Family planning program has been globally shown to reduce maternal mortality by reducing both total and high-risk pregnancies. Despite the national implementation of this program since the 1970s, Indonesia still faces many challenges in achieving family planning goals. Low modern contraceptive prevalence rate (mCPR) remains a problem that impacts public health, population growth, economy, and welfare issues. It should be tackled, especially in rural areas, with multifactorial causes and diverse needs. Various programs have been developed globally to overcome this problem; however, each region has different characteristics and demands that should be understood. This feminist qualitative study, embedding participatory action research principles and adapting the first three steps of the six essential steps for quality intervention development (6SQuID), aims to develop a theory of change by understanding the rural population's needs and actively collaborating with multiple participant groups to increase modern contraceptive uptake. The target location is West Sumba Regency, one of Indonesia's 100 lowest mCPR regencies and located in East Nusa Tenggara, which has the highest total fertility rate in Indonesia. Consisting of two rounds of data collection, this study includes different participant groups: rural women, men, mothers-in-law, religious figures, cultural leaders, community health workers, family planning educators, and family planning decision-makers with different strategies. We aim to recruit approximately 45 participants through purposive sampling, selecting participants based on the criteria for each group. The data collection methods are focus groups and semi-structured interviews. This study will encourage the community to collaborate and empower rural women to overcome their problems by identifying the reasons behind modern contraceptive refusal and developing a theory of change to reach the final goal: to create a meaningful change in modern contraceptive services. By understanding the diverse contexts and specific needs of the rural population, this study will be essential to transforming family planning programs. In doing so, it will significantly enhance reproductive and women's health while also addressing and reducing health disparities in rural communities. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement Yes ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The College of Medical, Veterinary, and Life Sciences (MVLS) Research Ethics Committee of the University of Glasgow, United Kingdom, issued ethical approval in August 2025 (200240450), and the Public Health Faculty of the University of Nusa Cendana, Indonesia, issued ethical approval in May 2025 (001922/KEPK FKM UNDANA/2025). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Datasets have not been fully generated or analysed during the current study. Deidentified research data will be made available under the University of Glasgow, following the University’s Code of Good Practice and ethical standards, upon completion of the study and publication.

Objective To gather evidence on the costs and cost-effectiveness of human papillomavirus DNA (HPV DNA) self-sampling worldwide and to determine whether these are influenced by the various HPV DNA self-sampling strategies employed.Design A systematic review conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.Data sources Articles were searched from Embase, Medline (Ovid), PubMed and EconLit, published from 2015 to 2025.Eligibility criteria Women eligible for cervical cancer screening. Studies on the economic evaluation of HPV DNA self-sampling worldwide. Peer-reviewed original articles published in English from 2015 to October 2025.Data extraction Data were extracted using the authors' developed template. Analysis was done descriptively, applying synthesis without meta-analysis (SWiM).Results 33 studies were included in 11 low- and middle-income countries (LMICs) and 9 high-income countries (HICs). Most studies (N=18) targeted women from the general population and 10 under/never-screeners. The HPV DNA self-sampling strategies include: opt-in, opt-out, point of care and community health campaigns. Community health campaigns were predominant in LMICs, while opt-in and opt-out in HICs. The cost per woman screened reported in micro-costing/cost-consequence analysis studies ranged from US$31.77 to US$72.20 in LMICs and from US$56.21 to US$78.34 in HICs. 21/23 studies found HPV DNA self-sampling strategies to be cost-effective/cost-saving: 11/12 from LMICs and 10/11 from HICs.Conclusions Community health campaigns and point-of-care HPV DNA self-sampling strategies in LMICs and opt-in and opt-out in HICs are cost-effective. Implementation studies are recommended, especially for populations at high risk.PROSPERO registration number CRD42024518867.

OBJECTIVE:Do post-program motivational regulations mediate the intervention effect of the SDT-based European Fans in Training (EuroFIT) program on self-esteem, well-being and vitality at 12-months follow-up? METHODS:A causal mediation analysis of data from the randomised controlled trial of the EuroFIT program that recruited 1113 overweight, male football fans in England, Norway, Portugal and the Netherlands. RESULTS:We found evidence of indirect effects of autonomous motivation on vitality (b=.487, 95% CI: .229, .767, p<.001) well-being (b=.063, 95% CI: .003, .131, p=.038) and self-esteem (b=.491, 95% CI: .278, .701, p<.001), but not controlled motivation, at 12-months follow-up in the EuroFIT trial. We also found that reductions in amotivation at post-program partly explained positive increases across outcomes at 12-months follow-up. When controlling for increases in outcome variables at post-program, only the mediating effect of autonomous motivation on self-esteem remained significant, whereas the indirect pathway through reductions in amotivation remained significant for all outcomes. None of the indirect effects were robust to potential mediator-outcome confounding. CONCLUSION:EuroFIT program produced small-to-moderate improvements in vitality, well-being, and self-esteem at 12-month follow-up that were partly explained by post-program increases in autonomous motivation and reductions in amotivation. All indirect effects estimates were sensitive to potential mediator-outcome confounding.

Background and Aims Maintenance of weight loss is a major challenge. Continuous glucose monitoring (CGM) could provide biofeedback to support lifestyle changes to facilitate weight maintenance. This randomised controlled trial evaluated the feasibility of incorporating CGM into a personalised, dietitian-led, weight loss maintenance programme (PWM), and whether CGM use led to greater improvements in dietary intake, physical activity, body weight, body composition, and cardiometabolic risk biomarkers over 24 weeks. Methods Adults who lost >5kg bodyweight in the past six months were eligible. Of 131 individuals who expressed interest, 99 met eligibility criteria. Forty-nine participants (17 men, 32 women) consented and were randomised to either PWM (n=25) or PWM/CGM (n=24) groups. Average recruitment rate was five participants/month. All participants received five one-to-one personalised dietitian consultations in weeks 1, 2, 4, 8 and 12; the PWM/CGM group also received a CGM for the 24-week intervention period and education on its use to support diet and physical activity behaviours. Results 19 PWM and 22 PWM/CGM participants completed the study (83.7% of randomised participants). All completers attended all dietitian consultations, and PWM/CGM participants wore their CGMs on 92.6% of intervention days. In completers, weight loss at 24-weeks was greater for PWM/CGM than PWM (-2.7±1.1 kg vs +0.5±0.8 kg, p=0.032). This difference remained significant in an intention-to-treat sensitivity analysis (-2.5±1.0 kg vs +0.4±0.6 kg, p=0.012). Change in energy intake from baseline to 24-weeks was greater in PWM/CGM than PWM (-235.0±123.0 kcal.day-1 vs +23.3±201.6 kcal.day-1, p=0.007). There were no differences in changes in physical activity or cardiometabolic risk biomarkers except triglycerides between groups. Conclusions These findings indicate that CGM is a feasible addition to an intensive weight loss maintenance programme and support a future fully-powered randomised controlled trial to determine long-term effectiveness. ClinicalTrials.gov (NCT05890209)

Background The high prevalence of COPD in sub-Saharan Africa is poorly understood. In high-income countries, COPD is the consequence of suboptimal lung growth during childhood and/or accelerated lung function decline in adult life. We have conducted cross-sectional studies to measure the lung function of children and adults in Kenya and to identify associations with age. Methods We performed spirometry in three groups in Kenya: a random sample of schoolchildren in two districts of urban Nairobi and age/sex-stratified representative community samples of adults in Nairobi and rural Machakos. Forced expiratory volume in 1 s (FEV 1 ) and forced vital capacity were expressed as z-scores using race-neutral GLI-Global reference equations. Results The mean (95% CI) FEV 1 z-score in Nairobi schoolchildren (n=2373, median age 10 years (IQR 8–13) 52% girls) was −0.60 (−0.64– −0.55); in Nairobi adults (n=2936, median age 32 years (24–43), 62% female) −0.49 (−0.53– −0.45); and in Machakos adults (n=1607, median age 46 years (35–59), 65% female) −0.67 (−0.72– −0.61). In adults, FEV 1 was negatively associated with age (FEV 1 z-score regression coefficient β −0.005/year (95% CI −0.009– −0.002) p=0.005, and there was a negative interaction between residence in Nairobi and age, β −0.006/year (95% CI −0.011– −0.001), p=0.020. Conclusion The lung function of children and adults in Kenya was lower than predicted by race-neutral Global Lung Function Initiative (GLI)-Global reference equations. In adults, a negative association between lung function and age was greater in urban, than in rural, settings. Further work is required to identify and mitigate relevant influences.

Introduction Cycling can be beneficial for health, well-being and the environment; however, cycling participation in the UK remains low. Effective and cost-effective strategies are needed to support people in the community to increase cycling. The Cycle Nation Communities randomised controlled trial (RCT) will evaluate whether a 9 week multi-component cycling programme (Cycle Nation) is more effective and cost-effective than an existing national cycle training session on cycling participation, transport use and health and well-being.Methods and analysis This pragmatic, single-blinded, two-arm RCT will recruit ≥268 adults who cycle infrequently. Participants will be randomised to the 9 week multi-component individual/social-level group-based Cycle Nation programme or an existing national standard single group-based cycle training session. Both arms will be delivered by community-based cycling organisations in Glasgow. Participants will complete self-reported measurements at baseline, 12 weeks and 12 months. The primary outcome is the proportion of participants cycling at least weekly at 12 months. Secondary outcomes include proportion of participants cycling at least weekly at 12 weeks; change in weekly number of rides and minutes of cycling and use of private car, taxi, public transport and walking at 12 weeks and 12 months; change in motivation, perceptions of cycling safety, confidence to cycle, self-esteem, vitality, health-related quality of life and perceived general physical health at 12 weeks and 12 months. A within-trial economic evaluation from a National Health Service/personal social service and a broader societal perspective will be undertaken. Pending within-trial results, a long-term model may be developed. An embedded process evaluation will use participant and facilitator interviews, participant acceptability questionnaires, facilitator delivery proforma and session observations.Ethics and dissemination Ethical approval has been obtained from the University of Glasgow Medical, Veterinary and Life Sciences Ethics Committee (11 April 25). Findings will be published in peer-reviewed journals and communicated to stakeholders and the public.Trial registration number NCT07005674.

BACKGROUND:To explore continuities and changes in gambling behaviour during the COVID-19 pandemic and the factors that influenced these among a sample of regular sports bettors. METHODS:A longitudinal qualitative study using in-depth interviews. Sixteen sports bettors living in Britain took part in the first interviews in July-November 2020, and 13 in the follow-up interviews in March-September 2021. RESULTS:Individual patterns of gambling were episodic: it was common for gambling to increase during some periods of the pandemic and to decrease during others, reflecting the dynamic and (often) challenging circumstances which people were living through at the time. Changes and continuities in gambling during the pandemic were influenced by a range of factors which we have grouped into two main themes relating to 'gambling and the sports landscape' and 'disruption to day-to-day life'. It was common for a constellation of factors to influence gambling behaviour rather than a single factor. These constellations of factors varied from person to person and at different times during the pandemic. CONCLUSIONS:Findings of the present study are consistent with earlier literature examining gambling careers before the advent of COVID-19 showing that gambling trajectories are non-linear. Our research suggests that 'typical' patterns of gambling behaviour (e.g. being episodic), and the broader known risk and protective factors within individuals, families, communities and societies have been amplified during the pandemic. Findings highlight the adaptability of the gambling industry to continue to reach consumers through product offerings and marketing even in a period of unprecedented restrictions on supply, and show the potential resulting harms of these actions among gamblers at risk of experiencing gambling problems. Taken together, findings from this study provide important new insights relevant to discussions about gambling regulation, and support calls for multifaceted and comprehensive policy, regulatory, and treatment approaches, to minimise gambling-related harms.

Obesity continues to grow as a public health concern and although dietary interventions can be effective at reducing body mass and improving cardiovascular risk factors, they also result in undesirable losses of lean tissue. The aim of this randomised controlled pilot trial was to investigate the effects of a home-based resistance training exercise programme on body composition and muscle function in people living with overweight or obesity undergoing dietary weight loss. Participants (n = 48) from Glasgow were randomly assigned to either a diet-induced weight loss group (WL) or a diet plus home-based resistance training exercise group (RT + WL) for 12-weeks. Body composition, muscle strength, and physical function were assessed at baseline and post-intervention. There was no effect of the resistance exercise training programme (all p > 0.05) on body composition including body mass index, total body mass, fat mass, fat free mass or muscle thickness during weight loss. However, the resistance training group showed improvements in muscle and physical function compared to the weight loss only group, resulting in higher grip strength (RT + WL: Δ2.65, 95% CI: 0.44, 4.86; WL: Δ-0.26, 95% CI: -2.04, 1.51:p = 0.046), maximal voluntary contraction force (RT + WL:Δ23.61, 95% CI: 3.39, 43.84 WL: Δ-11.95, 95% CI: -35.37, 11.48;p = 0.019), and sit-to-stand test scores (RT + WL:Δ5.9, 95% CI: 4.27, 7.53 WL: Δ1.47, 95% CI: 0.13, 2.82; p < 0.001). These findings suggest that incorporating home-based resistance training into weight loss programmes can preserve, or even enhance, muscle function without negatively impacting the effectiveness of dietary weight loss interventions, highlighting its potential to mitigate muscle function losses during weight loss in people living with overweight or obese. Name of the registry: ClinicalTrials.gov. The registration number: NCT05702840. Date of Registry: 18/01/2023. The registration title: EXerCise wEight Loss (EXCEL).

Background:Cost-effective weight loss interventions are needed for people with obesity, particularly men, who are less likely to engage with weight loss programmes. This study aimed to investigate the cost-effectiveness of text messaging plus financial incentives and text messaging alone compared to a waitlist control to help men lose weight. Methods:585 men with obesity were recruited to Game of Stones (GoS): a 3-arm randomised controlled trial in 3 UK areas. Text messaging alone participants received daily automated behavioural texts for 12-months (3% weight loss). Text messaging with financial incentives participants also received loss-framed financial incentives linked to achieving weight loss targets at 12-months (5% significant weight loss). A control group received no intervention for 12 months (1.3% weight loss) followed by 3 months of texts. We conducted a 24-month within-trial cost-effectiveness analysis and lifetime decision model from a UK NHS perspective. The PRIMEtime model extrapolated the impact of GoS weight-loss data on lifetime obesity related disease incidence, costs, and QALYs. Weight regain assumptions were explored in scenario analyses. Findings:Text messaging with financial incentives costs £243 and text messaging alone costs £110 per participant to deliver. There were no significant differences between 24-month total costs or QALYs across groups. When modelled over lifetime, the mean discounted QALYs per person were 12.48, 12.49, and 12.46 for text messaging with financial incentives, text messaging alone, and waitlist control, respectively. The corresponding mean discounted total costs per person were £15,277, £15,117, and £15,100. The between group results for text messaging with financial incentives versus control were: QALY difference (95% CI): 0.02 (0.007, 0.029); cost difference: £176 (£43; £311); Incremental cost-effectiveness ratio (ICER): £9748 (£7,705, £11,791). For text messaging alone versus control: QALY difference: 0.03 (0.015, 0.037); cost difference: £16.5 (-£117; £152); ICER: £628 (£-5,914, £5384). Interpretation:Text messaging with financial incentives and text messaging alone are cost-effective compared to waitlist control. Both are relatively low-cost interventions that can be scaled to improve weight loss for men. The optimal strategy between them depends on weight regain assumptions after 12 months. Funding:National Institute for Health and Care Research (Ref: NIHR 129703). Trial Registration isrctn.org Identifier: ISRCTN91974895.

Short sleep duration and poor sleep quality are associated with higher energy intake and increased preference for sweet foods. The aim was to determine whether cognitive behaviour therapy for insomnia (CBTi) i) improved sleep duration and quality and ii) altered dietary behaviours and food preferences. Participants (sleep duration <7 h; Pittsburgh Sleep Quality Index (PSQI) > 5; BMI ≥25 kg m-2) were randomised to 8 weeks of CBTi (n = 14) or Control (n = 13). Sleep characteristics, dietary intake (3-day food diaries), food cravings (Control of Eating Questionnaire), and explicit liking, explicit wanting, and implicit wanting of foods (Leeds Food Preference Questionnaire) were assessed pre- and post-intervention. Self-reported sleep duration increased by 49.2 min more in the CBTi intervention compared with the Control group (+1.11 ± 0.21 h vs +0.29 ± 0.30 h, p = 0.01), self-reported sleep quality (PSQI) improved more (-5.86 ± 0.73 vs -0.62 ± 0.92, p = 0.00002), and daytime sleepiness (Epworth Sleepiness Scale) decreased more (-2.64 ± 0.80 vs +1.54 ± 0.66, p = 0.00004) in the Intervention group. However, there were no differences accelerometer-measured sleep duration and sleep efficiency between groups. The Intervention group had greater increases in food craving control (+21.9 ± 4.7 mm vs -3.0 ± 4.3 mm, p = 0.002), and greater reductions in craving for sweet (-16.4 ± 6.0 mm vs +3.3 ± 4.2 mm, p = 0.01) and savoury (-15.0 ± 3.0 mm vs +0.8 ± 4.8 mm, p = 0.003) foods. Implicit wanting of low-fat savoury foods increased (+12.3 ± 3.2 vs -2.1 ± 3.1, p = 0.006) and implicit wanting of high-fat sweet foods decreased (-15.8 ± 7.4 vs +9.8 ± 4.4, p = 0.001) more in the Intervention group. There was substantial under-reporting of dietary intake with 19 participants reporting energy intake <1.1 x basal metabolic rate. Amongst those with valid dietary measures, there were no significant differences in changes in energy or macronutrient intake between groups, but statistical power to detect effects was limited. In conclusion, this study demonstrates that a CBTi intervention leads to improvements in food craving control and changes in food preference. Future research is needed to determine whether this translates into differences in dietary intake.

Community arms of professional football clubs have become key third-sector players in mitigating health and social inequalities. This paper examines the factors affecting their capacity for delivering social and public health programmes in the community setting. Semi-structured interviews were conducted with 24 community staff members from the community arms of 22 professional football clubs and one non-professional club. This provided the basis for an interpretive thematic analysis which led to the development of three themes: 'from football club community departments to charitable arms', 'the reach of community programmes', and 'challenges and opportunities of delivering social and public health programmes via community football club arms'. Charitable status has created more funding opportunities, enabling community arms to better prioritize community needs. The expanding reach of community programmes delivers social and health benefits to children, adults, and older adults (65 and over) from diverse cultural and socioeconomic backgrounds. However, numerous challenges and opportunities were reported as affecting community arms' capacity to deliver these programmes. Safeguarding is a challenge, but partnerships offer an opportunity to address it. Co-dependency with the football club presents both challenges and opportunities for community arms. Staffing and facilities, funding applications and reporting on programmes, were all identified as challenges. Our findings highlight eight key recommendations specific to areas of oversight in the community arms of football clubs, including professional development, partnership working, board members, resourcing, funding, programme reporting, and conflicts of interest.

Background: Vigorous (VILPA) and moderate to vigorous (MVILPA) intermittent lifestyle physical activity refer to brief bouts of physical activity (<1 and <3 minutes, respectively) embedded in daily routines. Evidence suggests that 4 to 6 daily bursts of VILPA/MVILPA can significantly reduce the risk of cardiovascular disease and some cancers. These micropatterns of activity may offer a time-efficient and accessible alternative to structured exercise, particularly for women from socioeconomically diverse backgrounds who face intersecting barriers to traditional forms of physical activity. This study aimed to explore womens perspectives and experiences of VILPA/MVILPA and co-design a micropatterns intervention to promote these behaviours among socioeconomically diverse women. Methods: The study involved a series of three co-design workshops with women in Glasgow (N=19) and Sydney (N=31). Workshops incorporated participatory activities, education, training, discussion, and reflection to explore the concept of micropatterns, related facilitators and barriers and co-design the intervention. This study was guided by the Behaviour Change Wheel and MRC and 6SQuID intervention development frameworks. Data were audio-recorded, transcribed, and analysed using thematic framework analysis. Results: Participants identified a range of barriers (e.g. concerns about ability and safety, low mood, sociocultural norms) and facilitators (e.g. adaptability, dual-purpose activities, minimal time commitment) to engaging in micropatterns. Following reflection on the barriers and facilitators, six modifiable factors were identified to be addressed in the intervention, these included: lack of knowledge and awareness, concerns about ability and safety, low mood and poor mental health, sociocultural norms and environmental constraints. Participants identified thirteen intervention components that utilized seven intervention functions (education, persuasion, training, environmental restructuring, modelling, incentivisation, and enablement) to promote VILPA/MVILPA activities. Participants emphasised the importance of educational content, social support, and inclusive delivery formats (e.g. short videos, visual materials). Terminology such as Mindful Movement and Boosting Everyday Movement were preferred over technical acronyms and jargon. Conclusions: The final intervention involved a six-week programme of education, training, goal setting and VILPA/MVILPA tracking. Due to the popularity of social components and mixed perceptions of the accessibility of digital technology, the intervention was designed with three different delivery mechanisms:1) a smartphone application, 2) a smartphone application and a wearable device (e.g. Fitbit) and 3) workshops, a smartphone application and a wearable device. With further testing, this co-designed intervention could offer a feasible approach to promoting physical activity micropatterns among women from diverse socioeconomic backgrounds. ### Competing Interest Statement ES is a paid consultant and holds equity in Complement 1, a US-based company whose products and services relate to healthy lifestyles. All other authors disclose no conflict of interest for this work. ### Funding Statement This study was funded by The University of Glasgow and University of Sydney Health Inequalities Initiative (227213) and an Australian National Health and Medical Research Council (NHMRC) Investigator Grant (APP1194510). The funders had no specific role in any of the following study aspects: the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The College of Medicine, Veterinary & Life Sciences Ethics Committee of the University of Glasgow (200240234) and Human Research Ethics Committee of the University of Sydney(HEOO1729) gave ethical approval for this work. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All qualitative data relating to the findings are included in the manuscript in the form of quotations.

Objective: Gender-sensitive approaches to increasing men's physical activity (PA) through sports settings have shown promise across cultural contexts. We examined changes to men's walking and the contribution of walking towards self-reported PA after participating in the men-only European Fans in Training (EuroFIT) programme before exploring men's experiences of sustaining walking to explain the quantitative findings. Design: A sequential mixed-methods design was used to collect self-reported PA questionnaire data as part of a randomised controlled trial at baseline, post-programme and 12-month follow-up, together with focus groups with participants. Setting: EuroFIT was delivered by football club/community coaches to overweight fans in football clubs across England, the Netherlands, Portugal and Norway. Results: Linear regression modelling demonstrated that self-reported walking was significantly higher at both post-programme (426 metabolic equivalents [METs], 95% confidence interval [CI]: 287-565, p < .001) and at 12-month follow-up (343 METs, 95% CI: 205-482, p < .001) in all countries in favour of the intervention group, despite a large decline in Norway from post-programme to follow-up. The contribution of walking towards total PA did not change after participating in EuroFIT. Qualitative analysis indicated that most men were positive about walking and had embodied learning from the EuroFIT programme, but also that some men also considered walking a transitional activity towards other more intensive forms of PA. Conclusion: EuroFIT succeeded in helping overweight, male football fans increase walking as part of their self-reported total PA. Although the percentage of walking in relation to total PA remained the same for participants in both groups, EuroFIT helped men to integrate walking into their daily lives.

BACKGROUND:Evidence supporting Self-Determination Theory (SDT) utility in facilitating and explaining physical activity (PA) behavior change and maintenance is robust and rapidly increasing. This paper aims to describe how SDT was used to develop the European Fans in Training program, and its adequacy, concerning the critical mechanisms theoretically provided, to predict objectively measured PA and sedentary behaviors. METHODS:European Fans in Training was a gender-sensitized, healthy lifestyle program that successfully attracted men and supported them in making changes in their PA and diet. This study analyzes self-reported psychometric and objectively measured PA data from the European Fans in Training intervention group of 560 overweight men aged 30-65 from 4 countries (The Netherlands, Norway, Portugal, and the United Kingdom). RESULTS:The motivational mediation sequence predicted by SDT showed an acceptable to excellent fit for the data: χ2 = 200.204; df = 87; P = .000; comparative fit index = .956; Tucker-Lewis Index = .933; root mean square error approximation = .050 (90% CI, .041 to .059); standardized root mean square residual = .056. Perceived need support by coaches was positively related to greater need satisfaction, which led to higher levels of self-determination and an increase in steps, lifestyle PA, and sit-to-stand transitions. Perceived need-thwarting behaviors were negatively associated with need satisfaction and indirectly with self-determination. CONCLUSIONS:Results confirm that interventions can create conditions for individuals to experience psychological need satisfaction, self-determined motivation, and PA-related health behavior change. These findings provide further support to the utility and acceptability of SDT among policymakers and practitioners wishing to promote PA in previously sedentary adults.

During COVID-19, people with type 2 diabetes (T2D) experienced increased vulnerability, including severe COVID-19 complications, disruptions in diabetes management, and social isolation. These aspects were heightened in many sub-Saharan African countries, such as Kenya and Tanzania, where healthcare systems already face critical challenges in coping with increasing non-communicable diseases (NCDs). Little is known about how people with T2D in these countries managed their diabetes or how the different approaches to COVID-19 control (Kenya imposed lockdown and curfew, whereas Tanzania adopted less strict measures) impacted their T2D management. This qualitative study aimed to compare the accounts of T2D patients in both countries to examine similarities and differences in the illness management challenges they faced during the COVID-19 pandemic.Semi-structured interviews were conducted with 52 patients (Kenya, n=22; Tanzania, n=30), and the transcripts were analyzed thematically. Despite different COVID-19 control measures, patients in both countries faced similar direct health challenges, such as difficulties accessing diabetic consultations and treatment, but they also experienced distinct socio-structural challenges. Direct health challenges included difficulties in accessing diabetic consultations and treatment, limited availability of diabetic medicine at health facilities and mental health distress. These were exacerbated by socio-structural challenges, many of which pre-dated COVID-19 but intensified during the pandemic. These included closure of diabetic clinics in Dar es Salaam, business instability, financial difficulties, health insurance challenges, higher food prices impacting patients' adherence to T2D dietary recommendations (in both countries), and price inflation of diabetic medicine and test kits (in Kenya). Together, these challenges led to patients practicing self-medication, missing doses and resulted in poor blood sugar control. People with T2D in Kenya and Tanzania have described similar illness management challenges. In both countries, future contingency planning is essential to ensure adequate routine management of T2D and to improve access to care in emergency situations. Affordable comprehensive health insurance, economic support, and psychosocial services are required to increase patient resilience and support the health and wellbeing of people with T2D.

Objective: To synthesise current evidence on knowledge, perceptions and practices towards type 2 diabetes risk in sub-Saharan AfricaDesign: Mixed-methods scoping review, which included 101 studies (seventy-three quantitative, twenty qualitative and eight mixed methods) from seven electronic databases.Setting: Sub-Saharan Africa, 2000-2023.Participants: Men and women without diabetes with mean ages ranging from 20 to 63 years.Results: The majority of participants in most studies knew the three main diabetes modifiable risk factors - excess weight, unhealthy diet and physical inactivity. However, most people with excess weight in almost all studies underestimated their weight. Further, the self-described ideal body weight was between midpoint of normal weight and the upper limits of overweight in most quantitative studies and was described as not too skinny but not too fat in qualitative studies. In the majority of studies, participants reported low engagement in weight control, high regular sugar intake, and low regular fruit and vegetable intake but moderate to high engagement in physical activity. Barriers to reducing diabetes risk were social (e.g. societal perceptions promoting weight gain) and environmental (e.g. limited affordability of healthy foods, high accessibility of Western diets and lack of physical activity facilities).Conclusion: There is a need for multicomponent type 2 diabetes prevention interventions that increase knowledge of identifying diabetes risk (e.g. what constitutes excess weight) and create social and physical environments that support healthy lifestyles (e.g. societal perceptions that promote healthy living, increased availability and affordability of healthy foods and physical activity facilities).

Objective To explore whether socio-economic, health and behavioural characteristics moderate effectiveness of a text message intervention with or without financial incentives versus a control group, and to examine differences in exploratory outcomes. Methods Three-group randomized trial including 585 men with obesity comparing daily automated behavioural text messages for 12-months alongside financial incentives; text messages alone; or a waiting list control. Moderator analyses examined percent weight change after 12 months for 9 socio-economic and 11 health factors. Exploratory outcomes included: self-reported physical activity, sedentary behaviour, smoking and alcohol behaviours, engagement in 15 weight management strategies, and weight-management related confidence. Results No moderator effects were found by any factors for either comparison versus control. There were no differences between groups for health behaviours. The texts with incentives group had higher levels of engagement in six strategies including weight goals, food changes and self-weighing, and higher levels of confidence compared to the control group. Conclusion No evidence of differential intervention effectiveness was found across socio-economic, health or wellbeing status. The texts and financial incentives group showed greater engagement in weight management and favourable changes in weight management confidence compared to the control group. ### Competing Interest Statement Dr Hoddinott reported receiving grants from National Institute for Health Research (NIHR), and the Chief Scientist Office, Scotland, during the conduct of the study and serving as chair or member of Independent Trial Steering Committees unrelated to weight management trials; being a member of the NIHR School for Primary Care Research Funding panel. Dr Dombrowski reported receiving grants from the NIHR during the conduct of the study. Mr Swingler reported receiving grants from NIHR during the conduct of the study. Dr Cotton reported receiving grants from NIHR HTA (grant funding to institution) during the conduct of the study. Dr Avenell reported receiving grants from National Institute for Health and Care Research funding project in submission during the conduct of the study. Dr Hunt reported receiving grants from NIHR, the Australian Heart Foundation, and the Department of Health, Australia, during the conduct of the study; and serving as chair of the Health Improvement, Protection and Services Committee of the Chief Scientist Office. Dr MacLean reported receiving grants from the NIHR during the conduct of the study. Dr McKinley reported receiving grants from during the conduct of the study.Ms Torrens reported receiving grants from NIHR during the conduct of the study. Dr Turner reported receiving grants from NIHR during the conduct of the study and having had served as a member of the NIHR Health Technology Assessment (HTA) commissioning board, December 2017 to September 2020. Dr van der Pol reported receiving grants from NIHR Public Health Research and the Chief Scientist Office, Scotland, during the conduct of the study.Mr MacLennan reported receiving grants from the NIHR during the conduct of the study. No other disclosures were reported. ### Clinical Trial ISRCTN91974895 ### Funding Statement This study was funded by grants from the NIHR ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The North of Scotland Research Ethics Committee 2 gave ethical approval for this work [20/NS/0141] I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors

Introduction COVID-19 affected healthcare access, utilisation and affordability, especially for patients suffering from chronic diseases, including type 2 diabetes (T2D). This study measured the occurrence and magnitude of changes in healthcare and broader societal costs among patients with T2D before and during COVID-19 in Kenya and Tanzania to understand whether and how COVID-19 affected T2D management in countries implementing different policies during the pandemic.Methods A cross-sectional study was conducted in Kenya and Tanzania in March–April 2022 among 500 patients with T2D in each country. We interviewed patients on direct healthcare costs (eg, inpatient and outpatient costs), societal costs (eg, productivity loss) and patients’ characteristics before and during the COVID-19 pandemic. We estimated changes over time using the Generalised Linear Model in Kenya and a two-part model in Tanzania, adjusting for patient-level covariates.Results The overall costs of management of T2D in most categories increased in both countries during COVID-19, but some of the increase was not significant. Transport and testing costs increased significantly in Tanzania (I$0.33, p<0.01 and I$0.85, p<0.01) but not in Kenya (I$1.69, p=0.659 and I$0.10, p=0.603). Outpatient costs increased significantly in Tanzania (I$8.84, p<0.01) but there was no significant change in Kenya (I$8.09, p=0.432). T2D medication costs did not change in Tanzania (I$0.19, p=0.197), but decreased significantly in Kenya (I$18.48, p<0.01). Productivity losses increased significantly in both countries.Conclusion The COVID-19 pandemic is associated with increased direct costs but with a significant increase in many cost categories (transport, testing and outpatient) in Tanzania than in Kenya. A significant increase in productivity loss was observed in both countries. The minimal cost increases in Kenya may be due to the inaccessibility of services associated with lockdown measures and higher insurance coverage compared with Tanzania. Pandemic preparedness initiatives and interventions are needed to safeguard the welfare of patients with chronic conditions during pandemics.

ObjectivesWe sought to extrapolate the long-term costs and clinical impacts attributed to the rugby fans in training–New Zealand (RUFIT-NZ) trial in Aotearoa, New Zealand.DesignA modelled cost-effectiveness analysis using efficacy data from RUFIT-NZ was conducted from the Aotearoa New Zealand healthcare perspective.SettingA Markov cohort model was constructed with a lifetime time horizon. The model simulated events of myocardial infarction (MI), stroke and type 2 diabetes mellitus (T2DM) occurring among a hypothetical cohort of 10 000 individuals receiving either the RUFIT-NZ intervention or no intervention. Efficacy data were based on the RUFIT-NZ trial, and the latest Global Burden of Disease study was used to extrapolate the impact of body weight reduction on clinical outcomes of T2DM, MI or stroke. Cost and utility data were drawn from the RUFIT-NZ trial and published sources.Primary outcome measuresThe incremental cost-effectiveness ratio (ICER).ResultsOver a lifetime time horizon, participants in the RUFIT-NZ intervention gained 0.02 (discounted) quality-adjusted life years (QALYs) at an additional cost of NZ$863, relative to no intervention. The estimated ICER was NZ$49 515 per QALY gained (discounted), which is above the arbitrary willingness-to-pay threshold of NZ$45 000 per QALY. Sensitivity analyses supported the robustness of these findings.ConclusionsRUFIT-NZ was associated with a reduction in cardiovascular and endocrine events for overweight and obese males. However, based on conservative assumptions, RUFIT-NZ was unlikely to be cost-effective from a healthcare system perspective.Trial registration numberACTRN12619000069156.

Abstract Men living with multiple long-term conditions and obesity are under-represented in behavioural weight management trials. Within an effective text messaging and financial incentives trial, our aim was to explore retention, secondary mental health and wellbeing outcomes, and experiences of men with multiple long-term conditions. Methods Mixed methods process evaluation within a 3-group randomised controlled trial: behavioural text messages with financial incentives, texts alone and waiting-list control, for 583 of 585 men with obesity. Trial retention, mental health and wellbeing outcomes, and experiences were compared for 235 (40%) participants with multiple long-term conditions, 181 (31%) with single conditions, 167 (29%) with no conditions, and for 165 (29%) with disability. Semi-structured interviews, analysed using the Framework method, explored experiences with weight trajectories. Concurrent descriptive and qualitative analyses were undertaken. Results Of the 235 (40%) trial participants with multiple long-term conditions, 99 were disabled and 93 were living in deprived areas. Participants with multiple long-term conditions and/or disability were older, fewer had a degree level qualification, and fewer were in full time work. Retention at 12 months was higher for men with disability (76%) or no long-term conditions (75%), and lower for men with diabetes (65%). Self-reported weight stigma, wellbeing and quality of life scores improved or stayed the same for men living with multiple long-term conditions in the intervention groups, however, results for anxiety and depression screening scores were inconsistent. Participant experiences indicated complex dynamic health, social and life situations which could provide motivation to lose weight for some but not others. Hospitalisation and poor mobility, with inability to exercise, was de-motivating for making changes to reach weight loss targets. Conclusion Men with multiple long-term conditions varied from very successful weight loss and improved health, to not prioritising or feeling helped by the programme or disengagement due to immobility or diabetes. ### Competing Interest Statement Dr Hoddinott reported receiving grants from National Institute for Health Research (NIHR), and the Chief Scientist Office (CSO), Scotland, during the conduct of the study and serving as chair or member of Independent Trial Steering Committees unrelated to weight management trials; being a member of the NIHR School for Primary Care Research Funding panel. Dr Dombrowski reported receiving grants from the NIHR during the conduct of the study. Mr Swingler reported receiving grants from NIHR during the conduct of the study. Dr Cotton reported receiving grants from NIHR HTA (grant funding to institution) during the conduct of the study. Dr Avenell reported receiving grants from National Institute for Health and Care Research funding project in submission during the conduct of the study. Dr Hunt reported receiving grants from NIHR, CSO, the Australian Heart Foundation, and the Department of Health, Australia, during the conduct of the study; and serving as chair of the Health Improvement, Protection and Services Committee of the Chief Scientist Office. Dr MacLean reported receiving grants from the NIHR during the conduct of the study. Dr McKinley reported receiving grants from NIHR during the conduct of the study. Ms Torrens reported receiving grants from NIHR during the conduct of the study. Dr Turner reported receiving grants from NIHR during the conduct of the study and having had served as a member of the NIHR Health Technology Assessment (HTA) commissioning board, December 2017 to September 2020. Mr MacLennan reported receiving grants from the NIHR during the conduct of the study. No other disclosures were reported. ### Clinical Trial ISRCTN91974895 ### Clinical Protocols ### Funding Statement This trial was funded by the National Institute for Health and Care Research (NIHR), UK (Ref: NIHR 129703) using UK aid from the UK Government to support global health research. The research team were invited to apply for additional funding from NIHR in 2021 to investigate UK policy priority areas: mental health conditions and multiple long-term conditions within the Game of Stones trial. The views expressed in this publication are those of the authors and not necessarily those of the NIHR or the UK government. This project was supported by NHS Bristol, North Somerset and South Gloucestershire Integrated Care Board; NHS Greater Glasgow and Clyde; NRS Primary Care Network and HSC R&D Division of the Public Health Agency [HSC R&D Award Reference PHR Project: NIHR129703]. The Funder did not have a role in the design (beyond their review of the application), and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The Nursing, Midwifery and Allied Health Professions Research Unit, the Health Services Research Unit (HSRU) and the Health Economics Research Unit (HERU) were core funded by the Chief Scientist. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethical approval was granted by North of Scotland Research Ethics Committee 2 (reference 20/NS/014). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The data collected for the study, including individual patient data and a data dictionary defining each field in the data set will be made available to others. The participant data will be de-identified and will comply with the ethical and regulatory approvals for the study. Requests for access to data can be sent by email to chart@abdn.ac.uk and will be considered by the study team.