football club settings
FFIT was being designed to be generalised to other football club settings at relatively low cost. If the FFIT programme is delivered in other clubs, using the FFIT coach and participants’ materials and following appropriate training for delivery, weight loss and other positive health changes can be expected.
It is possible to conduct ‘gold standard’ rese arch, such as randomised controlled trials, in sports-based settings in partnership with community organisations
The FFIT evaluation demonstrates that, despite the many challenges in conducting this type of evaluative research in community settings such as professional football clubs [30], it is possible to obtain objective measures and use ‘gold standard’ evaluative designs (such as a RCT). Building a strong evidence base on what works and for whom for interventions in community-based sports settings is only possible through the establishment of strong working partnerships with the organisations that deliver and fund novel interventions and requires considerable investment in relationships with all parties. Working with coaches and clubs in a competitive league environment to deliver a programme to a standardised protocol was facilitated by the coordination of the SPFL and the commitment of community coaches to their club’s fans.
Men will change
Assertions that men undertake ‘risky’ behaviours (such as smoking and drinking excessively) and avoid health-protective behaviours (such as help-seeking) to prove their status as ‘real’ men are commonplace [31], and reinforced in popular media and day-to-day interactions. Some have argued that ‘the very state of manhood’ is ‘a precarious social status that is hard won and easily lost [requiring], continual public demonstrations of proof’ [32, p. 101]. Findings from FFIT reinforce earlier evidence [16] that FFIT is valued by men who want to lose weight, is enjoyable and engaging, and enables men to undertake positive care of themselves and their health whilst ‘bolstering’ their masculine capital through their association with football clubs, symbolically and physically, and their participation and association with other men like them. The men’s own evaluations of the usefulness of various elements of the FFIT programme (see Table 20.2) show how they valued learning about diet, physical activity and how to sustain behaviour changes in a group setting with other men.
Table 20.2
Men’s rating of various aspects of the FFIT programme
