Background

In 2014, 62% of Canadian men self-reported being overweight or obese versus 46% of women [1]. Excess weight is a significant contributor to the rise in many preventable chronic diseases [2] and premature mortality [3]. Up to 70% of men’s risk for these diseases could be prevented through a healthy diet, being physically active, smoking cessation, and reducing excess alcohol consumption [4, 5].

Men are continually underrepresented and underserved in health promotion interventions [6, 7]. Men are more likely to view weight loss programs as “feminized” domains, contrary to the male narrative of independence and self-reliance [8, 9]. Successful interventions targeting men’s health behaviours have been tailored to work with the masculine narrative rather than against it [10, 11]. Targeting male sports fans in professional sports club/team settings has shown recent success [12, 13] as these fans tend to share a group identity with other fans of the same sport [14] and have poor health habits [15, 16].

Two thirds of Canadians, predominantly middle-aged men, identify as hockey fans [17]. The Hockey Fans in Training (Hockey FIT) program capitalized on the large male fan base of major junior hockey in Canada to recruit men into a gender-sensitized weight loss and healthy lifestyle program. Hockey FIT was adapted from the successful Football Fans in Training (FFIT) weight loss program [12, 18] and integrated new components including the HealtheSteps™ lifestyle prescription program [19] and an eHealth online social network. Adaptation of the Hockey FIT program to Canadian hockey culture has been discussed in detail elsewhere [20]. An outcome evaluation of the Hockey FIT pilot program showed promising results with men in the intervention group losing, on average, 3.58 kg more than the comparator, and maintaining this weight loss to 12 months [21]. In this paper, we report on the process evaluation of a pilot pragmatic randomized controlled trial (pRCT) of the Hockey FIT program.

Methods

Aim

The aim of this process evaluation was to evaluate the acceptability of the Hockey FIT program by exploring the: 1) coaches' experience delivering Hockey FIT; 2) men’s experience with Hockey FIT; and 3) ways of optimizing Hockey FIT.

The Hockey FIT program and pRCT have been described in detail elsewhere [20]. Briefly, we recruited 80 male fans of two Ontario Hockey League (OHL) teams (London Knights and Sarnia Sting), aged 35–65 years, with a Body Mass Index (BMI) ≥28 kg/m2, and meeting the physical activity safety requirements. Men were randomized (1:1) to intervention (Hockey FIT program) or comparator (Wait-list Control, beginning Hockey FIT 12 weeks later).

The Hockey FIT program consisted of a 12-week active phase delivered at local GoodLife Fitness clubs or OHL team hockey arenas (when available), followed by a 40-week minimally-supported phase. The active phase involved 12 weekly, 90-minute classroom education and group-based exercise sessions delivered by trained Hockey FIT coaches. Coaches were graduate students and hockey team staff. In-between program sessions, participants were encouraged to engage in an incremental pedometer-based walking program and set/tracked lifestyle prescriptions for physical activity (steps), exercise and healthy eating. During the 40-week minimally-supported phase, participants were encouraged to access the following support tools: 1) the HealtheSteps™ smartphone app providing tools to track and sustain physical activity; 2) a private online Hockey FIT social network (powered by Tyze Personal Networks: http://tyze.com/) for each site, only accessible to coaches and participants to share resources and support; 3) six motivational email messages (see Table 1) and an invitation to a 9 month booster session and reunion.

Table 1 Standardized Coach Messages Sent During 40 Week Minimally Supported Phase
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Process evaluation data were collected from the intervention group (n = 40) alongside the pRCT at baseline, 12 weeks, and 12 months. Mixed methods were used to conduct the process evaluation using the following data sources: attendance records; coach interviews (CI) at the end of the active phase; focus groups (FG) with participants who completed the active phase; program fidelity (post-session coach reflections and program observations) collected during the active phase; and 12-month participant interviews (PI) during follow-up assessments after the minimally-supported phase. Convenience sampling was used to recruit participants for the focus groups at both sites, and for the 12-month participant interviews. All ‘program completers’ (n = 33), defined as those who attended ≥50% of active phase sessions including at least one session in the final 6 weeks, were invited to attend a focus group at their site. All ‘program completers’ who attended the follow-up at 12 months (n = 30) were invited to stay for an interview with a member of the research team. Program fidelity was monitored by two trained assessors (one main and one back-up), who observed all 12 sessions at both sites, and tracked the delivery of key tasks by the Hockey FIT coaches during each session, which includes whether they were delivered as designed in the program protocol [20] (see Table 2 for Weekly Topics and Table 3 for Program Observation Framework for Week 5). The main assessor completed post-session reflections with the head coaches after each session recording the coaches' experience of delivering key tasks at each session, and what the coach thought went well or did not go well.

Table 2 Weekly Topics
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Table 3 Program Observation Framework – Session 5
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Fifteen participants (5 in London, 10 in Sarnia) from the intervention group attended the 12-week focus groups (one focus group was held in London and another in Sarnia); all four coaches (a head coach and an assistant coach in each club) completed 12-week interviews; and 28 participants (14 in London, 14 in Sarnia) from the intervention group completed 12-month interviews. Ethical permission was granted by the Western University Health Sciences Research Ethics Board and all participants and coaches provided written informed consent.

Coach and focus group transcripts were analyzed together with three members of the research team, one an expert in qualitative research, and guided by the framework approach [22]. An inductive approach was used to code the data line-by-line. The research team met and a framework of overarching codes was developed off of which new codes could be added based on the findings from the 12 month interviews. The 12-month interviews were reviewed by the research team and new codes were added to the framework. Fidelity data (program observations and post-session coach reflections) were read through by two members of the research team and summarized. Key tasks missed were identified through the program observations and supplemented by the post-session coach reflections along with suggestions for improving program delivery. The fidelity data was then ‘triangulated’ [23] with the findings from the focus groups, and interviews with coaches and participants, and additional codes were added to the framework. The final framework with all data sources was used to summarize the findings for publication.

Results

Based on the fidelity data, of the 51 tasks to be delivered by the coaches over the 12 weeks, 46 tasks were delivered (84% completion) in London and 49 tasks were delivered (96% completion) in Sarnia (See Table 2). Attendance did drop mid-program at both sites (see Fig. 1), but increased again during the final program sessions.

Fig. 1
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Weekly Attendance (Intervention group, separated by site)

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Coaches' experience delivering Hockey FIT

Coach interviews and post-session coach reflections informed the coaches' experience delivering Hockey FIT. Coaches enjoyed seeing the men progress throughout the program and the friendships that were developed, “…to see these guys from day one, they were nervous, coming in to a baseline assessment and not knowing exactly what they were doing, and then from week 12 where now they’re trying to organize golf games together and really enjoying each other’s company, so that was fun to watch. And then from a research side it was also extremely fun because you could physically see changes in these guys” (CI-2).

The coaches valued the relationships they developed with participants knowing they were helping the men improve their lifestyles, “My favorite part was just interacting with these guys every week and really building a rapport with them and knowing within myself I’m helping people, I’m helping 15 guys out here that want to be helped” (CI-1).

Some coaches felt they were “lecturing” participants at the beginning of the program in part due to the greater amount of classroom content and becoming familiar with the flow of the sessions. This changed as the program progressed, “Once we got into sessions 4 and 5 though I thought that it started to flow, it was a lot easier to deliver, it wasn’t quite as much me lecturing, it was more sort of facilitating discussions among them…” (CI-4). One of the coaches also identified feeling more comfortable with the physical activity portion of the program compared to delivering the nutrition information, “I felt more comfortable doing the exercise [components]. I’ve been coaching since I was 15 so it’s easy for me now that I can try to motivate people and I have a better idea of the body in a physical aspect than I do in a nutritional aspect” (C1–1).

As indicated by Figure 1, the attendance dropped mid-program. A coach described how they felt this made the program more difficult to deliver, “that was a barrier to overcome because a lot of the program is interaction and you want guys to be talking and coming up with ideas so if you only have 9 in a group and you only have one group of 5, one group of 4, it’s a lot harder than if you had 4 groups of 4 or 5, where you have more ideas coming out” (CI-1).

The coaches did have suggestions for improving the program. One coach expressed concern about participants exercising on the concrete surface of the arena as this can exacerbate previous injuries, “…I didn’t feel like I was giving them the exercises that they needed and again that was because we didn’t really take into account the environment that we’d be doing those exercises in.” (CI-4). Timing was a common difficulty noted by coaches throughout the post-session reflections and interviews, “I wish it was longer, not only number of weeks but I wish it was a 2 hour program instead of an hour and a half because sometimes they had a lot more questions than we anticipated” (CI-3). More hockey-related content was also suggested by coaches to take greater advantage of the men’s common interest, “…if we did more [hockey] drills with balls and sticks and things like that because they were all such big hockey fans…maybe incorporating more of what they all had in common, which was hockey, would have been nice” (CI-2).

Men’s experience with Hockey FIT

Participants in the intervention group were on average, 49.1 (SD 9.1) years of age, with the majority being married or common law (87.5%), of Caucasian ethnicity (95%), and having greater than a high school education (67.5%). At baseline, the average weight of participants was 112.5 (SD 24.6) kg, with a BMI of 36 (SD 5.9) kg/m2 and an average step count of 6859.6 (SD 3253.8) steps per day. Further information on the baseline characteristics of participants has been discussed elsewhere [21].

Active phase

Men’s experience with the active phase of the Hockey FIT program was explored through focus groups. Men joined Hockey FIT for a variety of reasons including weight loss, increasing physical activity levels, and a desire to improve their health for their families, “I want to live to see my family and my kids grow up and get married. I lost my dad at 13 and he was 33… it would be nice to, I passed him, but go way past him. Double.” (FG-1).

Most men appreciated how other members of the group were similar in size, shape, and desire to lose weight and improve their lifestyle, “we all have the general understanding that we’re all in the same boat” (FG-2). Participants compared themselves to each other and were quick to point out those who they felt did not belong, “Some of it was we wanted to improve our self-image and we didn’t like being compared to the model on the front of the magazine concept, and yet we had two [models] in the class” (FG-1). Others noted that the variation of exercise activities supported the range of physical abilities present in the group, “I liked the variation because I am not as fit as some of the other guys here, I used to be, but I’m not…” (FG-2).

The classroom content was valued by participants as this information both reinforced and added new knowledge to help participants make lifestyle changes, “…understanding exercise and target heart rate, its impact on obviously your fitness or your calorie burn, those are the things I didn’t know” (FG-1). One of the men explained how this new knowledge led to actual behaviour changes, “I never ate breakfast for 51 years, and now I haven’t missed breakfast in probably six weeks” (FG-1).

Participants felt the coaches were invested in their success in the program, “They really had a genuine interest in health and well-being and us” (FG-2). The men felt accountable to show up for the program and their coaches as they considered themselves a team, “It’s that whole teamwork…you’ve got to show up for the team” (FG-2). The men’s experience with the program left them eager to attend the next session, “The combination of everything, I wanted to learn, the next week I wanted to see what else. And the competition and everything. Everybody said they just wanted to come back” (FG-2).

Some participants felt the program was rushed to cover all of the content, “I found that with the class and the exercise it was almost you know, 3 hours squeezed into an hour and a half” (FG-1). Others were disappointed with the lack of hockey-related content and support from the OHL team personnel, “I thought that maybe the [OHL] trainer would come out and talk to us a bit about the training, and health, and sports, and exercise” (FG-2). Some participants suggested involving a dietitian or a chef in a session, “I can only cook so many types of food, so why not have a chef come in and go over different things to show us how to do it properly” (FG-1). Lastly, some of the men would have enjoyed competition between sites, “It would have been nice to see the competition between the Sarnia Sting and the London Knights” (FG-2).

Minimally-supported phase

Interviews conducted with the men at 12 months informed the participants experience maintaining their healthy lifestyle during the minimally-supported phase. Participants found the skills they had gained through the active phase of the program helped them to maintain their health behaviour changes, “…the lessons I learned during Hockey Fit continued to follow me, in the sense of the water, the fruits and the vegetables” (PI-3, Site 1). The emphasis on making simple lifestyle changes helped participants continue to be physically active, “I think the attention to the simple thing as walking and staying somewhat fit has helped me stay focused on maintaining what I learned in the program and keep it going” (PI-7, Site 1). Others noted the skills they learned through the handbook was helpful in maintaining their weight loss goals, “it was plain and simple, it was on paper, this is what you should do and if you follow this you’re probably going to lose weight” (PI-2, Site 2). The pedometer was also cited as helpful for maintaining physical activity levels after the program was completed, “…even the pedometer, it’s a really good thing because every day I was very cognizant of that thing and I always made sure that I was watching it…” (PI-14, Site 2).

Participants found they were encountering each other at community events, hockey games, and arenas and found it helpful to talk about their progress, “I was out in [rural city], out in nowhere at a hockey arena and just walking and walking and then I ran into one of our guys, he was playing with the other team and so it was funny, and are you getting your steps in, so it was just part of the program…” (PI-2, Site 1).

Men indicated the fear of regressing back into old habits as a reason for continuing with their healthy lifestyle changes, “I’ve seen these results, but I don’t want to regress” (PI-4, Site 1). Participants did identify barriers in maintaining their healthy lifestyles including medical conditions, injuries, and difficulties being active in the winter, “I would say the biggest challenge that I faced is winter. I think it’s tough to move in the winter and that tends to pack on weight.” (PI-14, Site 1).

Technology support

The HealtheSteps™ smartphone app was introduced to the men during session 11. It was not used by participants due to technical challenges experienced by the men (i.e., difficulties signing in, not tracking steps, crashing). Based on the 12 month interviews, the Hockey FIT social network was used passively with men only accessing the network when they received a message/post from their coach or another participant. Men admitted their own and other participants lack of interaction on the social network limited the potential of the network to support their progress during the minimally-supported phase, “It might help if more people were active on it, but I wasn’t active on it either so I can’t complain about it. I’m just saying if there’s more interaction going on than it might have inspired more people,” (PI-7, Site 2).

Nevertheless, many men found the standardized messages (see Table 1) sent regularly from their coaches through the social network (and also via email) helpful as they reminded participants about the importance of maintaining their healthy lifestyles, “They don’t shame you into doing it but they give you a good reminder of what you’re doing, makes you think about what you’re not doing” (PI-12, Site 2). Some participants would have valued more personal messages from the coaches as they felt left behind once the program ended.

9 Month Booster Session/Reunion

Eight out of 40 participants from the intervention group (4 out of 20 from London, 4 out of 20 from Sarnia) attended the booster session/reunion. Participants were asked at the 12 month interview why they could not attend. Reasons participants did not attend included work (n = 5), family commitments (n = 3), too far to travel (n = 4), not aware of the event/what it entailed (n = 2), or other commitments (n = 7). Participants noted this event was held on Super Bowl weekend, during the winter, and only in London making it difficult for some to attend.

The eight who attended enjoyed seeing each other again and found it highly motivating to hear about others’ success, “It’s kind of neat to see the guys, a couple of the guys did really well so it was kind of cool to see, it makes you think that you can actually accomplish something” (PI-2, Site 2). Some of the men found this session/reunion set them back on track with their goals, “It actually brought me back from a couple of weeks of falling off the wagon if you can call it that. Really because of the timing of it, it was towards the middle of winter, it really helped to actually say okay, yea you can still find some ways to do it…” (PI-9, Site 1).

Optimizing Hockey FIT

Based on the interviews with coaches and participants, a number of areas were identified for optimizing the program for future delivery. These items included improving mid-program attendance, coach training, nutrition education, timing, exercise modifications, amount of hockey skills and drills, app usability, the booster session/reunion, and the Hockey FIT social network (See Table 4). Overall, these items were minor and would not require significant changes to the program design.

Table 4 Items for Optimization
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Discussion

Findings from this process evaluation demonstrate Hockey FIT is highly acceptable – to both participants and coaches – for promoting healthy lifestyles and weight loss in male hockey fans who are overweight or obese. Previous research surrounding men’s health interventions have emphasized the importance of tailoring program materials to the male narrative [11]. Results from this process evaluation confirm the importance of tailoring interventions to the male narrative and supports the opportunity to further improve men’s health through engaging sports fans. Hockey FIT participants appreciated the program recruited men of similar interest regarding hockey, body size, and weight loss goals. Men felt a connection to each other, and in turn felt obligated to attend sessions and make lifestyle changes in order to contribute to their team. Suggested improvements included adding more hockey related skills and drills, sessions at the arena, more in-depth coach training and nutrition education, exercise modifications, greater opportunity for participants to attend the booster session, and more pro-active use of the Hockey FIT social network to better promote long-term support for health behaviour changes made by the men during the program.

Many of the qualitative findings from the focus groups mirrored the quantitative results of the program exit questionnaires completed by the men directly after the active phase of the program. These quantitative results were published in detail elsewhere [24]. According to results from the questionnaire completed at 12 weeks, 96% of participants found the exercise and educational classroom sessions beneficial to making health behaviour changes [24]. During the focus groups, men had expressed excitement and enthusiasm for coming back to the next session to learn more. All 27 Hockey FIT participants who completed this questionnaire indicated they had made changes to their eating habits as a result of being in the program [24]. In the focus groups, there were men who indicated they were now eating breakfast regularly because of Hockey FIT. Although the quantitative results from this questionnaire were positive and important in supporting the acceptability of the program, the focus groups and interviews provided a richer context over which these behaviour changes occurred. This allowed the research team to further understand why certain program components worked well or not well, how Hockey FIT impacted the men’s lives both in the short and long term, and the ways in which Hockey FIT can be improved to better meet the needs of participants.

Findings from Hockey FIT including a desire for more sport-specific activities were similar to findings from the FFIT process evaluation [25]. The Hockey FIT coaches also enjoyed delivering the program and meeting participants, but felt pressured to stay on time similarly to FFIT [25]. We found participants had a strong desire to compete between sites, which speaks to the longstanding rivalry between the two participating major junior hockey teams [26]. In contrast to FFIT, the standardized messages sent during the 40 week minimally-supported phase were viewed more favourably by the Hockey FIT participants as the men in Hockey FIT may have valued more information and support from coaches to help maintain their health behaviour changes. We also saw a drop in attendance mid-program which may have been a result of running the program in the summer (i.e., vacation).

Study limitations

There were several limitations to this study. The two head coaches may have responded more positively towards the program during the interview as they were both heavily involved in the development of the Hockey FIT program and materials. Only 15 participants (10 in Sarnia, 5 in London) out of 30 invited participants attended the focus groups limiting the generalizability of these findings to the wider group. Moderators noted one of the focus group participants was more vocal about his experiences with the program than others in the group. This may have swayed the results of the focus group more heavily in favour of this participants’ experience rather than the entire group. Data were only collected from the intervention group; collecting data from the wait-list group could have deepened our understanding of participants’ experience with the program. Lastly, there was a low turn-out for the booster session due to a variety of factors (i.e., Super Bowl, weather, and location) limiting the amount of data collected about this event.

Conclusions

This study supports the findings of other gender-sensitized programs targeting sports fans [12] and provides an innovative and effective approach for engaging men in health promotion interventions and improving men’s health. Hockey FIT was found to be a highly acceptable program by both participants and coaches involved in the pilot. Our results indicate only minor changes are needed to optimize Hockey FIT for future implementation in a definitive trial.