‘A Different Ball Game’: Adaptation of a men’s health program for implementation in rural Australia | BMC Public Health

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‘A Different Ball Game’: Adaptation of a men’s health program for implementation in rural Australia | BMC Public Health

This section presents the findings of the stakeholder focus group analysis, followed by a description of the specific adaptations made to the Aussie-FIT program for implementation in rural communities. Driven by the study objectives, five overarching themes were generated from the analysis. These were the ‘limited appeal of existing services to men’, ‘a common language’, ‘a smaller fishpond, ‘engaging rural men and diversity’ and ‘rural partnerships and sustainability’. The first theme most directly responds to the first study objective, to explore existing services in these rural communities. The second theme reports how Australian Football was considered a ‘common language’ in rural WA communities, with the sport described as extremely popular with strong rivalries between local clubs. The third describes the influence of the ‘smaller fishpond’ (population) within rural communities, including the importance of locally trusted community champions, and the potential benefits and drawbacks (‘double-edged sword’) linked to the power of word of mouth within close-knit communities. A variety of specific stakeholder recommendations around maximising the engagement of rural men including those from diverse backgrounds is then presented in the fourth theme. Finally, the importance of working closely with established organisations that are trusted, was considered vital for program sustainment. These findings directly informed the adaptations to Aussie-FIT for implementation in rural areas including to program recruitment and marketing strategies, the Australian Football program theme and linked program content, and planned partnerships with locally based organisations (see Table 2).

Table 2 Aussie-FIT program content and implementation strategy adaptations for rural Australian contexts guided by FRAME-IS and FRAME reporting frameworks

Focus group findings

Limited appeal of existing services to men

Access to existing physical activity and weight management services varied by site. Stakeholders in site 1 reported a “lack of choice” and suggested that this was likely to be the case in similarly small towns across rural Australia. The one gym in site 1 was expensive, posing a significant barrier to accessing the facility for many community members ‘watching their money’.

”rural, regional, remote is a different ball game as well. Just options are so much less out here compared to the city…” (Site 1, FG1, Male)

When opportunities to participate in mixed-gender programs were presented, few men were reported to engage. One stakeholder involved in delivering some of the few local fitness classes, alluded to a”stigma” associated with the opportunities available, suggesting they were viewed as more of a “feminine type” of program, or “not tough enough” and at odds with many men’s masculine identities.

“…running the fitness classes and stuff at work. There are no men. Like in the classes, there’s none. And I think a lot of that is because there is some stigma around like group exercise. I think men, it’s like not necessarily a sign of like weakness. It’s maybe like a more of like a feminine type thing” (Site 1, FG1, Male)

Stakeholders in the two larger rural sites, described more options for physical activity. However, in site 2, program options that appealed specifically to men appeared to be limited.

“…those programs attract a lot of females. More so than the male demographic. You know, the Zumba and they’ve got you know, all these sorts of things. But it’s getting that… the male activity in there, which is lacking” (Site 2, FG1, Female)

A soccer-based men’s weight loss initiative was running in site 3. This was viewed as appealing to some men, but not others, with an Australian Football theme considered more likely to attract a largely different demographic of local men. One stakeholder discussed how an Australian Football ‘hook’ would appeal to him, but that he (and others with similar sporting interests) would be averse to participating in a soccer-based program.

“… most of them were soccer players, because at end of the day, if you’re not…. I was a footballer, so a footballer, doesn’t go and play soccer. You just go, ‘nope, they’re different!’. And that’s how it is.” (Site 3, FG3, Male)

A common language

Popularity of Australian Football

Stakeholders depicted Australian Football as being a connection point for social interaction amongst peers for (many) men in Western Australia, particularly in “footy-mad” rural towns.

“I can understand the appeal, AFL being the common language of WA [Western Australian] males. Yeah, it’s interesting when I get some of my male colleagues together it’s you know, how dogs normally greet each other? Well, they talk football. You know, just to work out where they fit in it. I always sit back and go ‘yeah okay, that’s fascinating.” (Site 2, FG1, Male)

After the Aussie-FIT pilot study presentation, stakeholders reflected on the program’s popularity when delivered in association with professional AFL clubs in metropolitan Perth, the pride the men showed in participating, and the obvious “adulation” for their club. One stakeholder referred to the AFL club links and guest appearances from current or former players, as being a valuable form of “currency” that would be attractive to footy-oriented prospective participants. However, the need for a different approach in rural towns without access to professional football settings was recognised.

“I can see why you had such a popular uptake in Perth. Based, you know, you’ve got the two AFL sides, bang. You know, and access to the change rooms. Okay, it’s all there, packaged nicely. Here it’s going to be a little bit harder and you’re going to have to look at other alternatives.” (Site 2, FG1, Male)

Local club affiliations and footy exposure

One approach mooted was for Aussie-FIT to be affiliated with local amateur clubs, including using their team colours and football venue for program delivery. However, some stressed that close affiliations with any specific local clubs could lead to the program hitting “a few snags”. For example, eligible men with links to other local clubs could be hesitant to take part: “you would only alienate them”. Indeed, this stakeholder emphasised how little love is lost between some rival clubs:

“…. there’s that much animosity between the clubs, is a bit like over in Europe with the soccer teams, it’s alive and kicking with our footy as well.” (Site 3, FG3, Male)

Thus, if programs were delivered in association with specific local clubs some stakeholders considered that, in the interest of equity and maximising intervention reach, the program should be delivered “with each club”. Whereas others highlighted that close affiliation with any local club could also create barriers to participation for men with limited football experience. Men perceiving others as more skilled, experienced, or active within local football communities, could be “uncomfortable” or “embarrassed” about joining the program as an inexperienced outsider. Thus, stakeholders universally agreed that program marketing materials should highlight that all eligible men are welcome regardless of footballing experience or skill, and as one stakeholder put it; “… you don’t have to be skilled in X, Y and Z [to participate].”

A smaller fishpond

Trust, recognition and credibility: the importance of local champions

Stakeholders agreed that, in rural contexts, getting the right community champions involved would go a long way to ensuring program success. One stakeholder proposed that one well-known local contact would “give you 30 people” through their community connections alone. Prospective Aussie-FIT coaches, given their direct involvement in program delivery, were seen as ideally placed to play a critical role in championing the program, given their local knowledge and connections.

“They’d all have guys who they could tap on the shoulder and say ‘hey, come and join in’. Yeah, I think that would definitely be a good way to say lock in your core staff or people who are going to run the program locally. And then again it’s their good reputation in the community that would then potentially attract people. To know that it’s not going to be just some gimmick program or something that’s not going to have value.” (Site 3, FG1, Female)

Having trusted and potentially well-known community champions to support program implementation in rural towns was considered important in garnering local trust and attracting men.

“…there’s probably certainly people, [site 2] being a small community, that are very prominent in their community. You know, both for football and the professional lives that they have. So, but yeah, I mean maybe you could leverage their celebrity status. It’s completely the wrong word to use, but the recognition they have in the community and the trust that people… and credibility that they hold as well.” (Site 2, FG2, Female)

Another suggestion was that prospective participants registering their interest may themselves be an ideal and trusted source of participants in rural communities; “bring a friend or two is probably going to have to be a realistic approach.”

A double-edged sword

Stakeholders indicated that any discomfort around attending a local-club affiliated program could be amplified within close-knit rural communities, where men may know other participants that are more active in the local football community.

“…people who would then feel uncomfortable about like coming to the program if it’s closely aligned with the local team. If they’ve never really experienced football, but they’ve always wanted to. And then they think oh but I, I’m not at that level, I’ll be embarrassed, I’ll you know, the other guys they’re all so experienced and I don’t feel comfortable. I just wonder is that a risk too, that people may not want to because they think ‘oh I work with him and he’s [Club Name] you know, I don’t want to look silly…” (Site 1, FG1, Female)

To maximise the prospect of engaging men from diverse backgrounds within the “smaller [rural] fishpond”, stakeholders recommended adopting a multi-faceted recruitment strategy including Facebook promotion, local media sources, and word-of-mouth recruitment through local clubs, organisations, and community champions. Indeed, the power of word of mouth was frequently alluded to as being a particularly important consideration in rural communities. Whilst having the potential to be a key avenue for raising interest in new health initiatives, this was presented as a double-edged sword, with word likely to quickly spread should anyone get “shitty”.

“…with smaller towns and maybe you don’t get this in your metro setting. Is… and it can work wonders and it can be really positive. And you know, word of mouth can be positive. But also if something goes awry or if someone gets shitty about something, that goes through [site 1]’s Chinese whispers channels, like nobody’s business. So I think it would be a matter of getting like that champion, community champion to stay.” (Site 1, FG2, Female)

Stakeholders speculated that in urban areas, men would likely be able to limit knowledge of their participation to themselves or to close family or friends should they wish to. This degree of privacy was seen as unlikely to be an option in rural communities, where “people talk”. Stakeholders believed that local men will be aware of how their participation is viewed more widely in the community, including any potential threat to their identity as a local man. Given the football program theme, with careful consideration of how the program is marketed, Aussie-FIT was considered well placed to minimise this threat.

“…All country towns, like people talk. And it’s like ‘oh you know, such and such is doing the ol weight loss class’. You know what I mean? So I think guys won’t potentially engage because of a fear of that. Whereas like ‘oh you know that like, that footy program. Like you know, the old fellas footy program’. Just you know, something like that is, will make it more likely that they, they buy in. Hence why I think Aussie-FIT will make it. But how you market that will obviously, that’ll be the hardest thing…” (Site 1, FG1, Male)

Engaging rural men and diversity

Program marketing and cost

Whilst the football program hook was deemed fundamental to Aussie-FIT’s potential success in rural towns, the football theme was described as “a means to an end”. That is, stakeholders believed that the positive physical health outcomes of participating should be emphasised; “you need to market the end”. Particularly in the context of the Covid-19 pandemic, potential mental health benefits linked to participating in the program and meeting like-minded men were also regarded as important to include within promotional materials.

“…they formed those social groups at the end and people that maybe had been feeling a bit lonely. Particularly after this lovely year we’ve just had, I think that could be a real drawcard as well, around coming in, meeting new people. As opposed to perhaps going just purely for the fitness or the health angle.” (Site 2, FG2, Female)

The cost of participating in physical activity programs was regarded as a major barrier to engagement, so ensuring that marketing materials clearly highlight that there is no participation cost was considered important.

“…you’ve already ticked a big box by saying it’s free. That’s the biggest drawcard or a barrier that gets put up is cost.” (Site 2, FG1, Female)

Location of rural football settings

The number of football venues that could host Aussie-FIT varied by site. In site 1 there was only one venue option shared by two local football clubs, with this likely to be the case in similar smaller rural towns. Stakeholders described a lack of public transport across all sites, with those in site 2 specifically recommending the central football precinct to optimise accessibility. In site 3, two main venue possibilities were discussed. The first was the “premier football facility” where “people want to play”, which was a favoured site should there be availability at this in-demand facility. The second option, with greater availability, was considered well placed for accessibility and promotion to men from diverse socioeconomic backgrounds.

“…location-wise that’s where (venue option 2) would be a good one, because that’s the area where there is, a lower socioeconomic area, state housing, some Aboriginal involvement there. So that’d be a good thing” (Site 3, FG3, Male)

Aboriginal engagement

Sports sector specialists in site 3 discussed how even when programs are free to participate in, men from the Aboriginal community would often still not participate. In the context of Australian Football, stakeholders indicated that there is often little involvement of Aboriginal men at local clubs beyond their playing years due to “entrenched” barriers, “little hoops you have to jump through” and a sense of not being welcome.

“…even making things free seems as though that the lowest socioeconomic still don’t actually get involved all the time. It’s that like there’s a barrier. And we’ve seen that with Aboriginal participation….[…]… Aboriginal guys in particular, the barrier is always is that the sport is what actually keeps them involved because they actually feel welcome. And part of it, when they can actually go there and play, they don’t necessarily always feel that they’re welcome once they’re finished.” (Site 3, FG3, Male)

Aboriginal health specialists also reflected on challenges to engaging Aboriginal men in health initiatives due to issues with trust and deep-rooted barriers to participation. Suggestions for mitigating these barriers were focused on helping to support men to feel more “culturally comfortable”, including by seeking “early buy in [from the Aboriginal community]”, employing an “Aboriginal staff member” or providing bespoke deliveries (“run it Aboriginal specific”). Some optimism was expressed that a male-specific Australian football-themed program could potentially have greater appeal than existing weight management services for some Aboriginal men:

“…not quite comfortable with [mixed-gender program] that would potentially prefer to be in a predominantly non-Aboriginal setting with other men, than an Aboriginal setting with a bunch of women.” (Site 1, FG2, Female)

Seasonality, work and weather

The optimal time of year to engage local men varied across rural sites. In site 1, where a large proportion of the workforce are farmers, scheduling the program to run outside of seeding and harvest months (when “every eligible bloke disappears”) was considered essential. In site 2 avoiding the cold, wet and dark winter months was considered the most important factor. Stakeholders in site 3 also advised against scheduling the program in the winter months and highlighted that the high proportion of fly-in-fly-out/rotation workers in the area was an unavoidable barrier to participation. These workers would struggle to participate in structured initiatives requiring consistent (weekly) attendance.

Rural partnerships and sustainability

The concept of using Australian Football to help engage men was well received by stakeholders, who could see real potential for the program in rural towns.

“…it’s got the potential to be so successful in [site 1] I think. I think it would be… it would be awesome. It would be really, really good.” (Site 1, FG2, Female)

Whilst this stakeholder’s optimism is palpable, the emphasis on the word “potential” in the context of a discussion around program sustainability, hints at prior challenges to health program implementation. Indeed, many stakeholders reflected on programs which had come and gone from their communities due to funding limitations. Moreover, stakeholders cautioned that, particularly where physical activity options were lacking (e.g., Site 1), participants would inevitably be enquiring as to “what [is] next?”.

“Especially with funded programs like that, that run for a very short period of time. It gets very tricky. Because you know, we sort of… we manage, in the network we manage a few funded programs which runs for a year. And there’s… people love it and then funding stops. And so yeah, you’re going to have definitely that’s going to be a challenge and people… participants will definitely ask that question. What’s going to happen after 12 weeks? I mean, you do… you’re going to do a follow up in three months, but then what next?” (Site 1, FG2, Female)

Various organisations that could play a role in supporting program implementation were proposed, including those in health, sporting, and community sectors. With a view to sustainability, developing relationships with key local partner organisations was considered vital.

“That’s the big word, relationship. For it to be sustainable, you’ve got to build on it.” (Site 3, FG2, Male)

Stakeholders across the sites suggested that the Football Commission was an important potential partner to engage, ideally to help coordinate some local program logistics.

“… getting the footy commission side of it, so you’d often get the development officers down here conducting it. And that’s not saying that they would be the ones taking the sessions, because you can put it out to the local coaches around here who are AFL coaches at any level, to be the ones that administering it. Like WA Footy Commission is the face of it, but I think you’ll get better buy in down here type thing.” (Site 3, FG1, Male)

Rather than being promoted as a metropolitan-based university or professional football club affiliated program (as was the case in Aussie-FIT pilot deliveries), having a well-known and respected football organisation involved in grassroots work as “the face of it [the program]” was proposed as a potentially valuable strategy for garnering local community support. This points to the prestige, respect, and potential leverage of this organisation and their employees within their respective regions. Some stakeholders agreed informally to help “where they can”, whereas others pledged their support or appeared to take some ownership of the program through their choice of words (e.g., “that’s when we’ll really yeah, have to drive it…”).

“…we’ll just give a pledge. [Organisation] are happy to see this you know, delivered within [site 2]. And we’ll do what we can to support you in that.” (Site 2, FG1, Male)

Stakeholders emphasised that rural football clubs are volunteer run, and that capacity for active involvement from club personnel beyond their already stretched capacity was unlikely. Where local government representatives were not present in focus groups, stakeholders highlighted that getting their support would be important, suggesting they would likely “see the appeal” and “be quite receptive” to Aussie-FIT. Where local government representatives were present, they indicated that it may be possible to waive or reduce venue hire fees, and that they would support program promotion efforts. Two important strategies suggested for garnering support from local governments and other organisations were presented. These were: first, to make it “easy and simple for them to jump on [to support the program]”; and second, to highlight how supporting the program could help their organisation meet key performance indicators or how it aligns with their broader public health plans.

“…selling it to them as something that they can tick off the public health plan, and is probably going to be your best bet to get their support” (Site 3, FG3, Female)

Aussie-FIT adaptations for rural contexts

Informed by the stakeholder focus group results, adaptations were made to Aussie-FIT and the implementation strategies to be used for implementation in rural contexts (see Table 2). Adaptations were made to program content, participant recruitment strategies, marketing, coach recruitment and training delivery mode, program delivery settings, the football program theme, and program partners.

Focus group findings indicated that suitable Aussie-FIT adaptations (to the program originally delivered in AFL clubs by AFL coaches) for rural implementation include for the program to be delivered in local football settings and adopting an Australian Football theme, without specific affiliation to any local or non-local clubs. Rather than AFL club social media posts, the rural recruitment strategy will include promotion via local media, trusted community sources, local social media pages and word of mouth. The wording of marketing materials will aim to be inclusive of all eligible men. The aim for inclusive language includes emphasising that the program is free and that no prior football experience or skill-level is required. The research team will aim to partner with local trusted football, sporting, Aboriginal-specific and other health organisations, as well as local government authorities to help support inclusivity in program implementation.

Specific adaptations were made to sessions that originally included a stadium tour and Australian Football guest speaker, introducing more flexibility for the delivery of these program components to improve the intervention fit for rural contexts. Core program elements of the original Aussie-FIT program are retained. Namely, the number and length of sessions (i.e., twelve; 90min), mix of education and physical activity components in each weekly session, session topics (e.g., food labels and alcohol), integration of behaviour change techniques, theoretical underpinning (i.e., Self-Determination Theory), fostering of group camaraderie and positive banter, and an overarching Australian Football program theme [18]. The underlying mechanisms of action to support health behaviour changes are unchanged, and thus adaptations made can be considered fidelity consistent. Adaptations to interventions, and strategies to implement interventions, are often necessary to support the fit of the intervention to new contexts, and this can be important to preserve the fidelity of interventions when delivered across different settings [32].

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