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Enhancing the social and cultural relevance of interventions: the inter-disciplinary science of behaviour change Sally Wyke1 and Kate Hunt2 1 College of Social Sciences 2 MRC/CSO Social and Public Health Sciences Unit University of Glasgow
ISBNPA 2015, Edinburgh 3-6 June:
Advancing Behaviour Change Science
Enhancingthesocialandculturalrelevanceofinterven3ons:
theinter-disciplinaryscienceofbehaviourchange:FFIT–acasestudy
Enhancingthesocialandculturalrelevanceofinterven3ons:
theinter-disciplinaryscienceofbehaviourchange:FFIT–acasestudy
Physicalac3vity
Foodandea3ng
Bestevidenceandprac3ce
Scienceofbehaviourchange
Sociologicalunderstandings
Clinicalexperience
Group-basedweightmanagementprogrammeforoverweight/obesemenaged35-65yrs
Enhancingthesocialandculturalrelevanceofinterven3ons:
theinter-disciplinaryscienceofbehaviourchange:FFIT–acasestudy
Backtothe‘80s
“thereisnosociety”
“..focus on the individual as a unit of analysis emphasising unthinking, reckless or irresponsible behaviour or
incautious lifestyle as the moving determinant of health”
2
Prevalence of insufficient physical activity: adults, age 18+ (age standardised estimates), WHO 2010
Women
Effective interventions • Intervene at many levels • simultaneously & consistently
Community-level
Individual-level
Popula3on-level
ThankyoutoSusanMichieforslide
ResearchEffort
93 item BCT Taxonomy v1,
Annals of Behavioral Medicine, 2013
BCT Taxonomy v1: 93 items in 16 groupings
Evidence of effectiveness of BCTs for life for PA and healthy eating
3
Problemswithindividuallevelinterven3on:ReachandEngagement
Lowreach:programmesreachasmallpropor3onofthosewhocouldbenefit
e.g.11.4%ofobesemenwhoaFendedamen’shealthclinictookuptheofferofaspecificallydesignedweightmanagementprogramme1
Engagement:itishardtokeepgoingwithchanges;ourprogrammesstruggletoretainpeople;longtermmaintenancelow
~20-54%ofpeoplemaintainweightlosstoayear2,3
1GrayCM,etal.JournalofMen'sHealth2009,6:70-812WingRR,PhelanS:TheAmericanJournalofClinicalNutriBon2005,82:222S-225S;3BarteJCM,etal:ObesityReviews2010,11:899-906
TheSociologicalImagina3on
“...the vivid awareness of the relationship between experience and the wider society.”
Humanac3vity:shapedby,andshapes,structure
“Humanagencyandsocialstructureareinarela3onshipwitheachother,anditistherepe33onoftheactsofindividualagentswhichreproducesthestructure.”1
1GauntleF,David(2002),Media,GenderandIdenBty:AnIntroducBon,Routledge,LondonandNewYork.(Extractsavailableatwww.theory.org.uk)2Giddens,A(1984)TheCons3tu3onofSociety,PolityPress,London,p2
“Thebasicdomainofthesocialsciences…isneithertheexperienceoftheindividualactor,northeexistenceofanyformofsocialtotality,butsocialprac3cesorderedacrossspaceand3me”2
Socialprac3ce
“….arou3nisedtypeofbehaviourwhichconsistsofseveralelements,interconnectedtooneother:formsofbodilyac3vi3es,formsofmentalac3vi3es,thingsandtheiruse,abackgroundknowledgeintheformofunderstanding,knowhow,statesofemo3onandmo3va3onalknowledge1”
1 ReckwitzA(2002).EuropeanJournalofSocialTheory5(2):243–263.
SocialPrac3ceis….Afocusonsocialprac3ceenablesa
broaderviewthanafocusonbehaviourBehaviours–lotsofsingle,unique,ac3onsSocialprac3ces–endurebetweenandacrossspecificmomentsofenactmentPrac3cesareperformed.Theprac3ceiscarriedbyits
performers
ShoveE,PantzarM,WatsonM:TheDynamicsofSocialPracBce:London:Sage;2012.;SpotswoodFTransportaBonResearchPartF:TrafficPsychologyandBehaviour2015,29:22-33.
Meanings
Materials Competen-cies
Meaning:Symbols,ideasandaspira3ons
Materials:Stuff–things,technologies,tangibleen33es
Competencies:skills,embodiedknow-how,technique
4
Smokingbygender,OECD
• `typically,smokingdiffusesthroughpopula3ons,establishingitselffirstamongelitemen,thenworkingdownclassandstatushierarchiesandthroughthepopula3on'(Greaves,1996)
Source:HealthataGlance
Smoking–genderdifferencesvarygeographicallyandhistorically Smokingbygender,OECD
Source:HealthataGlance
Smoking–genderdifferencesvarygeographicallyandhistorically Smoking–genderedpromo3on
“Thetobaccoindustryrecruitsandretainssmokersbyassocia3ngitsproductswithexcitement,sex,wealth,rebellionandindependence”StantonAGlantz,BMJEditorial,2001
“Remarkablyelas3cmeanings”,even“contradictorymeanings”(Brandt1996)ofsmokingformenandwomenhistoricallyandcross-culturally
Whatis‘normal’,sociallysanc3oned,expected,taken-for-granted
is‘tacit’knowledge
locatedveryspecificallyin3meandspace
Smoking–“old‘normals’”:Smokinginconfinedspaces
Smoking–“old‘normals’”:Smokinginpromo3onfor‘good’paren3ng
5
Health–relatedbehavioursareomenrelated
togender
Gender(1) 1)Categorisa3onas‘male’or‘female’occursindailyinterac3on:“Sex-classplacementisalmostwithoutexcep3onexhaus3veofthepopula3onandlife-long”(Goffman,1977)
2)Genderdichotomisa3on:“Commonsenseknowledge[that]menandwomenactdifferently”(Connell,1995)
3)(Re)producinganappropriate‘genderiden3ty’islearnt,rehearsedandrelearntthroughsocialinterac3on
Gender(2)
“7 MACHO MISTAKES: WHY BEING A MACHO, MACHO MAN
IS BAD FOR YOUR HEALTH”
Real Men:
Can Handle Their Booze; Drive Fast; Don't Get Sick;
Are Never Vulnerable; Don't Eat Vegetables;
Are a Turn-on for Others; Work Out Hard http://
www.everydayhealth.com
Doinghealth,doinggender
‘strong public narrative … men will be strong, stoical and silent in matters relating to health and well-being’
Malegroup-roleofthepubHUGH(70units):Ithinkit’sacommunalartude...sortof“yourbrother’syourbrother”...Ithinkforguysourage..you’reinaGROUP,youstandyourROUND…it’sakindofactoffriendshipisn’tit,saying,“doyouwantapint?”Youknow,it’sahumanthing,it’sasociablethingEWAN(85units):Whensomeonesays..“wouldyoulikeadrink?”,..it’sanolivebranch..It’sasocialexchangethatsendsasign“Ithinkyou’reOK”..Mentheworldover,certainlymenintheindustrialwestofScotlandaren’tgoingtostarthuggingeachotherandsaying“let’sdoalaFe”..Itgetsroundthesortofawkwardnessyoumighthaveinthesortofmaletomalerela3onships
Alcoholconsump3on:intenselysocialandculturallylocated
Emslieetal,HealthPsychology,2013
‘Hegemonic’masculini3es
• “not..fixeden3t[ies]embeddedinthebodyorpersonalitytraitsofindividuals”butas“configura3onsofprac3cethatareaccomplishedinsocialac3on..inapar3cularsocialserng”(p836)”1
1ConnellandMesserschmidt,HegemonicMasculinity:RethinkingtheConceptGender&Society2005
• “hegemonyworksthroughtheproduc3onofexemplarsofmasculinity(e.g.professionalsportsstars),symbolsthathaveauthoritydespitethefactthatmostmenandboysdonotfullyliveuptothem”(p846).
• “paFernsofmasculinityaresociallydefinedincontra-
dis3nc3ontosomemodel(whetherrealorimaginary)offemininity”(p848)”
6
Gender,healthandhealth-behaviours Gender as performance and health Doing health, doing gender ‘By dismissing their health care needs, men are
constructing gender. When a man brags, ‘I haven’t been to a doctor in years’, he is simultaneously
describing a health practice and situating himself in a masculine arena.’ (Courtenay, 2000)
Gender as performance and health Doing health, doing gender
.’ (Courtenay, 2000)
Balancing ‘man points’
Reassuringly masculine
Suspiciously feminine
Malegroup-roleofthepubYoungmenanddrinking:trading‘masculinecompetencies’,JonnyWilkinson,‘Manpoints’
deVisserandSmith,2007;deVisserandMcDonnell,2013
A national sporting hero in a tough sport = MANPOINTS++
Malegroup-roleofthepubYoungmenanddrinking:trading‘masculinecompetencies’,JonnyWilkinson,‘Manpoints’
deVisserandSmith,2007;deVisserandMcDonnell,2013
Will:ButdoyouthinkJonnyWilkinsonisanylessofamanbecausehedoesn’tdrink?Imean,he’sanaBonalhero!
Jack:He’ssBllaonetrickpony.Will:Hedidn’thaveapintinthepuba]erhewontheWorldCup.
Tim:Yeah,that’sabitlameIthink.
But doesn’t drink = MANPOINTS ---
Malegroup-roleofthepubYoungmenanddrinking:trading‘masculinecompetencies’,JonnyWilkinson,‘Manpoints’
deVisserandSmith,2007;deVisserandMcDonnell,2013
Will:ButdoyouthinkJonnyWilkinsonisanylessofamanbecausehedoesn’tdrink?Imean,he’sanaBonalhero!
Jack:He’ssBllaonetrickpony.Will:Hedidn’thaveapintinthepuba]erhewontheWorldCup.
Tim:Yeah,that’sabitlameIthink.Charlie:Buthe’sgotareallyfitgirlfriend.Tim:Yeah,he’sgototherthings,whichkindofliAshimbackupagain
Really fit girlfriend and ‘other things’ = MANPOINTS++
7
Over75%ofmenareoverweightorobeseinScotland5-10%weightlosscanproducesignificanthealthbenefitsMenarereluctanttoaFendtradi3onalweightmanagementservices• Lessthan15%ofreferralstocommercial
sector1• Only23%ofaFendeesatNHSweight
managementservices2Manymenthinkslimminganddie3ng
arejust“forwomen”3Menomenprefertocontroltheirweight
throughexercise4
1JebbSetalTheLancet2011,378:1485-1492;2CounterweightProjectTeam:BrJGenPract2008,58:548-554.;3GoughB:SocSciMed2007,64:326-337.4PlinerP,ChaikenS,FleFGL:PersSocPsycholBull1990,16:263-273.
Innova3onneededtoadractmentoweightlossandhealthylivinginterven3ons
Guidingprinciples-The‘hook’
Professionalfootballremainsamale-dominatedenvironmentThreatsof‘weight-management’to‘masculinecapital’offsetbyenhancedphysicalandsymbolicproximitytotheclub.Thatis:
‘Manpoints’lostby‘die3ng’mightbegainedfromdoingahealthandfitnessprogrammebasedinafootballclub1.
1HuntK,etalBMCPublicHealth2014,14:50.
Enhancingthesocialandculturalrelevanceofinterven3ons:
theinter-disciplinaryscienceofbehaviourchange:FFIT–acasestudy
Physicalac3vity
Foodandea3ng
Bestevidenceandprac3ce
Evidenceonbehaviourchange
Sociologicalunderstandings
Clinicalexperience
Group-basedweightmanagementprogrammeforoverweight/obesemen(BMI>18)aged35-65yrs
DeliveryLedbytrainedclubcommunitycoaches12weekly,weightlosssessionswith‘classroom’educa3onandPA‘training’atScotland'stopprofessionalfootballclubs
IncrementalwalkingprogrammewithpedometersLighttouchongoingmaintenanceto12months
GrayetalBMCPublicHealth2013
GenderedContent:Healthyea3ng,notdiet,focusPA/alcoholContext:footballclubs,t-shirts,clubcoachesDelivery:men-only,par3cipa3ve,peer-supported,banter
GenderedcontentandstyleofdeliveryInforma3on(enhancingcompetencies)EnergybalanceandalcoholFood:por3onsize;foodlabeling;balance;notadiet“Sciencebutnotrocketscience”-
BCTs(enhancingcompetencies)Goalserngandreview;Implementa3oninten3ons;Feedbackonbehaviourandoutcomes;Encouragingsocialsupport(competency+materials)self-monitoring–scalesandpedometer“Itsreallygood,…it’s[an]amazingaweedevice”
GrayetalBMCPublicHealth2013
Socialenvironment(enhancingcompetencies)Coacheswelcomingandvaluemen;Lotsof3mefordiscussion,mutualgoalreviewandfeedback;vicariouslearning;mutualsupport;supportforgroupcohesion
8
12monthmeasurement(95%,n=355)
Losstofollow-up(7%,n=27)
Losstofollowup(12%,n=44)
Completeinterven3on12weekmeasurement
(88%,n=330)
12monthmeasurement(89%,n=333)
Analyzed(89%,n=333)
Analyzed(95%,n=355)
Analysis
Losstofollow-up(11%,n=41)
Losstofollow-up(5%,n=19)
Excluded(n=177)Didnotwishtopar3cipate(n=101)Ineligible(BMI<28kg/m2)
(n=76) Excluded(n=306)AllocatedtoFFITprogrammegroupsthatarenotincludedinRCT
Alloca3on
Randomiza3on
FFITEnrollmentBaselinemeasurement
(n=1,231)
Interven3ongroup(n=374)
Comparisongroup(n=373)*
Follow-Up
12weekmeasurement(93%,n=347)
Mul3-facetedrecruitment1) Media-based
e.g.newspapers,radio,websites2)Club-based
e.g.matchdayadverts,manager/playerendorsement3)Other
e.g.signpos3ngfromNHS,workforcemailshots
*Amerrandomisa3on,onepar3cipant
requestedtohaveallofhisdatadestroyed.
RCTin13clubsandembeddedprocessevalua3on
Embeddedprocessevalua3on:FGDs:12weeksFGDs:12monthsObserva3ons
ResultsfromaRandomisedControlledTrial:Weightloss(kg)at12months(primaryoutcome)
(Errorbarsrepresent95%confidenceintervals)
Adjustedbetween-groupdifference12weeks 5.18kg(CI6.00,4.35) p<.0001
Adjustedbetween-groupdifference12months 4.94kg(CI3.95,5.94) p<.0001
5.8 5.6
0.4 0.6
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
12weeks 12months
MeanWeightloss(kg)
Interven3on
Comparison
Hunt,Wykeetal.Lancet2014
MenwhohaddoneFFITprogramme
ResultsfromaRandomisedControlledTrial:Weightloss(kg)at12months(primaryoutcome)
(Errorbarsrepresent95%confidenceintervals)
Adjustedbetween-groupdifference12weeks 5.18kg(CI6.00,4.35) p<.0001
Adjustedbetween-groupdifference12months 4.94kg(CI3.95,5.94) p<.0001
5.8 5.6
0.4 0.6
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
12weeks 12months
MeanWeightloss(kg)
Interven3on
Comparison
Hunt,Wykeetal.Lancet2014
MenwhohaddoneFFITprogramme
ResultsfromaRandomisedControlledTrial:Posi3vechangesinsecondaryoutcomes
Hunt,Wykeetal.Lancet2014
6.77.3
1.0 2.0
0.0
2.0
4.0
6.0
8.0
10.0
12weeks 12months
Meanredu
c3on
in
waistcirc
umference
(cm)
0.3 0.3
0.10.1
0.00.10.20.30.4
12weeks 12monthsMeanchan
gein
selfesteem
(Rosen
berg)
-6.2
-4.2
-2.1
-9.0
-8.0
-7.0
-6.0
-5.0
-4.0
-3.0
-2.0
-1.0
0.0
1.0
2.0
Meanchan
ge7day
totalalcoho
l
-2.2
Menatveryhighriskofillhealthfromallwalksoflife
• Meanage:47.1(±8.0)yrs• MeanBMI:35.3(±4.9)kg/m2
• MeanBP:140/89mmHg
BMICategory
Overweight(BMI28-29.9) 8%
ObeseI(BMI30-34.9) 44%
ObeseII(BMI35-39.9) 31%
ObeseIII(BMI≥40) 17%
Over90%clinicallyobese
18% 18% 16%22% 25%
0
20
40
1 2 3 4 5
SIMDQuin3le*
WhatmakesmenwanttoaFendFFIT?
WhatmakesmenwanttoaFendFFIT?Itworkedwithnotagainstsociologicalunderstandingsof
masculini3es
Huntetal2014BMCPublicHealth;Grayetal,2013IntJBehNutandPA;Huntetal,2013,HealthPsychology;
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The‘push’ofhealthandthe‘pull’oftheclub
P1:I’vestruggledwithmyweightsince,maybe,early-twen3esandI’vetriedvariousdiets,variousthings,....So,whenIseenthisadver3sedinthepaper...Ithinkthemainthingthatdrewustoitwasbecauseit’s[Club].You’regoingtobeinvolvedat[club]..Thatwaswhatreallyadractedmetoit.
thetrousersizewasgerngbigger,andIjustwasn’thappywiththat…Ijustwantedtoaddressit.Andwithitbeing,havinga3einwiththeteamI’vesupportedallmylife,Ifeltthatthetwokindof–they,itfidednicely.ItmeantIcoulddosomethingandIcouldmaybegetaweesneakypeekbehindthescenesat[Club].
MenlikemeP1:Thegoodthingwas,straightfromthestart,weallhadsomethingincommonwitheachother.Ratherthanbeingsixteenstrangers,we’dallsomethingincommon,andthatwastheclubandaloveforit.P5:Twothingsincommon.Wewerefatandwesupported[Club]P1:Sorry,wewerecuddlyandsupported[Club],andthatwasthebigfactor.SonomaFer,youmetupthefirstfewweeks,youdidn’tknoweachother’snames,weimmediatelywereabletoconversewitheachothereasily.
InsiderviewP1:Justtheenjoymentofcomingalongandbeinginvolvedintheclub..evenwalkinground[Clubground],tome,wasanexci3ngpartoftheMondaynight,andyouknow,walkingupanddowntheterraces.Youmightonlyberestrictedtooneareawhenyoucometoagame,butyouknow,thefactthatyou’vegotcarteblanche,youcangowhereveryoulike,otherthanthepitch.
Clubserng:‘menlikeme’with‘insider’access
AFendanceat(ini3al)FFITsessions–thisisformen‘likeme’
FFITISNOT:Forwomen,diet,thegym Incongruentwithcoreiden3ty FFITIS:ForMenlikeme(similarbodies,sharedinterestinfootballetc);Anopportunitytogainedprivilegedaccesstotheclub,physically/symbolicallyFun,congruentwithcoreiden3ty
Congruencewithpar3cipants’iden33esasmen
‘You’redoingitataplacewhereyougotosupportyourteamandyouareactuallyinvolvedinit(theteam,)you’reinsidethestadiumandyouareactuallygerngshownabout.Itsfantas3c’
Theserng:anuplisingandexci3ngcontext Understandingmechanisms-Teamspirit,groupiden3tyandsupport:Emile
Durkheim’scollec3veeffervescence
“acommunityorsocietymayat3mescometogetherandsimultaneouslycommunicatethesamethoughtandpar3cipateinthesameac3on.Suchaneventthencausescollec3veeffervescencewhichexcitesindividualsandservestounifythegroup”
“Collec3veeffervescenceisaperceivedenergyformedbyagatheringofpeopleasmightbeexperiencedataspor3ngevent,acarnival,arave,orariot.Thispercep3oncancausepeopletoactdifferentlythanintheireverydaylife”(collec3veevervescence.com)
Teamspirit,groupiden3tyandsupport:
Durkheim’sanalysisofactsofreligiousritualandworshipas‘momentsofsocio-genesis’
– Par3cipantsallow/experienceasymbolicfusionofselfandcollec3vesymbolstotakeholdofthemthrough‘collec3veeffervescence’–groupnarra3on,singing,dancing,moving(Durkheim,1926)
– Throughsuchprocessesofassimila3on,thepar3cipant‘approachestheworldwithconfidenceandthefeelingofenergy’
Bunnetal,underreview
10
WhatmakesmenwanttoaFendFFIT?‘Effervescent’experiencesacrossthe12
weekFFITprogramme
Grayetal,2013IntJBehNutandPA;Huntetal,2013,HealthPsychology
‘Effervescence’:joiningFFITEffervescenceandclub‘totems’andcontext
P4:thefirst3me...Ijustdidnaewanttobehere.Ifeltverynervousabootthewholething….It[gerngweighed]wasveryembarrassing…Thatwasthefirst3meImet[Coach],andIgenuinelythought,“AserIgetouthere,I’mjustgoinginthecar,ignorethephonecalls,ignoretheemails,I’mnotdaen[doing]that...”AndIsatinherewith[Coach1],andhewastellingus,“right,youknow,ofcoursewetrainhere[clubground]...we’llgetyousometraininggear...you’llberunningaboot[about]inthe[club’s]traininggear.”Andhonestly,Icouldnaegetthegrinoffmyface.Iwaslikeabairn[child].Ithought,“Iwanttobetrainingat[attheclubground],”withthe…withthekit
‘Effervescence’,support,theteamP2:Thegrouphelped,eh,becausetobehonest…weaw[all]goton.Wewereontheparkandwewerehelp[ingeachother],ken,“comeon,dae[do]this.”Andwewereawhopingthateverybodycameeveryweekandlostweight..P1:Ithinkself-encouragementis,we’rethere,becausewe’repartofagroup,wewereallencouragingeachother.It’snot,youwerenolongeranindividual.Youwerepartofateam
‘Effervescence’:enjoymentofbeingthere
P4:Andthecraicwasgreat.P1:Thebiggestthing,Ithink,inlife,islaughingbecause,youknow,aw[all]thechemicalsgooffandyouknow……P1:Butthingslikethatwasjust,andlike,weebitsofbanterwhenwe’reinthegym[attheclub],orplayingfitba[football]orthat–you’dhaveaweecraicwithsomebody.Andthelaughter….Andthatwastheenvironmentwewereworkingin[ontheFFITprogramme].
P5:Itwas[like]goingtothepubforthebanterwithoot[without]thedrink.P1:Aye.(Laughing.)P5:Youknow?That’swhatitwas.P2:Rightenough.[Club13_12wkFGD]
‘Effervescence’–renego3a3ng‘acceptable’maledietswithinthe‘team’
M4:Blokesdon’tdoit…Un3lwegetthatsupportfromeachotherandthenwestartlookingatpor3oncontrols,andwhatyou’vesaidthere,what’sonthelabels–blokeswouldjustgoandlookfortheeasyop3on.That’swhatmendo.D1:Itwasfunny,listeningtomen–andIdon’twanttosoundsexist–butmengoingonaboutweighingthemselvesinthemorningandwhatdiettheywereonandwhattheywereea3ng,and,“Ihadmyporridgeeverymorning,”andIthinkanditwasgood.Andtherewasareallycamaraderieaboutthecourse.
AFendanceat(ini3al)FFITsessions–thisisformen‘likeme’
FFITISNOT:Forwomen,diet,thegym Incongruentwithcoreiden3ty FFITIS:ForMenlikeme(similarbodies,sharedinterestinfootballetc);Anopportunitytogainedprivilegedaccesstotheclub,physically/symbolicallyFun,congruentwithcoreiden3ty Teamspirit,group
supportthroughinterac3on
Greatersustainabilitythrough‘new’iden3ty?
ThechangesIhavemadeare‘thenewme’:new‘healthy’(male)iden3tyincorpora3ngnewsocial
prac3ce
11
Socialprac3ceschangedthroughFFIT
Meanings
Materials Competen-cies
Meaning:throughpar3cipa3oninFFITthemeaningofwhatmenate(ordidnoteat);ofphysicalac3vity,wasre-nego3ated
Materials:thematerialsoftheclub,thepedometershelpedsupportchangedmeaningsandenabledchange
Competencies:learningfromothersandskillsinBCTswereapplied
FFIT: How does it work?
Men can, want to, will lead healthier lives
Social practices CAN be changedTowardsaninterdisciplinaryscienceof
behaviourchange
Michieetal(2011)ImplementaBonScience
Meanings
Materials Competencies
Aim
AIM:TousecurrentevidenceofbestpracYce,state-of-the-artpsychologicalandsociologicaltheoryandco-developmentwithend-users(fansandfootballcoaches)todevelopaculturally-sensiYzedprogrammethatengagesinacYvemenaged30-65,withBMI≥27inbecomingmoreacYve,si[nglessandea3ngahealthierdiet
Acknowledgements
CollaboratorsCindyGray,ChrisBunn,AnnieAnderson,ShaunTreweek,PeterDonnan,NanedeMutrie,JimLeishmanElizabethFenwick,AlanWhite,AdrianBrady,PetraRauchaus,EleanorGrieve,NickiBoyerThankstoPar3cipants,coaches,MRC/CSOSPHSUSurveyOfficeandGenderandHealthTeam,TaysideClinicalTrialsUnitFFITProgrammeDeliverySPLTrust–BillySingh,EuanMiller,StuartMcPhee,MarkDunlopandIainBlair.CoachesinSPLclubsFFITProgrammeFundingScorshGovernment,FootballPoolsFFITResearchFundingCSO,SPLTrust,MRC/CSOSPHSUGenderandHealthprogramme,NIHRPHRprogrammeTheFFITRCTresearchwasfundedbytheNa3onalIns3tuteofHealthResearchPublicHealthResearch(NIHRPHR)programme(projectnumber09/3010/06).TheviewsexpressedherearethoseoftheauthorsandnotnecessarilythoseoftheNIHRPHRprogrammeortheDepartmentofHealth
