Launched in March 2009 by NHS Hull, Fit Fans is a free weight management service designed primarily for men aged 40 to 65 who want to lose weight.
This is because rates of overweight and obesity amongst middle-aged men in the city is particularly high, at around 75 per cent, and this group was failing to access support in managing their weight.
Fit Fans offers a structured 12-week programme covering important nutritional information and exercise advice, with the opportunity to participate in exercise sessions. The programme is sports-related and professionally delivered by experts linked with two of the big sports clubs in the city, thereby giving participants the chance to receive the same fitness expertise given to their sporting heroes.
Results for 2009/10:
- 413 men completed the 12-week programme
- 78 per cent of participants were obese or morbidly obese at the start of the programme, dropping to 64 per cent at the end of the programme
- 50 per cent of male participants who completed the 12-week programme achieved a 5 per cent or more drop in weight; of these 77 per cent maintained this weight loss after a further 12 weeks
Following Lord Darzi’s wide ranging review of the NHS in 2007, NHS Yorkshire and Humber published Healthy Ambitions, its strategic framework for improving health and healthcare in the region. This report outlines the alarming trend in rising obesity in Yorkshire and Humber, which could mean that by 2025, 47 per cent of men and 36 per cent of women will be obese. Additionally, the Hull Health and Lifestyle Survey 2007 showed that the city had an even higher prevalence of obesity and overweight in the adult population; 66.9 per cent of men and 55.8 per cent of women were overweight or obese. For males aged 40 to 65, this figure rose to 75.2 per cent.
These men are at a greater risk of dying prematurely (before age 75) due to obesity related illnesses, such as stroke, some cancers and cardiovascular disease. They also have an increased risk of experiencing long-term limiting health issues, such as type 2 diabetes, reduced mobility, erectile dysfunction, depression and low self-esteem. These health issues put an increased burden on their families and the NHS. The 2007 Foresight report estimated that obese and overweight individuals directly cost the NHS £4.2bn per year, and weight problems cost the wider economy in the region of £16bn per year.
In light of this, The Hull Adult Obesity Strategy Group sought to tackle the issue locally. Access to weight management services was available through a number of programmes in Hull, including Active Lifestyles, Health Trainers, Why Weight and Stay Healthy Live Longer. While approximately 1,380 people were using these services annually for weight management issues, it was found that only 10 per cent (138) of these were men. This inequity of access contributes to the widening health inequality gap between men and women in the city, and it was recognised that work was needed to re-dress this balance.
In 2008, NHS Hull decided to create a weight management service that focused on men aged 40 to 65, to address the lack of uptake of services by adult males in Hull and subsequently help deal with increasing obesity within this group. This work sat alongside the development of a single point of access (SPoA) for weight management services, supported by NHS Hull. Around half a million pounds of funding from the public health directorate was committed to establish and pilot over two years a new weight management service.
“We had a big issue around the confusion of people accessing the various weight management services that we had, but also around the lack of men coming onto the programmes as well. They just weren’t interested in the offer that we had at the time and we needed to tackle this.” (Peter Dawson, Public Health Manager)
Men aged 40 to 65, particularly those from lower socio-economic groups, were chosen as the target audience, since they were identified as less likely to participate in weight management activities overall and more likely to fall into the categories of overweight or obese.
NHS Hull data indicated there were 42,400 men in the 40 to 64 age range registered with a GP in Hull in 2007. Given that approximately 75 per cent of these men are overweight or obese, the target group comprises around 32,000 men in the city who could be eligible to access weight management services. Encouraging these men to adopt a healthier lifestyle and lose weight would bring significant long-term health benefits and increase life expectancy in Hull.
The target audience was segmented according to demographic and behavioural variables:
- Male, aged 40 to 65, and overweight or obese
- Routine and manual workers, low paid or unemployed
- Living within the most deprived wards in Hull, where there is a high prevalence of heart disease and smoking
- Have an unhealthy or poor diet and excessive alcohol consumption
- Participate in little or no physical exercise
- Significant family history of heart disease or diabetes
- Reluctant to attend GP or other health services when in poor health (have not attended GP within the past 12 months
NHS Hull commissioned external research and evaluation agency Information by Design to carry out extensive research to understand the target audience and provide insight into their characteristics, motivations and behaviours. This comprised of four main elements:
1. Literature review
This drew together evidence from the commercial and public health sectors around approaches used to target men in marketing campaigns (rather than on the effectiveness of obesity interventions, which are well documented by the National Institute for Health and Clinical Excellence).
2. Stakeholder consultation
Depth interviews were held with a number of key staff in NHS Hull (like GPs, pharmacists and nutritionists), and with other staff who had an interest in weight management initiatives (like local leisure clubs, community centres, employers and occupational health). A fact-finding exercise was also carried out with local companies on shift working patterns.
3. Qualitative research with residents
Focus groups and depth interviews were held with local residents, including men and women who were, and were not, engaged in weight management initiatives in the city.
4. Quantitative research with residents
A survey was undertaken with almost 300 male and female residents in Hull, either face-to-face or over the telephone. A structured questionnaire was used to provide quantitative data on:
- Self-assessed health and limiting illness
- Perceptions of weight
- Attempts to lose weight in the past and current status (in terms of weight loss)
- Barriers to losing weight and motivations to lose weight
- Likely involvement in possible NHS Hull interventions, influences on involvement and referred types of intervention
- Effectiveness of potential links of weight management intervention to Hull City Football Club
The survey also collected claimed data on height and weight to allow the Body Mass Index (BMI) of male respondents to be calculated.
1. Carrying a bit of weight is more manly
“Overweight men still see themselves as more attractive than a skinny bloke”
Being overweight is more acceptable for men than it is for women. In Hull, the culture of rugby and associated activity of drinking entrenched the view that it is ‘normal’ for men to be overweight. To some men, being overweight represents masculinity and is a sign of ‘good living’ or of being able to ‘provide’ enough for one’s family.
Overweight or obese men involved in the qualitative research did, however, have aspirations to reduce their weight and improve their health. Reducing the risk of illness and feeling fitter were key motivators for weight loss. They also recognised the importance of exercise in achieving these goals.
2. Dieting is for women
“Men won’t go to sessions where there are too many women”
Men tend to consider their ‘fitness’ levels rather than their ‘weight’, and frequently use the terms ‘getting into shape,’ ‘getting fit,’ or ‘in training’. Findings from the literature review also suggested that men respond to status, power and humour.
Some men would not consider attending weight loss groups, because they were viewed as female oriented, having high associated costs and using unappealing ‘methods’. Some men did feel they would be encouraged by men-only sessions. Some key stakeholders felt that men prefer a scientific approach to weight management and any weight loss programme would need to be simple and more masculine – such as a ‘wild boar’ low fat microwave meal. Weight management for men needs to be informal and activity based, and not about ‘counting points’.
3. It needs to fit my lifestyle
“I can just about cut out chocolate and a fry up, it’s booze that’s the killer”
Many men in Hull have a strong identification with sport and may be passionate fans of the three big sports clubs in the town. Sport is a major ‘pull’ factor for men and is commonly used in marketing to men. Sport appears to represent masculinity – power, control and indestructibility – and is undertaken for enjoyment and ‘having a laugh’. Men do not always make the direct connection between sport and health, which is commonly thought to be a result of genes or fate.
Many men involved in the qualitative research felt that a ‘gym’ was inappropriate, either because of their age or weight. Key stakeholders also emphasised the timings of any service delivered needed to be appropriate for working class men, who work shift patterns that can be unpredictable and change week by week.
4. Health professionals and family members are key influencers
Despite the fact that men do not traditionally access healthcare services, GPs and nurses are seen as important providers of support in losing weight, and a referral from a GP could be used as a powerful tool to promote men’s involvement. However, as men are not traditional users of health services, it was therefore key to find different pathways for men to access services.
The majority of men surveyed mentioned that their wife or partner would have an influence on them in considering a service to help them lose weight. Sons and daughters were also commonly highlighted.
It became clear that there are many barriers and motivators that men face in their approach to weight management:
- Lack of time: Labour intensive to cook from scratch; eat out regularly and drink alcohol; too busy to exercise
- Costs: Affordability of healthy food choices; expense of joining weight loss groups; cost of fitness facility membership
- Shift working patterns: May need to attend at different times each week
- Someone else takes care of household cooking
Attitudinal and perceptual barriers:
- Lack of willpower or motivation: “It’s willpower, that’s what it boils down to, everything else is nothing really, if I want to do it I’ll do it, like when I quit smoking I did it and I mean losing weight will be willpower.. Maybe if I could go in and get help focusing on my objectives, maybe that would help.”
- Perceive weight loss groups as being female oriented and put off by ‘methods’ used to lose weight, like being required to purchase speciality food items
- Belief that it is ‘okay’ for men to carry extra weight
- Change of lifestyle seen as too significant
- Losing weight can be lonely and boring
- Denial of problem or potential problem
- Improving overall health
- Feeling fitter
- Reducing the risk of illness
Potential competition for a new weight loss programme:
- Trying to lose weight independently
- Current services in the local area
- Peer and social norms
- Accessibility of cheap fast food and alcohol
The behavioural goals of the Fit Fans programme were to get men aged 40 to 65 to use the SPoA and subsequently attend the newly commissioned weight loss service designed specifically for them.
Participants would be encouraged to attain a 5 per cent drop in baseline weight over the 12-week programme and to keep that weight off over a subsequent 12-week time period.
First year targets:
- Minimum 730 clients accessing the project (April 2009 to March 2010)
- Minimum 80 per cent completing the 12-week programme
- Minimum 30 per cent achieving 5 per cent weight loss (and maintaining that weight for a further 12 weeks)
NHS Hull commissioned external provider Weight Management Centre Ltd to develop and deliver a weight loss programme for men aged 40 to 65, based on the research findings from the scoping phase.
Fit Fans programme
A new free 12-week weight loss programme was specifically developed for men in Hull. Each weekly session consists of 20 to 30 minutes of classroom style discussion followed by approximately 40 minutes of physical activity. Classroom sessions provide information on various aspects of fitness and weight management in a scientific but fun atmosphere. The physical activity sessions are made up of three key elements: cardiovascular work, core stomach strengthening exercises, and muscle toning using flexible bands. The sessions are run by highly skilled professionals and set in the big sport clubs in the city. Clients participate at a level suitable for their ability and are encouraged to build regular 10 minute exercise sessions into their daily routine between weekly visits to their respective groups. In addition to group sessions, one-to-one coaching is provided each month.
At the conclusion of the 12-week programme, clients are encouraged to continue attending weekly physical activity sessions.
A new website (www.fitfans.co.uk) was created, containing: information on the Fit Fans programme; a weight loss league table; diet and nutrition advice; a BMI calculator; other local weight management services available; and a blog.
Single point of access
Alongside the Fit Fans 12-week programme, a new SPoA was created to coordinate and promote existing weight management services available in Hull. Anyone in Hull, male or female aged 18 to 75, who would like information about healthy eating, exercise and losing weight, could now call a single number to access NHS Hull's Weight Management Service. A phone-based service makes it convenient and easy for people to gain access to a wide variety of services to suit their needs and lifestyle. It helps to remove some of the confusion for members of the public and health professionals and creates efficiencies.
Callers are asked some simple questions about their health and the kind of help they would like to receive. Based on their characteristics, such as weight, height and co-morbidities, and on local supply and demand, the referral service offers a suitable range of options and services. For example, callers could be sent information about healthy eating or physical activity (or both) through the post, or they could be invited to attend a personal health assessment to look at their situation more closely and explore further treatment options that would suit them. Meanwhile, by phoning the same number, male callers can also be offered a place on a Fit Fans course.
A total weight management and obesity resource centre was also set up in the city centre. This drop-in centre provided advice and signposting to weight management services, including Fit Fans. Located in the city centre, the drop-in centre emphasises the community aspect of healthy weight.
Working with the Central Office of Information (COI), NHS Hull commissioned a creative agency to deliver a 12-month communications campaign to promote Fit Fans. The city of Hull has a strong sporting tradition and hosts a championship league football team and two super league rugby league teams. The campaign seeks to prominently incorporate these interests in the promotional materials. Posters and leaflets depicting images of overweight or obese shirtless male supporters on the terraces were developed. These posters use text copy that is associated with being overweight, but is also related to common football and rugby phrases. For example, the tagline ‘Time to change your tactics?’ is used, along with a strong call to action to ring a local telephone number to join the Fit Fans programme.
While the programme had originally been planned to start in the 2009 New Year, to capture those setting New Year’s resolutions, because of commissioning delays the Fit Fans programme was not launched until the start of March 2009, shortly after the SPoA was launched.
From the start of the programme, communication materials were distributed throughout Hull:
- Billboards on main routes into and around the city
- Bus panels
- Washroom panels in pubs
- Health professionals and community events across the city
- 30-second radio adverts on local radio stations
Regular performance monitoring meetings are held quarterly between the PCT and the Weight Management Centre Ltd, who deliver the Fit Fans programme. This allows the public health team to receive performance update reports and ensures the programme is coordinated and on track to meet its objectives and outcomes, which have been detailed in a service level agreement between the different parties.
As referrals to the Fit Fans programme increased, more sessions have been created to suit demand. The programme has received good feedback from participants; particularly successful aspects identified include the social element of getting men together and having training tailored to their needs. The classroom element is also appreciated, as it enables participants to build up a portfolio of information over the 12-week period, which they can take home to help maintain their fitness during the programme and to share with family members.
“I think the men really liked the group sessions. There’s 10 and 15 guys usually, generally working class factory based men. You can imagine a group of those guys getting together can be a bit boisterous, but the social element of it works really well. They all get on really well together and have fun. They take the Mick out of each other a bit, but it’s all done in good fun.” (Peter Dawson, Public Health Manager)
During the programme, many of the female partners of the men using Fit Fans started asking if there was anything similar for them, as they had tried other weight management services unsuccessfully. Subsequently a ‘Fit Fans for Her’ pilot was developed and launched in the last quarter of 2009/10, with approximately 100 women participating. This has proved to be very successful and has since been incorporated into the Fit Fans programme and existing contract with Weight Management Centre Ltd.
While the programme has been very successful, the project team is always looking to improve it and to see what areas might be proving a barrier for some people attending or completing the programme. One area that has been identified is whether the outside nature of the physical activity sessions can put off participants in the winter months, and whether more sessions should be moved into indoor venues to ensure turnout.
“I think during the winter months the outside physical activity elements can be discouraging for some of the guys and for the women on the female programme. It hasn’t been massively detrimental, but I think if there was a venue where they could do the physical activity indoors that would improve the service.” (Peter Dawson, Public Health Manager)
Evaluation of the Fit Fans programme has been completed by Information by Design. Evaluations were conducted half a year and a full year after the programme began running. Data from the programme is provided by the Weight Management Centre Ltd.
Results show that in 2009/10:
- 491 men and 104 women started the Fit Fans programme (the women’s programme only began in the last quarter of 2009/10)
- 413 male participants (84 per cent) and 97 female participants (93 per cent) completed the 12-week programme
- 78 per cent of participants were obese or morbidly obese at the start of the programme, dropping to 64 per cent at the end of the programme
- 50 per cent of male participants who completed the 12-week programme achieved a 5 per cent or more drop in weight, and of these 77 per cent maintained this weight loss after a further 12 weeks
- Of the 97 women who completed the programme in the last quarter of 2009/10, 37 per cent achieved a 5 per cent or more drop in weight, and of these 33 per cent maintained that weight loss after a further 12 weeks
While this shows that the Fit Fans programme fell slightly short of achieving its first year target of 730 men accessing the service, it did successfully exceed its target of achieving a minimum of 80 per cent completing the 12-week programme and of those, 30 per cent achieving a 5 per cent weight loss and maintaining that weight for a further 12 weeks.
Awareness (as of May 2010):
- 40 per cent of respondents from a sample of the general population in Hull recalled seeing some form of advertising around the city about weight management or getting fit, while 42 per cent of a sample made up of men aged 40 to 65 recalled seeing the advertising
- 51 per cent of respondents from the sample of men aged 40 to 65 recalled Fit Fans messages (26 per cent unprompted, 25 per cent prompted), while 46 per cent of respondents from the general population recalled the Fit Fans messages
- The highest recalls from men aged 40 to 65 were from the radio (39 per cent) and billboards (35 per cent), with smaller proportions recalling newspapers (26 per cent) and washroom panels (9 per cent)
- 79 per cent of all male respondents aged 40 to 65 agreed or strongly agreed that linking up with Hull City Football Club was a good way to encourage men to lose weight and get fit
- 22 per cent of all male respondents aged 40 to 65 claimed they were likely to recommend Fit Fans to a friend, while 9 per cent said they would like to join Fit Fans themselves
NHS Portsmouth City has commissioned the Weight Management Centre Ltd to run the Fit Fans programme in Portsmouth. This programme is currently available by GP referral only, unlike the Hull programme which is available both from health professional referral and self-referral. The Portsmouth Fit Fans has male and female sessions and is run over either a 12- or 24-week period.
The SPoA wrapped up in November 2010, while the Fit Fans programme will continue until March 2012. It has been examined as part of the weight management services review to see whether funding would continue or whether the programme would need to be adapted or combined with other programmes in light of the reductions in public sector spending. However due to its successes it was decided that it should continue in its existing capacity.
Presentations about the Fit Fans programme and the lessons learned from the work have been made locally, regionally and nationally, including at the 18th Annual Public Health Forum in Bournemouth during March 2010.
It is vital to know who your target audience is and to understand what they would want from a weight management programme. You must do good scoping work before you develop your programme and your marketing materials. Pre-testing intervention ideas and materials is essential to ensure you produce something that will resonate with your audience, rather than what you think will resonate with them.
“We developed three or four various routes to go down with our social marketing campaign materials and then we pre-tested that with our target audience. We as health professionals had an understanding of what we thought would work, but we got it wrong! We took the various routes out to our target audiences and pre-tested it and then we went with the findings of the pre-testing, and our evaluation has shown we did right in listening to the guys who wanted to come on to the programmes.” (Peter Dawson, Public Health Manager)
While there is considerable noise about weight management generally, NHS Hull does feature highly with good levels of recall, and radio and billboard channels appear to create the highest levels of awareness. Some key messages became clear – KC Stadium and Craven Park have reached the target audience though the current media and are an important part of the success of the campaign. The use of sports as a hook for the intervention came directly out of the research, and for this reason NHS Hull strongly recommends developing your programmes based on strong insight. The evaluation of Fit Fans has shown the elements that have been directly informed and influenced by the insight have been key to the achievements of programme.