Football Fans in Training (FFIT) Southampton

An Evaluation

Dr Robin Poole – Public Health Registrar

Southampton City Council
October 2015

With a forward by Dr Bob Coates, Consultant in Public Health, Southampton City Council
Forward

Men's Health: Football Fans in Training in Southampton

The men’s health programme in Southampton has focussed on a range of initiatives over the last 7-8 years.
These include targeted interventions for men, offering health promotion and education alongside football
coaching, support for men struggling with addictions (where 7 out of 10 local clients are men), diversion activities
for those recently treated for addiction, and inclusion work with men leaving the criminal justice system.
Sporting activities, together with coaching, educational interventions and volunteering opportunities offered a
powerful combination that both engaged men effectively and motivated them to tackle some deep routed
emotional, addiction, and physical health problems. Over this period the Saints Foundation has become a key
partner in delivering these programmes in the city, alongside local homeless charities in the city, the Society of
St James and Two Saints.

The FFIT programme in Scotland first came to our attention when it was evaluated by the Medical Research
Council in Glasgow (funded by a NIHR public health grant). The intervention package targeted men at ‘very high’
risk of type 2 diabetes, hypertension and cardiovascular disease, and delivered a clinically effective intervention
that reduced obesity, helped lower blood pressure, and increased physical activity, overall reducing the risk of
heart disease by a clinically important reduction in risk factors.

This intervention programme had a good fit with the sort of challenges we faced locally and was tailor made for
delivery by an organisation like the Saints Foundation. The decision was made to implement a similar programme
in Southampton, and the Saints Foundation, supported by local public health funding, agreed to do this. The
programme has just completed delivering the intervention to 15 men recruited at the last game of the 2014/15
football season. An independent evaluation by a local specialist registrar has captured the quantitative
outcomes (waist circumference, BMI, Blood Pressure etc.) alongside a more qualitative investigation of the
motivation and attitudes of the participants. We wanted to ensure we could replicate the health benefits
demonstrated in the Scotland study, and we were also interested in how we could ensure the benefits of the
12-week programme would be maintained longer term. Robin's investigation has explored both aspects of the
programme - the initial impact and the prospects for longer-term maintenance of the target weight.

The evaluation is encouraging, with clinical outcomes at least as good as the outcomes reported in Scotland, the
club coach delivered the programme in a high impact way, and participants engaged enthusiastically with the
programme. Robin’s report goes into the detail of his evaluation, which explores the participants’ motivation
and experience of being in the FFIT programme, alongside the outcomes they achieved. A second cohort of men
is already engaged, and we look forward to the results they will achieve. I recommend Robin’s study to you, and
wish to thank the team at the Saint’s Foundation for the way they have implemented this programme so
effectively. This is an excellent example of getting research into practice in an effective and efficient way. We
should also extend thanks to the FFIT researchers and coaches who helped to manualise and deliver the local
programme with such high fidelity to the original intervention package. This no doubt helped us to achieve such
good outcomes in our first cohort.

Dr Bob Coates
Consultant in Public Health
Southampton City Council
2nd October 2015
Contents

Plain English Summary Page 1

Executive Summary Page 1

1. Background Page 3
2. Aims Page 5
3. Objectives Page 6
4. Implementation of FFIT Southampton Page 6
4.1 First Steps Page 6
4.2 Coach Training Page 7
4.3 Facilities & Recruitment Page 7
4.4 Programme Delivery Page 7
4.5 Post-programme activity Page 7
5. Methods of Evaluation Page 8
5.1 Quantitative Data Page 8
5.2 Qualitative Data Page 8
6. Results page 10
6.1 Quantitative Data Page 10
6.1.1 Attendance Page 10
6.1.2 Baseline characteristics Page 10
6.1.3 Quantitative Results at 12 weeks Page 11
6.2 Results of Survey, Participant Focus Group and Coach Interview Page 12
6.2.1 Participant motivation and importance of team Page 12
6.2.2 Fidelity to the original FFIT programme Page 15
6.2.3 Characteristics of the coach associated with success Page 15
6.2.4 Participant perception of barriers to future success Page 17
6.2.5 Participant perspectives on program improvement Page 18
6.3 Costs Page 19
7. Conclusion Page 21
8. Strengths and weaknesses of the evaluation Page 22
9. Recommendations Page 24
10. Acknowledgements Page 25

List of abbreviations used in the text Page 26

References Page 26

Appendix A – Participant Questionnaire Page 28

Appendix B – FFIT Qualitative Focus Group – Focus Group Topic Guide Page 31
Appendix C – FFIT Qualitative Interview – Structured Interview Questions for Coach Page 33
Appendix D – Mapping of behaviour changes Page 35
Plain English Summary
Approximately six in every 10 people in England are currently overweight and it is well recognised
that this is bad for health. It is putting a lot of pressure on NHS resources and the situation is not
affordable. Men are more likely to be overweight than women. Men are also less likely to attend
traditional weight loss programmes. Football Fans in Training (FFIT) is a 12-week weight loss
programme designed especially for men to help them become more physically active and to eat
more healthily. The programme has been tested in a large number of overweight Scottish football
fans and was shown to help them lose weight and become healthier when compared to similar
men who were not in the programme. The programme is delivered at football clubs where football
fans feel at home. The public health team in Southampton City Council worked with the charity
division of Southampton Football Club (the ‘Saints Foundation’) to see if the FFIT programme
could work as well in Southampton as it did in Scotland, when run at St Mary’s stadium. Fifteen
overweight football fans had their weight and other measurements taken at the start and finish of
the programme and discussions were held with the coach and some of the participants to
understand how well the programme had worked. Efforts were also made to understand why
some of the men had joined the programme and how they felt things would go in the future. On
average each man taking part lost 6.9Kg (about one stone), an average loss of over 6% from their
starting weight. This level of weight loss was slightly greater than the weight loss found when the
programme was first tested in Scotland. Men in Southampton felt that the programme had been
successful and enjoyed being part of a team of other men at the football club. They highlighted the
importance of continuing to meet up as a group on a regular basis to help maintain the healthy
changes into the future. Some of the men thought that they may struggle to maintain their new
weight if they leave the group. The programme has some possible limitations. For example,
overweight men who do not like football as much may not benefit from FFIT in the same way, but
this would have to be tested. Overall the programme appears to be a success, although it is early
days. More Southampton football fans will be invited to go through the programme and further
assessments will be made to ensure that FFIT is also able to help these fans to lose weight.

Executive Summary
Overweight and obesity prevalence is increasing in England and is more common amongst men
than women1. The negative impact on the health of the individual and the huge and unsustainable
financial burden for the NHS are well documented2. Men are less likely than women to engage
with traditional weight loss interventions3. Football Fans in Training (FFIT) is a novel weight loss
and healthy lifestyle programme, developed in Scotland. It is designed for men in content, context
and delivery, which facilitates engagement with high risk individuals (Age 35-65, Body Mass Index
≥28 Kg/m2, Waist Circumference >100 cm) by connecting with their love of football and football
club3. The programme consists of twelve, 90-minute, weekly sessions combining classroom-based
learning and physical activity. It has become well established amongst several Scottish Premier

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Football League clubs, which was the setting for a robust randomised controlled trial (RCT) in
2011, funded by the Scottish Government and evaluated by the National Institute of Health
Research (NIHR)3. This trial demonstrated impressive 12-month weight loss outcomes and within
National Institute for Health and Care Excellence (NICE) recommended cost-effectiveness
thresholds3. The Public Health team within Southampton City Council, working in collaboration
with the charitable wing of Southampton Football Club, the ‘Saints Foundation’, saw an
opportunity to bring the programme to Southampton, based at St Mary’s stadium. This built on
recommendations from the English government which highlighted that a collaborative approach
between public, private and third sector organisations was crucial in ‘preventing and tackling’
obesity2. This evaluation was conducted using quantitative and qualitative methods shortly after
completion of the first delivery of the Southampton FFIT programme in order to compare whether
the benefits of FFIT would be transferable from the Scottish football club context to a Premier
League club on the English south coast. An initial cohort of 18 men enrolled for the programme, of
whom, 15 completed. At 12 weeks the mean weight loss for the group was 6.9 Kg (6.3% of initial
weight) with a range of -0.3 to 15.6 Kg (-0.3 to 13.5% of initial weight). These weight loss outcomes
exceeded weight loss at the same stage of the original RCT and percentage of participants reaching
5% weight loss exceeded NICE thresholds for a weight loss intervention. Long-term cost
effectiveness will only be realised if participants do not regain their weight within 2-3 years and
that at least 1 Kg of individual weight loss must be retained for a lifetime3. There was subjective
and objective evidence of fidelityi to the original programme. All participants completing a
questionnaire about the programme believed their participation to have been a success and
evidence from the qualitative evaluation suggested participants believed that being part of a
‘team’ was fundamental to this. Team participation was also seen as key to future maintenance of
weight and behaviour change. The majority of the participants continue to meet up on a weekly
basis for physical activity sessions, which are partly supported by the FFIT budget. These weekly
sessions may mitigate against future weight regain by maintaining the supportive power of ‘team’
and extrinsic motivation derived from this; participants who fail to continue to engage are less
likely to be protected against future weight regain. Should future participants be less enthusiastic
about football, football club, or the sense of ‘team’, they may also be less responsive to the FFIT
programme; this would need to be evaluated. FFIT has delivered the expected benefits in the first
cohort of men who were recruited in Southampton. The benefits, if maintained over coming years,
will significantly improve the health and fitness of the successful participants. FFIT has potential
to improve men's health and reduce the risk of diabetes and cardiovascular disease in the
community, and offers a highly effective model for men struggling to control their weight.

i Programme Fidelity refers to how well the programme was delivered as originally intended

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1. Background

Adverse health outcomes associated with overweight and obesity are well established and the huge
financial burden to the NHS is unsustainable2. The current prevalence of obesity in men in England is
26.0%, as defined by a Body Mass Index (BMI) of ≥30 Kg/m2, and overweight and obesity combined
has reached 67.1% of the male population (BMI ≥ 25 Kg/m2) and has risen with time1. This
prevalence of obesity, or overweight and obesity, is higher in men than women (23.8% obese, 57.2%
overweight and obese) and men are less likely to engage with weight loss interventions3.

Novel weight loss interventions, designed specifically to appeal to men, have been developed in
recent years to address this inequality. Football Fans in Training (FFIT) is one such male focused
intervention. It is a weight loss and healthy lifestyle intervention, designed for men in context,
content and delivery. The programme consists of twelve, 90-minute, weekly sessions, each
incorporating a classroom and physical activity component. The football club context for the
programme was purposefully chosen to appeal to male participants. It was developed by the
University of Glasgow in collaboration with the charitable wing of the Scottish Premier Football
League (The SPFL Trust) and following a successful optimisation phase4, underwent a rigorously
conducted pragmatic randomised controlled trial (RCT) in 20113, funded by the Scottish government
and evaluated by NIHR5.

Suitable men (Age 35-65 years old, BMI≥28, Waist circumference ≥100 cm) were randomised
between the intervention group (n=374), or a control group (n=374) who were scheduled to delay
the start of the programme by one year. The primary outcome measure was mean difference in
weight loss between intervention and control groups at 12 months (difference in average weight
between the groups). Compared to the control group, mean weight loss at 12 months after
adjustment 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).

A secondary outcome was mean difference in weight loss between intervention and control at the
earlier stage of 12 weeks. Compared to the control group, mean weight loss at 12 weeks after
adjustment for baseline weight and club, was 5.18 Kg (95% CI=4.35-6.00) or 4.71 % (3.98 to 5.44)
both in favour of the intervention (p<0.0001). Other secondary outcome measures are detailed in
the original research paper and included changes in waist circumference, body mass index (BMI),
body fat percentage, self-reported physical activity, self-reported eating and alcohol intake, and self-
reported psychological health and quality of life outcomes. A summary of outcome measures and
significance of results can be seen in table 1 on the next page:

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Table 1: Summary of outcome measures and significance in the FFIT RCT3

Primary Outcome Measure Differences between Significance

intervention & control
groups
Weight loss at 12 months 4.94 Kg (4.36%) Significant in favour of intervention
Secondary Outcome Measure Differences between Significance
intervention & control
groups
Weight loss at 12 weeks 5.18 Kg (4.71%) Significant in favour of intervention
Waist circumference reduction at 12 weeks 5.57 cm Significant in favour of intervention
Waist circumference reduction at 12 months 5.12 cm Significant in favour of intervention
BMI reduction at 12 weeks 1.66 Kg/m2 Significant in favour of intervention
BMI reduction at 12 months 1.56 Kg/m2 Significant in favour of intervention
Percentage body fat reduction at 12 weeks 2.16% Significant in favour of intervention
Percentage body fat reduction at 12 months 2.15% Significant in favour of intervention
Systolic Blood Pressure reduction at 12 weeks 4.51 mmHg Significant in favour of intervention
Systolic Blood Pressure reduction at 12 months 2.27 mmHg Significant in favour of intervention
Diastolic Blood Pressure at 12 weeks 2.51 mmHg Significant in favour of intervention
Diastolic Blood Pressure at 12 months 1.36 mmHg Significant in favour of intervention
Self-reported Physical Activity at 12 months 1.49 MET-min/week Significant in favour of intervention
Self-reported Diet See reference for details Significant in favour of intervention
Self-reported Alcohol at 12 weeks -4.47 units/week Significant in favour of intervention
Self-reported Alcohol at 12 months -2.59 units/week Significant in favour of intervention
Self-reported self-esteem See reference for details Significant in favour of intervention
Self-reported positive & negative affects See reference for details Significant in favour of intervention
Self-reported physical health related quality of life See reference for details Significant in favour of intervention
Self-reported mental health related quality of life See reference for details No significant difference at 12 months

Following the success of the RCT, the programme has been replicated in 26 Scottish football clubs. In
2013/14 the cost per participant in the Scottish model was £338 with an average weight loss of 7.62
Kg6. After the completion of the twelve-week programme there is considerable variability between
clubs in whether there is a continuation of some form of regular organised physical activity session
for the groups. Strictly speaking these sessions are not part of the programme although the FFIT
manual content includes encouragement for the participants to meet up for group sessions outside
the programme and for these to be maintained following the 12-week delivery.

Building on previous collaborative relationships with the charitable wing of Southampton Football
Club, ‘The Saints Foundation’, and in conjunction with SPFL Trust, the FFIT programme was
introduced in Southampton. The agreement was to pilot the programme in approximately 15
suitable participants and to evaluate the translation into the new setting. Two further cohorts of 15-
18 participants were also agreed in the original commissioning arrangements. This was the first
iteration of the FFIT model in an English Premier League Club. However, a further RCT, based on the
FFIT programme, is currently underway in fifteen clubs from four European countries, including five
English Premier League Clubs: Manchester City, Everton, Stoke City, Arsenal and Newcastle7.

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Figure 1 below summarises the structure and chronology of the FFIT programme, measurements and
the evaluation process:

Figure 1: Chronology of the FFIT programme, measurements and evaluation

(* PAR-Q is a brief questionnaire designed to screen for health conditions which necessitate a doctor’s advice before undertaking physical
activity)

2. Aims

To evaluate the delivery (process) and outcomes of the FFIT Southampton programme in order to
identify whether the benefits of FFIT would be transferable from the Scottish football club context to
a Premier League club on the English south coast. The evaluation will help inform the cost-
effectiveness of commissioning FFIT as a tier 2ii weight loss intervention for the public health
department and as a potential vehicle for sourcing funds elsewhere to expand the programme’s
reach.

ii Different tiers of weight management services cover different activities. Definitions vary locally but usually tier 1 covers universal
services (such as health promotion or primary care); tier 2 covers lifestyle interventions (like healthier eating and physical activity
programmes); tier 3 covers specialist weight management services; and tier 4 covers bariatric surgery.

5|Page
3. Objectives

3.1 To quantitatively:

3.1.1 Assess attendance, baseline characteristics and weight loss outcomes and compare these
between FFIT Southampton and the original Scottish FFIT RCT

3.1.2 Assess whether FFIT Southampton can deliver the minimal effectiveness of a tier 2 weight
loss intervention as suggested by NICE guidance8 of:

 Programme is completed by at least 60% of participants

 Average weight loss amongst participants of at least 3%
 At least 5% weight loss achieved by 30% of participants

3.2 To qualitatively investigate:

3.2.1 Participant motivation and importance of ‘team’

3.2.2 Fidelityiii to the original FFIT programme
3.2.3 Characteristics of the coach associated with success
3.2.4 Participant perception of barriers to future success
3.2.5 Participant perspectives on programme improvement

3.3 To ascertain:

3.3.1 Cost per participant and compare this to the recommended thresholds in weight loss
interventions as suggested by NICE in order to project the future weight loss maintenance
needed in FFIT participants to ensure cost-effectiveness.

4 Implementation of FFIT Southampton

4.1 First steps

Communication between the Saints Foundation and the SPFL Trust followed initial discussions with
Public Health Southampton. A fact-finding visit to Edinburgh to meet with SPFL Trust personnel and
observe an FFIT coach training session in progress was then arranged. A member of the
Southampton public health team accompanied a representative from Saints Foundation during the
visit. The programme is not subject to copyright and SPFL Trust are keen to share the model in order
to extend the reach of the public health benefits. However, in order to ensure fidelity of the
programme, the SPFL Trust prefer prospective FFIT coaches to be trained by their two day training
course delivered by an experienced FFIT trainer. The SPFL Trust also supply a two-part delivery

iii Programme Fidelity refers to how well the programme was delivered as originally intended

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manual. This manual offers a comprehensive and systematic guide to delivering the programme in
order to ensure the programme is delivered in a reliable way. Participant programme booklets and
an equipment kit containing weighing scales, height stadiometer, blood pressure machine, and an
‘Eat well Plate’ demonstration kit, were also supplied by the SPFL Trust. There is a fixed initial cost
associated with the training, stationary and equipment and on-going equipment costs would include
participant programme booklets.

4.2 Coach Training

Saints Foundation chose a suitable coach from their existing staff resource and the SPFL Trust coach
trainers delivered the coach training at Southampton Football Club on February 12th and 13th 2015. A
number of other Saints Foundation coaches and coaching assistants from Solent University also
attended the training at no additional cost.

4.3 Facilities & Recruitment

The Saints Foundation secured a booking for premises within their own facilities for the weekly
sessions to be held and recruitment was rolled out via advertising within the stadium on a match
day. Adverts were pinned above sinks and urinals in the toilets, and leaflets in food halls. From the
initial call for interest, 18 men were selected on a first come first served basis, assuming they fitted
the programme inclusion criteria, which were the same as the original RCT (Age 35-65 years old,
BMI≥28, Waist circumference ≥100 cm).

4.4 Programme delivery

The first cohort attended their first session on Wednesday 25th March and the last session was held
on Wednesday 10th June 2015. Sessions were held on Wednesday evenings 5-6.30 p.m. at
Southampton Football Club stadium, St Marys, Southampton.

During the 12-week programme, participants were informed about the future opportunity to attend
an FFIT football tournament against other FFIT participant groups from Scotland. Accommodation
and football kit expenses were covered by the FFIT Southampton programme budget and the
weekend football tournament took place in Scotland following the completion of the 12-week
delivery. Not all participants were available to participate in the weekend tournament.

4.5 Post-programme activity

Following the completion of the 12-week programme, 12 of the 15 participants continue to meet on
a weekly basis for a Wednesday evening football training session and/or a Thursday evening boxing
exercise class. The football training is held on club grounds at no additional cost and the boxing
exercise classes at a local boxing gym. FFIT Southampton supplemented the boxing exercise sessions
and each of the participants contributed £1 per session.

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5 Methods of evaluation

A combination of quantitative (numerical) and qualitative (non-numerical) methods was used to

assess process and outcome. Such mixed methodology gives a richer evaluation of the programme
delivery than can be understood from simply focusing on the numerical outcomes.

5.1 Quantitative Data

5.1.1 Anthropological data

The standard programme delivery includes the collection of anthropometric data (height, weight,
waist circumference and blood pressure) at programme registration, six weeks and 12 weeks. This
data was available for 15 of the original 18 participants recruited for the programme and was
measured by the coach. How to take accurate measurements is part of the FFIT coach training. The
coach was also asked to discuss contacting the participants after 12 months to collect further data.

5.1.2 Attendance rates

An attendance record was available for the 12-week programme.

5.1.3 Participant Survey

A five-question tick-box survey was collected from 11 of 15 participants (a convenience sample of

100% of those present at an event planning evening), which captured motivation for joining FFIT,
perceived main reason for success, perceived importance of the coach to success and aspects of
coach characteristics they associated with success. The questionnaire was developed specifically for
this purpose in the absence of an existing fit-for-purpose alternative. The questionnaire was not
piloted but face validated by colleagues. A copy of the questionnaire can be found in Appendix A.
The survey is considered to generate quantitative data in the context of this evaluation due to the
closed nature of the questions.

5.2 Qualitative Data

The qualitative work attempted to investigate a number of different areas:

5.2.1 Participant motivation and the importance of ‘team’

To understand the importance of ‘football’, the ‘Saints’ brand and the concept of ‘team’ in
the motivation and engagement of participants.

5.2.2 Fidelity to the original FFIT programme

Consistent programme delivery of a proven weight loss intervention is more likely to deliver
beneficial outcomes. Objective evidence for fidelity was sought by mapping statements

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 evidenced in the interview and focus group to the original behaviour change mapping of the
FFIT programme4.

5.2.3 Characteristics of the coach associated with success

Participants' views on the coaching methods and style of delivery were elicited. The coach’s
perception of his own style was also explored. This could help in the future selection and
briefing of coaches in order to try and reproduce the recipe for success.

5.2.4 Participant perception of barriers to future success

Long-term weight maintenance following weight loss interventions is known to be very poor.
Understanding perceptions at this early period following the completion of the 12-week
programme may help to interpret further outcomes when measured at 12 months.

5.2.5 Participant perspectives on programme improvement

Whilst fidelity to the original programme is vital as already discussed, there may be areas
not specifically covered by the programme structure that participants feel could help to
improve the overall experience.

In order to facilitate the qualitative enquiry a focus group was conducted with five participants, two
weeks after the end of the first 12-week delivery period. The focus group topic guide was structured
to enquire about perceived barriers and enablers to longer-term weight maintenance and lifestyle
changes. A structured interview was also conducted with the FFIT coach on the same occasion as the
focus group. This was structured to enquire about programme fidelity and to ascertain the coach’s
own perception of his coaching style. The interview and focus group were transcribed verbatim.
Thematic Analysisiv was used to analyse the qualitative data.

A copy of the focus group topic guide and coach interview guide can be found in Appendix B and C
respectively. These templates were adapted from the original FFIT trial evaluation interview and
focus group templates5.

5.3 Costs

Budgetary information was obtained from the FFIT manager at the Saints Foundation to facilitate
calculation of a cost per participant and these were cross-referenced with the NICE guidance on
cost-effectiveness of a weight loss intervention.

iv Thematic Analysis is a method of qualitative data analysis which involves coding transcripts of a focus group or interview and then
creating subthemes and themes to capture the essence of the data.

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6 Results

6.1 Quantitative Data

6.1.1 Attendance

Figure 2 below represents participant flow in the programme.

Figure 2: Participant Flow in FFIT Southampton

Three men dropped out, two after the first session, and one after the second session. The reason
cited for dropping out for all three was a change in personal circumstances, rather than any adverse
aspect of the programme. The retention of 15/18 participants equates to 83% and exceeds the
recommended retention for a weight loss intervention by NICE8. Of the fifteen participants who
remained in the programme, all 15 attended at least 83% of sessions, 11 attended 92% of sessions,
and 8 participants attended 100% of sessions. Four of the missed person-sessions occurred on week
11, which was held on a different day of the week to accommodate a visitation to a local
recreational facility, which is an FFIT programme-manual activity. Twelve participants continue to
engage with the weekly, post-programme, physical activity sessions. The reasons why three of the
men, having completed the programme, did not continue to engage with the post-programme
sessions are unknown.

6.1.2 Baseline characteristics

Table 2 on the next page shows the baseline characteristics of the participants who completed the
FFIT Southampton programme and how these are similar to the baseline characteristics of the
original RCT.

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Table 2: Baseline characteristics of the FFIT Southampton and the RCT participants

Characteristic Southampton Southampton Scottish FFIT RCT

FFIT Range FFIT Mean Mean
Age 41 to 63 Years 49 Years 47 Years
Weight 76.5 to 128.7 Kg 109.0 Kg 109.5 Kg
BMI 30 to 44 Kg/m2 35.7 Kg/m2 35.3 Kg/m2
Waist Circumference 109 to 136 cm 120 cm 118 cm
Blood pressure 111/77 to 161/101 138/87 mmHg 140/89

Based on BMI and waist circumference all fifteen participants were classified as ‘very high risk’ for
health-related problems due to their degree of overweight or obesity at baseline, as classified by
NICE8.

6.1.3 Quantitative Results at 12 weeks

Table 3 below shows the weight loss results at 12 weeks along with the BMI, waist circumference
and blood pressure reduction.

Table 3: FFIT Southampton and RCT Quantitative Results at 12 weeks

Variable Southampton Southampton Scottish FFIT RCT

FFIT Range FFIT Mean Mean
Weight Loss (%) -0.3 to 15.6 Kg (-0.3 to 6.9 Kg (6.3%) 5.18 Kg (4.7%)
13.5%)
BMI Reduction (%) -0.29 to 5.43 Kg/m2 (- 2.3 Kg/m2 (6.3%) 1.66 Kg/m2
0.8 to 12.9%) (4.7%)
Waist Circumference 7 to 16 cm (2.4 to 11 cm (9.0%) 6 cm (5.1%)
Reduction (%) 14.0%)
Blood Pressure 105/70 to 149/98 132/78 mmHg 135/86
mmHg
Blood Pressure Reduction -3/-11 to 36/23 mmHg 6/9 mmHg 5/3 mmHg

The mean weight loss of 6.3 % exceeds the minimal weight loss of 3% of baseline specified by the
NICE guidance8. Similarly, a weight loss of 5% from baseline was achieved by 10 (67%) of 15
participants at 12 weeks (30% of these achieved in excess of 10% weight loss from baseline) and this
also exceeds the minimal recommendations from NICE. Of the 5 (33%) of participants who did not
achieve 5% weight loss only 2 increased their weight during the programme and by <1%. However
these two individuals reduced their waist circumference by 7 cm (5.7% of baseline) and 11 cm (8.7%
of baseline) respectively.

Blood pressure was also seen to reduce at 12 weeks by an average of 6/9 mmHg and was
comparable to the reduction seen in the original FFIT trial. Whilst this is a clinically significant
reduction9, blood pressure is known to reduce with repeated measurement10, and this may have
contributed to the changes seen.

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Additionally, of the 15 participants who were initially classified as ‘very high risk’ for health-related
problems associated with their degree of overweight or obesity, two participants had reduced from
‘very high’ to ‘high’ risk and two participants reduced from ‘very high’ to ‘increased’ risk. The
remaining 11 would still be classified as at ‘very high risk’. However the evidence behind this risk
stratification is not made clear by NICE nor does it necessarily account for those in whom weight has
been reduced.

6.2 Results of Survey, Participant Focus Group and Coach Interview

6.2.1 Participant motivation and importance of ‘team’

Eleven out of fifteen participants completed the five-question survey. In 82% (9 out of 11) of
participant’s, the main reason for joining FFIT was to get healthier. One participant’s main reason
was because of his love of the football club and a second participant was because he wanted to
become part of a team. These findings are represented in figure 3 below.

Figure 3: Participant main reason for joining FFIT

All respondents considered their involvement in FFIT to have been a success. However, the
perception of the single most important reason for success was more variable. The single most
commonly selected response was ‘because they were part of a team’ (five out of 11 respondents),
whilst the others were split equally between ‘because it was held at the football club’ and because

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of ‘the structure of the FFIT programme’ (each 3 out of 11 respondents). These findings are
represented in figure 4 below.

Figure 4: Participant perceived key reason for individual success in FFIT

Whatever the initial motivation to join FFIT, some of the participants in the focus group described
being anxious about joining the programme. However, the participants overcame initial fears to
come together as a team of like-minded and like-bodied individuals with a focus on team success.
The similarities were based around their love of football, passion for Southampton football club,
sharing of similar body habitus and physical capabilities. This is exemplified by the following focus
group quote:

Participant 3: “I think the nervous thing, the thing about being nervous about joining, is a
really valid point, because I remember how I signed up for this, the posters were in the loos,
whichever game it was – the last one of the season I think - and I had a few beers before the
game and I thought it was a great idea on the spur of the moment and completely forgot
about it until [the coach] rang me on the Monday. And then I was in then as far as I was
concerned and the thing is that this particular group is a really nice group of lads there’s no
egos or characters – everyone’s here for the same reason, no taking the mick if you can’t run
up the stairs or whatever, its all, everyone’s here with the same bench mark”

Football was a key focus for the recruitment, motivation and commitment to the FFIT programme.
Participants were recruited when at a match, gained access to physical elements of club, had an
opportunity to represent the club and play football as a team:

Participant 5: “It’s the whole involvement with the club and the way its advertised and
having that first meeting when you could almost try before you buy and when [the coach]

13 | P a g e
 hooked everyone into it and getting to know each other and explaining the reasons why we
are all here and that kind of broke the ice and gave everyone the same motivation.”

However, the football stadium environment without the football element would not have been
accepted in the same way as participant 3 pointed out:

“It was the combination – because if Southampton football club was holding a knitting circle I
wouldn’t have been interested. I’m overweight and this is a good opportunity but it was the
badge and the promise of what we didn’t know – we were in the programme - twice we met
one of the players, going to Staplewood, kit…”

The importance of the team as well as new habits gained as a result of FFIT were highlighted by the
focus group participants as being important as a way of overcoming perceived barriers to long term
success:

Participant 1: “I think commitment from everybody is a good thing. We see the emails
floating about. As soon as someone puts out an email, [the coach] puts an email, everyone’s
replying with some funny comment and there’s a bit of banter”

Participant 3: “I haven’t seen many funny comments.”

Participant 1: “That will still drive us though the winter months hopefully because we’ll still
have the team”

Participant 3: “That team ethic”

The focus group participants went a step further to highlight the team as being generally more
helpful and a source of greater motivation in maintaining changes moving forward than wives and
partners:

Participant 3: “My wife, and myself, have been together for thirty years. We were both
overweight and talked about it until the cows come home but didn’t do anything about it.
They’re important partners but it’s the team, this team, that’s more important.”

The sense of team generated by this first cohort of FFIT participants may have been enhanced by the
additional prospect of the Scottish football tournament and the participation in this. When asked
about the importance of the trip to Scotland in their success from the programme, participants
responded:

Participant 5 “Massively. Massively. Not the carrot but the incentive. An all-expenses paid
trip to Scotland and playing at another high profile ground with all the other teams.”

Participant 2: “Definitely when [the coach] said about it. …….the first proper week he
mentioned it to a few people, to everybody, and that certainly made my ears prick, I thought
hang on this could be good and it gave you something else to aim at, not only to make

14 | P a g e
 yourself better, well twelve weeks, that’s three months I’ve got quite a bit of time to lose a
bit here and there and erm and get your football boots on again as well.”

Participant 3 who had not been available to go to Scotland stated:

“I don’t want to be slimmer of the week but you want to be part of a group that’s successful.
You all [referring to other four focus group participants who had gone on the Scottish trip]
came back from Scotland and you want do what you want to do – you want to go back
because you want to do better as a team. That’s the team ethic thing. It’s not that they came
back and said they want to play better – they want to do better as a team.”

6.2.2 Fidelity to the original FFIT programme

Flexibility in session length ensured that the coach was able to deliver the required manual material
and ensure inclusiveness of participant contribution in what were perceived as unrealistic delivery
timings. However, competing commitments of the coach’s time sub-optimally effected preparation
especially for the more complex sessions. When asked directly about programme fidelity, the coach
estimated that between 85 and 90% of the manual had been delivered as intended. The coach
training was seen as a useful stepping-stone and of sufficient quality to enable the actual delivery of
the programme and was perceived as superior to just reading the manual.

When cross-referencing with the behaviour change mapping4, evidence arose for 28 of the 37
specific behaviour changes mapped in the original development of the programme. The mapped
behaviour changes and examples of evidence from the evaluation (focus group, coach interview or
attendance rates) can be found in Appendix D. No direct evidence was available for much of the goal
setting since this did not arise in the focus group discussion. There was also no direct evidence
available for verbal persuasion about capability (the coach expressing belief in the participants’
ability to succeed) or for re-attribution (suggesting alternative explanations for perceived causes of
behaviour).

6.2.3 Characteristics of the coach associated with success

The interview with the coach suggested that he created a relaxed atmosphere, which arose from a
combination of his own personality and more purposefully in wishing to keep the men engaged. He
found that delivering the programme in this manner offered a high level of personal satisfaction.

In the five-question survey to participants, the characteristics of the coach were not selected by any
participant as the single most important reason for success in FFIT. However, 100% of respondents
considered the characteristics of the coach as important (45%) or extremely important (55%) in the
success of FFIT.

When asked to choose five from 31 characteristics of the coach (see Appendix A) that they felt were
most important, only 17 of 31 characteristics were selected. Figure 5 on the following page shows
which characteristics were chosen and the frequency of responses.

15 | P a g e
 Figure 5: Characteristics of the coach associated with success

The summation of the characteristics most frequently selected suggest that the coach was able to
create a fun and positive atmosphere, underpinned by a non-judgemental and respectful manner,
where participants were made to feel at ease and encouraged to succeed at a rate that was
acceptable to the individual participant. The importance of the coach’s respectful manner whilst also
being respected as the group’s coach was also demonstrated by these results. The importance of
being able to create a positive team experience was evident from some of the selections. This gels
with a theme from the coach interview in which individual participants come together as a peer-
supporting team; individual differences in ability were catered for in the delivery of the physical
activity but the emphasis is in their functioning as a group. Some participants highlighted the
importance of the coach’s employment by the football club, which links strongly to the influence of
football and football club in perceived success.

16 | P a g e
Table 4 below shows the 15 characteristics that were not chosen as the top 5 characteristics by any
respondents. It cannot be assumed that these characteristics were either not important nor the
antithesis of success, but merely that they were not prioritised by any respondents over the other 17
characteristics.

Table 4: Characteristics NOT chosen as top five associated with success

He limited negative feedback

He listened to me

He understood my situation

He was optimistic

He had a healthy weight

He allowed me to make my own decisions

He was lively

He was quiet and thoughtful

He was chilled out

He closely followed the manual

He dealt with people fairly

He let me drop out when I wanted

He appeared knowledgeable

6.2.4 Participant perception of barriers to future success

Seasonal variation in weather was perceived as the greatest barrier to maintaining positive changes
to physical activity moving forward:

Participant 5: “I think just the weather and the nights closing in as the season’s change. At
the end of the day being unhealthy and overweight is hard and making room for exercise is
going to be hard and it’s just choosing which it is. I’ve got room for it now and I will adapt
over the winter.”

Likewise seasonal holidays and social events were perceived as the greatest barrier to maintain
positive changes to eating improvement moving forward:

Participant 4: “The acid test for me is going to be the onset of Autumn. Come August you get
the start of the football season that means that every other Saturday it’s been 5 or 6 pints
and a pie or a burger but this season I am going to try and stop that but once it’s starts to get
cold I tend to migrate to eating stews and casseroles and the stodges”

Participant 3: “I think [Participant 4] is right I think once the weather starts changing and it’s
not easy to go out for a cycle and it’s not easy to go out for a run or walk. It’s finding
something during the autumn or winter.”

17 | P a g e
As described above, the importance of the team to support future success was a key theme from the
focus group:

Participant 1: “We might be at the stage now when if anybody in the group feels like ‘ow
god’ [suggests down or unmotivated] you can tell someone they will take the Micky out of
you but then you hopefully get a buzz [out] of that and think I do need a pick up and as a
team I think we’ll be alright”

The coach highlighted the importance of the continuation of the weekly sessions, which would allow
the group to meet and ensure on going physical activity. Whilst the focus group participants
described an enjoyment in the FFIT sessions, this enjoyment appeared to arise from the extrinsic
motivation generated by the power of the team and jointly meeting up for physical activities.
However, intrinsic motivation appeared to be lacking in respect of the ability to maintain changes
should the team be disbanded. In fact, the continuation of weekly sessions and other team activities
were seen as crucial to maintaining the positive changes to date; no additional components of the
programme were seen as having the ability to prevent this:

Participant 3: “Crucial. Otherwise it’s like…”

Participant 2: “Yeah like shutting the door. I think if you just shut the doors at twelve weeks a
lot of people would just go back to”

Participant 3: “I don’t think there’s anything else you could put it that 12 weeks – if you did
this for 12 weeks then that was the end of it – I don’t think that would – it’s the continuation
of that – 12 weeks that’s great – that’s me changed for life - we’re starting here for a reason
– some of us would have been different but It’s a continuation thing that’s really important.
What that looks like almost doesn’t matter. Whether it’s boxing or football.”

Part of the perceived importance of on-going sessions may lie in the support network that the team
offered individuals, support that they may not get to the same extent in their personal relationships.
As previously discussed, the power of the team was seen as generally more helpful and a source of
greater motivation in maintaining changes moving forward than wives and partners.

6.2.5 Participant perspectives on programme improvement

During the focus group, participants raised two aspects that they felt could help improve the FFIT
Southampton programme. The first was in the timing of sessions. Whilst they realised the sessions
were held at 5-7 pm due to availability of the football club facilities, the early start made it difficult
for participants to guarantee they would be able to get there from work on time.

The second area of interest for a number of participants in the focus group was around being able to
measure fitness in some way as a bench mark at the beginning of FFIT, and as a way of measuring

18 | P a g e
improvement. This was seen as especially useful for those in whom weight had plateaued despite
continuing to feel more physically fit and perhaps having a reduced waist circumference:

Participant 4: “On the measurement side we have been measured on waist size and body
weight. Fitness side of thing has not been measured at all. From my point of view I love the
numbers. I love the improvement numbers. I grew a cm taller and that made my day as my
posture changed so much and I use a heart rate monitor and all that sort of stuff and I watch
my progress on that and getting the number of steps in the day watching the amount of
effort, the rate of perceived effort if we had some sort of metric right at the beginning to
measure at the midway point and the twelve week, I think that would go a long way in
improving performance”

Participant 1: “Every week I come and I lost weight and that motivated you for the next
week.”

Participant 5: “Once your weight plateaus and you start to put muscle on you’ve still got
other metrics then to measure it against.”

Participant 4: “You’re absolutely right as I didn’t lose weight per se but I lost 7 cm from
around my waist but my BMI still says I am obese – and if I am, I am – we all know that
muscle is heavier than fat – I feel fitter, I know my blood pressure was lower, I feel fitter, I
can do more than I did before, so I know it’s worked somehow It’s not perhaps measured in
those stats.”

6.3 Costs
The start-up costs for the FFIT Southampton are shown in tables 5 and 6 below. There are non-
recurring start-up costs of coach training and equipment bundle as previously described. The
assumption is that these will be non-recurring although should a new coach be assigned to deliver
the programme there may be a future cost associated with training. A number of club coaches were
trained in the original coach-training sessions to mitigate this situation. Equipment replacement or
maintenance may also represent future costs.

Recurring costs for the start of each cohort are likely to include promotion of the programme and
the purchase of Southampton football club branded football kit, which is given to each participant.
Participant manuals and coaching log-books are the final recurring cost.

Table 5: Non-recurring start-up costs for FFIT Southampton

Non-recurring start-up costs Amount (£)

Coach Training 1000.00
Room hire 263.00
Equipment bundle 800.00
Total 2063.00

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 Table 6: Recurring start-up costs for FFIT Southampton

Recurring start-up costs

18 Participant Manuals/Coach books 535.20
Training Kit for Participants 487.00
Promotion 287.00
Total 1309.20
Cost per participant (based on 15 participants) 87.28

Based on 15 participants completing the FFIT Southampton programme gives a cost per participant
of £87.28 when removing the non-recurring costs of coach training and equipment bundle. Including
the non-recurring costs for the first cohort increases the cost per participant to £224.81. However it
should be noted that coaching salary and hire of football club facilities are not accounted for in the
expenses. The coach is salaried as an employee of the Saints Foundation and the use of the football
club facilities is a unique situation in which the Saints Foundation do not pass on any associated
costs to the FFIT Southampton programme. Should this arrangement change in the future then the
cost per participant would increase greatly. The Scottish model is slightly different in that the SPFL is
funded by NHS Scotland to pay the clubs to deliver the programmes at a cost that may include these
additional expenses.

As described previously, a unique feature at the culmination of this first FFIT Southampton
programme was the participation in the Scottish FFIT football tournament. This is not anticipated as
an on-going expense for each cohort. However it is currently an annual event and future cohorts
may have this cost associated with their programme delivery. However, whether this should be
included as part of the commissioned programme will need to be discussed further between
Southampton Public Health Team and Saints Foundation.

The costs associated with the Scotland football tournament are shown in table 7 below. Accounting
for this expense increases the cost per participant to £155.68 for 15 participants excluding non-
recurring costs or £293.21 with these included.

Table 7: Special Scotland FFIT Football Tournament Expenses

Scotland FFIT Football Tournament

Travel 0.00*
Accommodation 679.50
Kit 346.46
Total 1025.96
*Travel said to be participant-funded

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NICE suggests that when a 12-week weight loss programme has a cost per participant of less than
£100 participants will need to maintain a weight loss of 1 Kg for life to ensure cost-effectiveness. For
any programme costing more than £100 per participant if weight is regained within 2-3 years then
the programme has not been cost-effective. However NICE also states that cost-effectiveness for
participants with BMI≥40 Kg/m2 is not so clear. Based on the current FFIT Southampton cost per
participant, whether non-recurring costs are included or not, the future cost-effectiveness is based
on this premise. The weekly boxing session is currently supplemented by the FFIT programme to the
value of £45 per week.

6 Conclusion
Fifteen participants successfully completed the first delivery of the FFIT Southampton programme.
The benefits of the FFIT programme appear to have transferred effectively from the Scottish FFIT
model to Southampton, with subjective and objective evidence of fidelity matched by 12-week
weight loss outcomes that compare favourably to the 12-week outcomes from the original RCT.
These outcomes exceed the minimal effectiveness of a weight loss programme as recommended by
NICE.

All participants who completed the programme believed their involvement to have been successful,
a success driven mainly by the trio of ‘football’, ‘team’ and the nature of the ‘programme’. Although
not cited as a primary reason for success, the characteristics of the coach were believed to be
important or extremely important in the success of the programme. The coach created an
atmosphere that was safe, fun and encouraging, underpinned by a respect for the participants. They
in turn respected his professionalism.

Participants believed that the continuation of some form of weekly activity sessions were vital to the
continuation of their success. These sessions would maintain the integrity of the ‘team’, which was a
powerful form of support and a buffer against the perceived barriers of changing seasons and
seasonal events, in challenging the physical activity and healthy eating changes that they had made.
Twelve of the original fifteen men completing the programme continue to meet up for weekly
physical activity sessions.

The power that the participants drew from the union of ‘football’ and ‘team’ and the lack of belief in
their individual, intrinsic, abilities to maintain the changes without them, suggest that long term
weight maintenance and behaviour change is going to be a challenge for some of these individuals.
The men did not believe that the FFIT programme itself could be adapted to protect against this
problem.

Longer-term success may be possible if the participants are able to continue to maintain their
involvement with the ‘team’ although it is not sustainable for the FFIT Southampton programme to
continue to fund weekly sessions of physical activity ad infinitum. Additionally this reliance on ‘team’
expressed by this cohort of football supporters who have successfully engaged with the FFIT
programme and reached impressive weight loss goals may suggest that this may not generalise to
men who are less connected with the idea of ‘team’ and/or football.

21 | P a g e
Revisiting this evaluation when the 12 month data is available for this cohort will assist in
understanding the longer term success of the programme and will allow comparison with the
primary outcome from the original RCT. Further qualitative work may help to further understand
how barriers and enablers will affect the weight trajectory of these participants. This in turn may
offer a greater insight into the cost effectiveness of FFIT since current cost per participant of greater
than £100 (when start-up costs included) suggests that weight cannot be regained within 2-3 years
for cost-effectiveness to be assured. There is currently a 3-year evaluation in progress of the original
FFIT RCT trial participants and this may offer further evidence towards cost-effectiveness.

Whilst the idea of a fitness metric was raised by several participants, this has not been part of the
FFIT programme to date. There may be cost implications associated with advanced metric
measurements and more basic fitness tests may not be desirable for a competitive individual,
unaccustomed to recent highly intensive physical activity at the start of the programme. The other
suggestion for improvement from participants was for a later start time for sessions. Whilst this is
desirable to help facilitate commuting from a workplace to the club it may continue to be restricted
by availability of club facilities.

The culmination of the programme for this first cohort was participation in a Scottish FFIT football
tournament. It is difficult to separate the additional benefit of this trip from the basic programme
structure. It is unlikely to be a recurring feature of the FFIT Southampton programme, although the
additional sense of ‘team’, which arose out of the road trip and representation of the club, is likely to
have positively contributed towards the success of this cohort. Quantitative outcomes from
subsequent cohorts without this benefit may offer further insight into this.

Addressing the high prevalence of obesity is a priority for public health services in England - it is
highlighted as one of the seven priorities of Public Health England11 as well as in the NHS Five-year
Forward Plan12. FFIT is an evidence-based weight loss and healthy lifestyle programme that can
successfully achieve the recommended weight loss goals for a weight loss intervention as advised by
NICE. Such weight loss will help to reduce the future risk of a number of conditions, including
cardiovascular disease and diabetes, benefiting the individual and the healthcare system. Targeted
at men, it can help to reduce gender inequality in access and uptake of weight loss interventions and
represents an additional component of the armoury that is needed in the fight against obesity.
Whatever the long term outcomes for the individuals in the first FFIT Southampton cohort, it is
hoped, as stated by one of the focus group (Participant 2), that “Twelve people might just live
another five years now.”

7 Strengths and Weaknesses of the evaluation

Strengths of this evaluation include using both quantitative and qualitative data to investigate the
effectiveness of FFIT Southampton. The interview and focus group were conducted shortly after the
completion of the 12-week programme, which offered contemporary responses from the coach and
the participants to avoid recall bias.

The focus group was a convenience sample of five of eleven men present at a planning meeting for
an FFIT group event. The five-question survey was completed by all 11 participants at this event. The
motivations for joining FFIT and perceptions about success are not known for 4 participants who did

22 | P a g e
not fill in a survey and who were not at this event. Their responses may have been different from
those discussed in the evaluation. Additionally the focus group was only populated by one third of
participants but was of a size accepted as good practice in qualitative research. The presence of a
focus group facilitator from the public health team that helped fund the FFIT programme may have
influenced the responses from the participants.

The current evaluation represents an interim step towards further conclusions when further
quantitative outcomes are available at 12 months for the same cohort of participants. Conclusions,
derived so far, are based on a very small number of participants. The programme is designed for a
coach to participant ratio of approximately 1:15. The first cohort thus represented one delivery unit.
The accumulation of quantitative outcomes over subsequent cohorts will provide a more accurate
evaluation of programme success. Subsequent cohorts are already underway.

Another weakness of the current evaluation is in the coach-reported programme fidelity. Fidelity
may be better ascertained objectively by observation of sessions. This was not possible due to the
time available for the evaluation and in itself has the potential to introduce bias due to the effects of
being observed. However an attempt was made to objectively map evidence from FFIT Southampton
to the behaviour changes identified during the original programme development.

A further weakness of the evaluation is in the exclusion of discussion about inequalities. Accurate
ethnicity and employment data were not specifically collected at registration into the programme
and therefore it is not possible to make conclusions about the ability of the programme to reduce
inequalities other than in gender.

23 | P a g e
8 Recommendations

8.1 Saints Foundation to:

 Continue delivery of the FFIT Southampton programme

 Focus on continuation of high programme fidelity and maintenance of coaching
characteristics associated with success
 Continue to enrol from the Saint’s pool of eligible football supporters who appear to
benefit from the current FFIT model
 Record ethnicity and employment status at registration to allow subsequent evaluations
to investigate equity of access to the programme, uptake and outcomes
 Continue post-programme weekly sessions and record attendance and costs

8.2 Public Health Southampton to:

 Review the quantitative outcomes of subsequent cohorts

 Review the impact and long-term feasibility of the post-programme sessions at 12 months
 Complete further qualitative work at 12 months with the first FFIT Southampton
participants to:
o Explore perspectives on post-programme sessions
o Revisit perception of barriers and enablers to future success
 Review the longer-term outcomes in these groups before deciding whether to extend the
reach of the programme to eligible non-football supporters who may not benefit from the
FFIT approach to the same extent
 Review cost-effectiveness when longer-term data becomes available

24 | P a g e
Acknowledgements

I would like to thank the Saints Foundation for all their help in bringing the FFIT programme to
Southampton and for their continued passion for making a positive difference to people living in our
great city. I would also like to thank them for their help in conducting this evaluation. I would
especially like to thank the FFIT coach for his dedication in delivering the programme and for his
natural ability to bring the best out of the participants by creating a ‘fun, safe and encouraging’
atmosphere.

I would like to thank the SPFL Trust for making the FFIT programme available to help high-risk men
become healthier outside of Scotland and in their help in bringing FFIT to Southampton.

I would like to thank Dr Simon Fraser for his support and mentorship in producing this evaluation
document and to Dr Bob Coates for giving me the opportunity to conduct the evaluation on behalf of
the public health team in Southampton.

I would like to thank the participants who took part in the focus group and those who completed the
survey. I would like to thank the entire ‘team’ of fifteen FFIT Southampton participants who
achieved great things in just 12 weeks. I hope you will always be ‘Football Fans in’ some form of
‘Training’ and inspire others to do the same.

Dr Robin Poole

September 2015

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List of abbreviations used in the text

BMI Body Mass Index

FFIT Football Fans in Training
NHS National Health Service
NIHR National Institute for Health Research
NICE National Institute for health and Care Excellence
RCT Randomised Controlled Trial
SMART Specific, Measurable, Achievable, Realistic and Time-limited goal
SPFL Scottish Premier Football League

References
1. Health and Social Care Information Centre. Statistics on Obesity, Physical Activity and Diet:
England 2015 [Internet]. 2015. Available from:
http://www.hscic.gov.uk/catalogue/PUB16988/obes-phys-acti-diet-eng-2015.pdf

2. Department of Health. Healthy Lives, Healthy People: A call to action on obesity. 2011.

3. Hunt K, Wyke S, Gray CM, Anderson AS, Brady A, Bunn C, et al. 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. Lancet
(London, England) [Internet]. Elsevier; 2014 Apr 5 [cited 2015 Aug 14];383(9924):1211–21.
Available from: http://www.thelancet.com/article/S0140673613624204/fulltext

4. Gray CM, Hunt K, Mutrie N, Anderson AS, Leishman J, Dalgarno L, et al. Football Fans in
Training: the development and optimization of an intervention delivered through
professional sports clubs to help men lose weight, become more active and adopt healthier
eating habits. BMC Public Health [Internet]. 2013 Jan [cited 2015 Sep 21];13(1):232. Available
from: http://www.biomedcentral.com/1471-2458/13/232

5. Wyke S, Hunt K, Gray C, Fenwick E. Football Fans in Training (FFIT): a randomised controlled
trial of a gender-sensitised weight loss and healthy living programme for men–end of study
report. 2015 [cited 2015 Sep 22]; Available from:
http://www.ncbi.nlm.nih.gov/books/NBK273998/

6. Trust S. SPFL Football Fans in Training (FFIT) delivery report 2013/14. 2014.

7. EuroFIT 2014. EuroFIT | National Football Fans In Training (FFIT).

8. NICE. Managing overweight and obesity in adults - lifestyle weight management services
[Internet]. 2014. Available from:
https://www.nice.org.uk/guidance/ph53/resources/guidance-managing-overweight-and-
obesity-in-adults-lifestyle-weight-management-services-pdf

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9. Harsha DW, Bray GA. Weight loss and blood pressure control (Pro). Hypertension [Internet].
2008 Jun 1 [cited 2015 Nov 4];51(6):1420–5; discussion 1425. Available from:
http://hyper.ahajournals.org/content/51/6/1420.full#xref-ref-24-1

10. Burstyn P, O’Donovan B, Charlton I. Blood pressure variability: the effects of repeated
measurement. Postgrad Med J [Internet]. 1981 Aug [cited 2015 Nov 4];57(670):488–91.
Available from:
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2426112&tool=pmcentrez&ren
dertype=abstract

11. PHE. From evidence into action: opportunities to protect and improve the nation’s health
[Internet]. 2014. Available from:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/366852/PH
E_Priorities.pdf

12. NHS. Five year forward view [Internet]. 2014. Available from:
https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf

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Appendix A: Participant Questionnaire

TICK
What was your main reason for joining FFIT?
Q1 (Please TICK one answer)

Love of the football club

To become part of a team

To get healthier

To improve how I look

Because my wife/partner/family told me to do it

Other: Please specify

Do you consider your involvement in FFIT to have

Q2 been a success?

Yes

No

Unsure

If yes, Which one of the following factors would you

say was the most important reason for your
Q3 success in FFIT?
It was held at the football club

I was part of a team

The characteristics of the coach/trainer

The structure of the FFIT programme

None of the above

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 How important do you consider the characteristics
Q4 of your coach/trainer in the success of FFIT? (Tick
one answer)

Extremely important

Important

Neither important nor unimportant

Unimportant

Extremely unimportant

Please tick FIVE of the following which you feel

Q5 were most important aspects of your FFIT coach?

He was Cheerful

He limited negative feedback

He offered positive feedback

He let me do physical activity at my own pace

He always made me feel welcome

He listened to me

He understood my situation

He commanded me to complete the physical activity

He was optimistic

He used humour

He valued my opinion

29 | P a g e
He had a healthy weight

He encouraged me to take personal responsibility

He allowed me to make my own decisions

He was enthusiastic

He helped us get on well as a small group

He was lively

He gently encouraged me to push myself

He was quiet and thoughtful

He was chilled out

He closely followed the manual

He encouraged teamwork

He always appeared in control

He appeared committed to FFIT

He was friendly yet formal and polite

He had a commanding manner

He treated everyone with respect

He dealt with people fairly

He let me drop out when I wanted

He appeared knowledgeable

He worked for Southampton FC

30 | P a g e
Appendix B: FFIT Qualitative Focus Group – Focus Group Topic Guidev

Introduction

Thank you very much for agreeing to take part in this discussion. The aim is to find out more
about how FFIT has helped you to make healthy changes in your life and how you might
continue these changes into the future.

I am simply here as a sort of chairperson to make sure that everyone gets a chance to
speak. What you have to say is important to me and my colleagues working in public health
and so please don’t be afraid of speaking your mind.

I will make an audio recording of the discussion which will be converted to text by myself,
some of which may appear in an evaluation report, but everything you say will be
anonymised – such that no one’s actual names will appear in the report. However I’m quite
happy for you to use your names during the discussion.

Questions and consent forms

Start by getting the men to introduce themselves and say what was their most memorable
week of FFIT (for voice identification).

1. Looking back at taking part in the FFIT programme and any time since, would you
say that it has affected any aspect of your day-to-day life or your health?

2. What motivated you to join FFIT?

3. Are you planning to continue with the changes you have made around eating and
physical activity now that the programme has ended? If so why?

4. What might stop you continuing with the healthy changes you have made?

5. Now that the twelve-week programme has finished, how important do you think the
continuation of the weekly activities for your group will be in helping you to maintain
the positive changes you have experienced?

6. Conversely what do you think would have been the effect on yourselves if the
programme had finished at twelve weeks and that was that?

7. Is there anything else you feel could help you continue to make the positive changes
as time goes on?

8. Thinking about your eating habits, what were the main changes you managed to
make, if any, while on the FFIT programme at Southampton?

v Adapted from Wyke at al5

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 9. With respect to eating, do you see any difficulties to continuing to make the positive
changes that you made moving forward? (Prompts: What are they?)

10. With respect to eating, what do you think might be helpful in continuing to make the
positive changes moving forward?

11. With respect to eating, how important do you find the support of your partners and
family in making the changes you have experienced and how important will this be
moving forward?

12. Thinking about your physical activity habits, what were the main changes you
managed to make, if any, while on the FFIT programme at Southampton?

13. With respect to physical activity, do you see any difficulties to continuing to make the
positive changes that you made moving forward? (Prompts: What are they?)

14. With respect to physical activity, what do you think might be helpful in continuing to
make the positive changes moving forward?

15. With respect to physical activity, how important do you find the support of your
partners and family in making the changes you have experienced and how important
will this be moving forward?

16. If FFIT had not existed do you think you would have found another way into making
the positive changes that you have made in the last few months? (Prompt: Such as
joining other types of weight loss programme)

17. Are there any other changes you have made to your lifestyle as a result of being on
the FFIT programme? If yes, how do you feel you will be able to maintain these into
the future? (Prompt: For example alcohol)

Summary
At end of discussion, summarise what has been said and ask men if there is anything else
they would like to add.

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Appendix C: FFIT Qualitative Interview – Structured Interview Questions for Coachvi

Introduction

Thank you for agreeing to take part in this interview. The aim is to understand more about
the delivery of the FFIT programme in Southampton. This interview will be recorded and
transcribed into text, some of which may appear in written form within an evaluation
document. Please be as open as you can. Your comments will be anonymised for the
evaluation document. There are no right or wrong answers.

Questions

1. Can you tell me about your programme? (Prompts: no. of men, date and time and
why these were chosen.)

2. What methods of recruitment to FFIT did you use? How successful were these?
Would you do anything differently?

3. How do you feel it went overall?

4. How did you find it to deliver? Any specific problems?

5. Was there sufficient time to deliver the material within each session? How flexible
where the sessions in length?

6. How easy was it to follow the manual?

7. Did you deviate from any of the planned sessions or rearrange the order of any
sessions? What were the reasons behind any changes?

8. Were there any parts of the manual that were missed out? What were the reasons
behind this?

9. Overall if you were to guess a percentage of how close to the intended delivery you
achieved – what would it be?

10. Was there sufficient time for you to attend to the paper work around other
responsibilities you have in your work?

11. How do you feel the two-day training you received to deliver the programme
prepared you for delivering the programme as intended? What could have been done
differently?

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12. How did you find the support you were given to deliver the programme (Prompts:
from the SPL, 
from the programme trainers? – Did you need to contact the programme
trainers about any aspects of the delivery – if so which?)

13. Which parts of the programme did you think were effective in helping the men to lose
weight? Why?

14. Which elements did you think were effective in helping the men to increase physical
activity? Why?

15. Were there any elements that you thought weren’t useful for helping the men to lose
weight? Why?

16. Were there any elements that you thought weren’t useful for helping the men to
increase physical 
activity? Why?

17. Was there anything that made delivery of the programme more difficult? (Prompt age
range; different 
physical activity abilities.)

18. In the original evaluation from the work in Scotland, some coaches had concerns
about the responsibility they had around supervising the physical activity in men they
perceived as being at high risk if they were to ‘overdo’ it. How did you feel about this?

19. In the original evaluation from the work in Scotland, one of the difficulties highlighted
by both coaches and participants was around the use of SMART goals (Specific,
Measurable, Achievable, Recorded and Time Limited), which they found did not suit
everyone. Did you have any experience of this?

20. Can you tell me about the weekly sessions the men attend now that the 12 week
programme has finished? How did these come about?

Summary

At end of interview, summarise what has been said and ask the coach if there is anything
else they would like to add.

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Appendix D: Mapping of behaviour changes evidenced by evaluation to original behaviour
changes identified in programme development
Label
Social Support Social Support
Regulation Reduce negative emotions
Feedback & Monitoring Feedback on behaviour
Feedback on outcomes of behaviour
Self-monitoring of behaviour
Self-monitoring of outcomes of
behaviour
Repetition & Substitution Behaviour Practice/Rehearsal
Habit Formation
Behaviour substitution
Generalisation of a target behaviour
Graded tasks
Antecedents Avoidance/Reducing exposure to cues
for the behaviour
Adding objects to the environment
Restructuring the social environment
Shaping Knowledge Information about antecedents
Re-attribution
Instructions on how to perform a
behaviour
Self-belief Focus on past success
Verbal persuasion about capability
Goals & Planning Goal Setting (behaviour)
Goal Setting (outcomes)
Behavioural contract
Commitment
Action Planning (implementation
intention)
Reviews behaviour goals
Reviews outcome goals
Discrepancy between current behaviour
and goal
Problem solving
Evidence from FFIT Southampton
(Quantitative, Focus Group or interview)
“We’ve found out that three of us go to
the same gym …”
“We might be at the stage now when if
anybody in the group feels like ‘ow god’
[suggests down or unmotivated] you can
tell someone they will take the Micky out
of you but then you hopefully get a buzz
of that and think I do need a pick up and
as a team I I think we’ll be alright”
“it’s just portion control and cutting
back.”
Evidenced by 6 week measurements
“I still wear the pedometer all the time”
“I weigh myself once a week”
“using the stadium to run up and down
the stairs”
“…. I’ve got 10000 in my head and if I’ve
not done 10000 by 7 o’clock I need to go
for a walk or something”
“…maybe have a rum with some diet
coke instead of having six pints…”
“…and enjoying now the boxing which
we have carried on doing as well which
is very enjoyable”
“In the training we were informed that
you need to periodically build up the
exercise and that’s exactly how I did it.”
“I’ve totally changed my snacking habits.
I use to spend a lot of time driving.
Eating service station food. If I know I’m
out on the road I’ll prepare a snack box.”
“I still wear the pedometer all the time”
“…and now I’m back in the gym – albeit
only recently – its shifting from the old
habits of getting in and sitting on your
backside and watching telly to the new
habits of actually doing something”
“I’ve totally changed my snacking habits.
I use to spend a lot of time driving.
Eating service station food. If I know I’m
out on the road I’ll prepare a snack box.”
No direct evidence available
Evidenced by use of pedometers by
group
“Twelve weeks ago there’s no way I
would have survived an hour doing what
we did last week”
No direct evidence available
No direct evidence available
No direct evidence available
No direct evidence available
Evidenced by attendance rates
“I threw it out there to the groups and
made them announce what their SMART
goals were and their reasons for it and
that allowed people in the room to get
confidence”
No direct evidence available
No direct evidence available
No direct evidence available
“We’ve brought a new dinner service.
The old plates were like this big [shows
very large dinner plat size with hands]
and we used to fill them up and now the
one’s we brought are like this big [shows
small dinner plate size with hands]”
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Comparison of outcomes Persuasive Source
Identity Framing/Reframing
Natural consequences Information about health consequences
Information about emotional
consequences
Salience of consequences
Monitoring of emotional consequences
Comparison of behaviour Social comparison
Demonstration of the behaviour
Covert Learning Vicarious consequences
“..twice we met one of the players”
“I don’t want to be on a diet so to speak
Whenever I’m doing anything I’m, as far
as my kids and my missus whoever, I’m
just healthy eating regime kind of thing,
just watching what I eat, not on a diet”
“I’ve been on blood pressure tablets for
five years and my blood pressure’s
normal now”
“coming here and doing physical activity
has made me generally happier feeling
better about myself and releasing those
endorphins”
“we find out when after six weeks we
lost the same amount of weight as one
of the helpers”
No direct evidence available
“you see him compared to when he first
started… but he looks like a completely
different person from twelve weeks till
now”
“using the stadium to run up and down
the stairs”
“There was one chap up there who was
running the programme for Hamilton
Academical , he used to be 25 stone
and he was normal, so yeah just shows
what you can achieve and really good to
see that”
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