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.

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.

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/m² 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.

Trial registration

ISRCTN: 81935608. Registered 16 June 2015.

A national research agenda for pre-hospital emergency medical services in the Netherlands: a Delphi-study

BACKGROUND

In pre-hospital Emergency Medical Services (EMS) more research is needed to direct and underpin care delivery and inform policy. To target future research efforts, this study aimed to determine future research priorities with representatives of the EMS field.

METHODS

A four-round online Delphi survey was used to discuss different viewpoints and reach consensus on research priorities. A multidisciplinary panel of experts was recruited in the field of pre-hospital EMS and adjoining (scientific) professional organisations (n = 62). 48 research topics were presented in Delphi I, and the panel was asked to rate their importance on a 5-point scale. In Delphi II and III the panel selected their priority research topics, and arguments why and suggestions for research questions were collected and reported back. In Delphi IV appropriateness of the remaining topics and agreement within the expert panel was taken into account to make up the final list of research priorities.

RESULTS

The response on the Delphi-survey was high: 95% (n = 59; Delphi I); 97% (n = 60, Delphi II); 94% (n = 58, Delphi III); 97% (n = 60, Delphi IV). The panel reduced the number of research topics from 48 topics in Delphi I to 12 topics in Delphi III. A variety of arguments and suggestions for research questions were collected, giving insight in reasons why research on these topics in the near future is needed. Delphi IV showed an adequate level of agreement with respect to the 12 presented research topics. The following 9 topics were rated as appropriate for the national pre-hospital EMS research agenda: Non-conveyance to the hospital (ranked highest); Performance measures for quality of care; Hand over/registration/exchange of patient data; Care and task substitution; Triage; Assessment of acute neurologic signs & symptoms; Protocols and protocol adherence; Immobilisation; and Open/secure airway.

DISCUSSIONS

The research priorities identified in our study resemble those in other studies. However, the topic 'non-conveyance to the hospital' was determined as a priority in this study but not in other studies.

CONCLUSIONS

The national pre-hospital EMS research agenda can focus future research efforts to improve the evidence base and clinical practice of pre-hospital emergency medical services. Dissemination and implementation of the research agenda deserves careful attention.

Implementation strategies to enhance management of heavy alcohol consumption in primary health care: a meta-analysis

BACKGROUND AND AIMS

Screening and brief interventions (SBI) delivered in primary health care (PHC) are cost-effective in decreasing alcohol consumption; however, they are underused. This study aims to identify implementation strategies that focus on SBI uptake and measure impact on: (1) heavy drinking and (2) delivery of SBI in PHC.

METHODS

Meta-analysis was conducted of controlled trials of SBI implementation strategies in PHC to reduce heavy drinking. Key outcomes included alcohol consumption, screening, brief interventions and costs in PHC. Predictor measures concerned single versus multiple strategies, type of strategy, duration and physician-only input versus that including mid-level professionals. Standardized mean differences (SMD) were calculated to indicate the impact of implementation strategies on key outcomes. Effect sizes were aggregated using meta-regression models.

RESULTS

The 29 included studies were of moderate methodological quality. Strategies had no overall impact on patients' reported alcohol consumption [SMD=0.07; 95% confidence interval (CI)=-0.02 to 0.16], despite improving screening (SMD=0.53; 95% CI=0.28-0.78) and brief intervention delivery (SMD=0.64;95% CI=0.27-1.02). Multi-faceted strategies, i.e. professional and/or organizational and/or patient-orientated strategies, seemed to have strongest effects on patients' alcohol consumption (P<0.05, compared with professional-orientated strategies alone). Regarding SBI delivery, combining professional with patient-orientated implementation strategies had the highest impact (P<0.05). Involving other staff besides physicians was beneficial for screening (P<0.05).

CONCLUSIONS

To increase delivery of alcohol screening and brief interventions and decrease patients' alcohol consumption, implementation strategies should include a combination of patient-, professional- and organizational-orientated approaches and involve mid-level health professionals as well as physicians.

Making the connection-factors influencing implementation of evidence supported and non-evaluated lifestyle interventions in healthcare: a multiple case study

Many implementation barriers relate to lifestyle interventions (LIs) being developed by scientists. Exploring whether implementation of non-evaluated LIs is less complicated, might offer insight how to improve the use of effective interventions. This study aimed to identify influencing factors for implementation and compare factors between evidence supported and non-evaluated LIs. Evidence-supported (n = 7) and non-evaluated LIs (n = 7) in hospitals, general practices and community care organizations were included as cases. Semi-structured interviews (n = 46) were conducted. Additionally, documents (n = 207) were collected describing intervention, implementation process, and policy. We used a stepwise approach to inductively identify factors, organize them by diffusion phase, and an existing framework. A total of 37 factors were identified. 'Dissemination' factors were mainly observed in evidence-supported LIs. 'Compatibility to existing structures' ('adoption'), 'funding' and 'connection to existing care processes' ('implementation') was factors identified in all cases. 'Quality control' and 'ongoing innovation' ('maintenance') were reported in evidence-supported interventions. In all domains of the framework factors were observed. Factors identified in this study are in line with the literature. The findings do not support the assumption that implementation of non-evaluated LIs is perceived as less complex.

Physician-patient communication in single-bedded versus four-bedded hospital rooms

OBJECTIVE

To examine whether physician-patient communication in multi-bedded rooms differs from communication in single rooms during ward rounds.

METHODS

Ward rounds in single-bedded patient rooms and ward rounds in four-bedded rooms were audiotaped and analyzed with an adapted version of MIARS. The researcher completed an observational checklist of each encounter. We measured: the duration of speech time, the types of verbal and nonverbal communication, the extent to which patients and physicians raise intimate subjects.

RESULTS

Encounters during ward rounds in single rooms significantly took up more time than encounters in four-bedded rooms. The patients asked more questions and made more remarks in single rooms compared to four-bedded rooms. Empathic reactions of the physician were scored significantly more often in single rooms than in four-bedded rooms. No differences were observed concerning the extent to which intimate subjects were brought up.

CONCLUSION

This study is the first that investigated this subject. Findings suggest that single rooms contribute positively to physician-patient communication.

PRACTICE IMPLICATIONS

The research findings indicate the relevance of taking account of the context in which physician-patient communication takes place.

Do patients in hospitals benefit from single rooms? A literature review

In the context of growing attention for 'healing environments' and 'evidence based design' an increasing number of hospitals have decided to provide single-bedded rooms. However it remains unclear to what extent these policy decisions are based on scientific evidence. The aim of this study is to review the literature on benefits of single patient rooms for patients. The following outcome measures were used: privacy and dignity, patient satisfaction with care, noise and quality of sleep, hospital infection rates, recovery rates, and patient safety issues. We selected 25 studies for review. Randomized controlled trials on this subject were scarce, but other empirical studies have been found. We found that single rooms have a moderate effect on patient satisfaction with care, noise and quality of sleep, and the experience of privacy and dignity. Conflicting results have been found on hospital infection rates. Some studies did not show significant differences, while others concluded that single rooms decrease the risk of hospital infections. Evidence on recovery rates and patient safety was lacking. Too few sound studies were found to evaluate the effects of single patient rooms thoroughly. Future research should build the body of knowledge on single-bedded rooms in order to explore their impact on well-being and healing on both patients and staff. Also consequences of single rooms to management of care should be explored. Research should support policy making by exploring, indicating and initiating improvements in patient housing and quality of care.