This mixed-methods process evaluation within the Game of Stones randomised controlled trial examined how men living with multiple long-term conditions (MLTCs) and/or disability experienced a male-targeted weight management intervention. The evaluation explored health outcomes captured as secondary trial measures, participant retention at 12 months, and in-depth qualitative experiences obtained through semistructured interviews.
The parent study was a three-arm randomised controlled trial comparing behavioural text messages plus financial incentives, texts alone, and a waiting-list control. Secondary outcomes relevant to this evaluation included the Weight Self-Stigma Questionnaire, the EuroQol 5-Dimension 5-Level (EQ-5D-5L) instrument (including its anxiety and depression subscale), and the Patient Health Questionnaire-4. Retention at 12 months was recorded.
Qualitative data comprised semistructured interviews conducted at 12 months with a subset of participants from the two intervention groups. Interview data were analysed using the framework method to identify themes related to health, social context, motivation, and barriers to engagement.
The trial was conducted across three UK centres: Belfast, Bristol and Glasgow. A total of 585 men with obesity were randomised. The mean age of participants was 50.7 years (SD 13.3). Fifty-four participants from the two intervention arms took part in semistructured interviews at 12 months.
Among the trial population, 235 men (40%) lived with MLTCs, 181 (31%) had a single long-term condition, and 167 (29%) reported no long-term conditions. Disability was reported by 165 men (29%). There was overlap: 99 participants had both MLTCs and disability. A subgroup of men with MLTCs—93 individuals—were living in areas classified as deprived.
Compared with men without MLTCs or disability, those with MLTCs and/or disability tended to be older. Fewer men in these groups had degree-level qualifications and fewer were in full-time employment. These baseline differences highlight that MLTCs and disability clustered with socioeconomic factors that can influence engagement with weight management interventions.
Retention at the 12-month follow-up varied by health status. Men reporting a disability had a higher retention rate (76%) and men with no long-term conditions had a similar retention (75%). By contrast, men with diabetes had lower retention at 12 months (65%). These retention patterns indicate differential trial engagement across clinical subgroups.
For men living with MLTCs who received the intervention, several secondary outcome measures either improved or remained stable. Self-reported weight stigma, overall well-being, and quality-of-life scores (EQ-5D-5L) showed improvement or no deterioration in the intervention arms for this subgroup. Screening results for anxiety and depression (captured via EQ-5D-5L subscale and Patient Health Questionnaire-4) were inconsistent across participants with MLTCs, without a uniform direction of change reported in the source.
Interview data revealed complex and dynamic health, social and life situations among men with MLTCs and/or disability. For some participants, these circumstances provided motivation to change behaviour and pursue weight loss goals. For others, the opposite was true: hospitalisation events, poor mobility, and an inability to exercise were demotivating and undermined the ability to reach weight loss targets. Experiences ranged from substantial success and perceived health benefits to disengagement or not prioritising weight management.
The mixed quantitative and qualitative findings demonstrate heterogeneity in outcomes for men living with MLTCs and disability enrolled in a text-based weight management intervention. While some men achieved meaningful improvements in weight-related stigma and quality of life, others—particularly those constrained by mobility limitations or diabetes-related issues—showed lower engagement or mixed mental health outcomes. Socioeconomic factors and baseline functional status were relevant to both retention and intervention responsiveness.
Men with MLTCs and/or disability experienced a broad spectrum of outcomes within the Game of Stones trial, from very successful weight loss and improved health to limited engagement or benefit when immobility or comorbid diabetes impeded participation. The trial registration identifier is ISRCTN91974895.