Stage 2 qualitative findings

Overview

Interviews were conducted to explore participants’ experiences with the HelpMeDoIt! intervention, app and website. In addition, helpers were interviewed about their experiences of using the app and website and of providing social support to the participants. The interviews also explored fidelity, recruitment and retention, and contributed to testing the logic model as part of the study process evaluation.

Thirty-five individuals were interviewed: 22 participants and nine helpers at 6 months, and another four participants at 12 months. Only four participants were interviewed at 12 months (from a proposed maximum of 20). This was a result of challenges in contacting participants and recruiting people to complete the interview and does not reflect a decision about data saturation. Table 30 presents the interviewee characteristics. The findings are presented below in three sections: (1) interviews with participants, (2) interviews with helpers and (3) how these findings map onto the overall study objectives.

Findings from interviews with participants

Participant data at 6 and 12 months were combined for analysis. Thematic analysis identified five key themes and accompanying subthemes (Table 31). These will be described in turn below. Quotations from participants are identified using an identification number, gender (M/F), age in years, extent of app use, and time since randomisation (6 months/12 months).

Theme 1: contextual factors

Participants described contextual factors that influenced their behaviour with regard to losing weight, physical activity and diet. These including the importance of social influences and their own traits and preferences. Life context was seen as influencing both past and current experience with weight loss.

Subtheme 1.1: relapse or previous experience

Participants talked about relapse and the difficulties of maintaining weight loss over time, as well as a history of trying different approaches to weight loss:

. . . over the years I’ve sorta tried an awful lot of things. I’ve had hypnotherapy, I’ve gone to women’s clubs, slimming clubs, I’ve had lots of ways that I’ve been trying to lose weight.

Subtheme 1.2: life change

Substantial life change, especially around jobs, could influence participants’ weight:

My main thing was I was walking 15 mile a day to and from work and then I changed jobs and that went from 15 miles to nothing since November, so since November I’ve put on a stone.

Subtheme 1.3: insight into self

Participants commented on how their mood and personality traits or preferences might affect their decisions around healthy lifestyle choices:

It might be appropriate to know just in general that I am often very angry . . . that angriness seems to be very related to the way that I eat.

Subtheme 1.4: concern for health

Some participants explained how concerns about their health influenced when they exercised and why they started exercising:

I was diagnosed with type 2 diabetes . . . You go along to the doctor and basically first thing they say is that it’s your weight. If you lost all this weight, everything will be hunky-dory [laughing] and you will be able to do everything you would love to do.

This woman describes the reasons why she wanted to lose weight, specifying that her appearance was not a driving factor:

I know some people who are much more kind of, em, focused on their look and their appearance and things but, ya know, I’m somebody who doesn’t use hair product in the hair, ya know, it’s just . . . it just doesn’t, it’s not that important. It would be for health reasons.

Subtheme 1.5: social or group norms

Participants commented on how social or group norms can influence their ability to make healthy lifestyle choices. They were most affected by family and workplace norms around eating:

I’ll just say, ‘Well, I’ll have a cup of tea’. And then they’ll give me a cup of tea and the cake with it. And they’ll say, ‘Oh just have it, we can’t eat all of them’.

Subtheme 1.6: barriers to lifestyle change

In addition to discussing barriers to using the app, participants provided insight into barriers to making healthy lifestyle change and otherwise engaging with the HelpMeDoIt! intervention.

Contextual/environmental barriers

Participants spoke about contextual or environmental factors, such as the weather, the workplace, lack of routine, injury, and the cost of gym memberships, which contributed to difficulties in maintaining healthy lifestyle behaviours:

When I am on a routine it works fine, I seem to kind of drop a couple of pounds every week, you know, at lunch time I’ll have a light dinner and so on. If I’m careful with the amount of wine I drink then it’ll come down and I also get exercise as well. I do walking as a part of exercise, but it’s difficult when I am on the road, which is probably about 70% of my time, really.

The price of food, and the time it could take to prepare healthy food, tempted individuals to make unhealthy purchases instead of healthy purchases:

Pound Shop sweeties are so cheap or biscuits in the Pound shop, that’s my big downfall. And it’s quick and fast, and you can eat it on the move.

Participant-related barriers

Factors to do with self-control, willpower, wanting to eat, routines and motivation were identified as barriers to making, and sticking to, healthy lifestyle changes:

Probably another challenge would be self-control. Whenever I am sitting down, watching TV I just continue eating a lot of crisps.

Although I eat an enormous amount, well quite a lot, I also have to be thoughtful that at the right times I’m actually eating enough so I’m not extremely hungry or you know so there’s a tension between the two things.

Social context

Five participants felt uncomfortable having to ask people to be helpers. They were concerned that this would be a burden for helpers or wondered if they should be able to manage on their own:

. . . maybe you feel a bit guilty having to ask someone [to be a helper], maybe I should just be able to do it you know?

A small minority of participants said that they did not have people in their social network whom they felt they could ask to take on the task of helping them make lifestyle changes. These participants were usually worried that their potential helpers had too much going on to ask them to do something else:

I felt kind of ashamed because I couldn’t come up with a friend to help me do it. I have friends but nobody that I felt that I could call on to do this sort of thing. This seemed to be a very difficult thing . . . my daughter works 12-hour days, she’s really tired, my stepbrother is in Canada, erm you know he also gets tired, and I don’t . . . yeah, I don’t know someone that I feel I could ask for that kind of day-to-day [support].

Theme 2: software and barriers to use

Subtheme 2.1: the HelpMeDoIt! app

Participants were asked for feedback about the HelpMeDoIt! app. Feedback covered the design of the app (i.e. how it was set up and how it looked) and the functionality of the app (i.e. how it worked).

Design of the app

We asked participants what they thought of the app design, and most gave positive feedback. Part of the app design included push notifications and reminders to thank helpers or to remind participants to update their goals. Most participants valued the reminders and said that they were an important part of engaging with the app and helping them adhere to their weight loss goals:

I do like the reminders coming up . . . as well as weight loss tips and things.

Functionality of the app

Some participants reported that the app was easy to use right away but others found it more challenging and requested further guidance. For example, using the app to set goals was difficult for some participants:

I didn’t find it easy [laugh]. No, because it was asking you to set a target and then it told you to change your target. And I didn’t understand what weekly targets were and what daily targets were. It wasn’t clear for me what I was doing.

Regarding push notifications, one participant suggested it would be better to set the default push setting to ‘on’. As most participants wanted push notifications, we made this change. There were a number of initial technical problems with the app that affected some participants’ ability to use it. Some of the discussion around functionality centred on these technical issues, which are reported separately under the ‘barriers’ theme below.

Subtheme 2.2: the HelpMeDoIt! website

Participants did not access the website regularly. Many participants reported looking at it once or twice, while others did not use it at all. However, a couple of visits to the website is likely all that is needed to give the participants the information they need. The app also delivered some of the key website information via daily messages and push notifications. Some participants did not realise there was an accompanying website. Individuals who did visit the website often did not return for subsequent visits, either because they forgot about it or because they did not feel that they needed the information again:

I didn’t see any point in going back onto the web page tae tell me tae go tae the gym . . . I think if sometimes if you were feeling that you needed a wee boost, the web page could’ve been a wee bit helpful. The other stuff on the webpage was OK, but it wasnae for me.

The majority of participants who did visit the website provided positive feedback:

. . . it was quite friendly. I liked the clean interface. Sometimes I can get annoyed with websites that are overly complicated, but that one’s quite clean. I liked it.

I just liked the whole idea that you could go in [to the website] and it wasnae preaching to you, ‘You will lose weight’. It was kinda doing it in a fun way that, you know, you thought, ‘Well, aye, maybe . . . that’s quite a good idea’.

Subtheme 2.3: barriers to using the app

We explored participants’ barriers to engaging with the HelpMeDoIt! app.

App-related barriers

Participants’ barriers to engaging with the app primarily revolved around technical problems with the app when it was first implemented. Despite a 3-month testing period prior to launch, the software company continued to resolve many ongoing technical issues and software bugs during the initial months of the intervention (see Chapter 6). Problems for participants included difficulty downloading the app, the app not remembering login passwords, and other issues highlighted in the quotes below. The majority of these issues were resolved, after which participants were more likely to give positive feedback about the app, especially related to features that did not initially work, such as push notifications. Several minor issues were not resolved for several participants, as the app was otherwise working well for them, and we were keen to avoid new software bugs:

. . . it [the app] made me set up more goals and then when I was hitting the back button it would send me back through all the forms I completed for the previous goals.

I think the worst part was probably being quite frustrated with the app at first, and that probably led me not to use it as much because there wasn’t really any point in using it because I couldn’t really do anything with it at first, and then I think I got more correspondence just after Christmas about it and reset it and everything and it was working much better after that so, but I think if the app had been better at first I might have you know used it more often if that makes sense?

Beyond technical problems with the app, a minority of participants had other criticisms.

. . . it was just so basic . . . I think because things are so sophisticated these days it was kind of childish.

The HelpMeDoIt! app seemed a little old-fashioned and so I thought it would be a bit better.

Participant-related barriers

A small number of participants admitted that their reasons for not engaging with the app had more to do with themselves, rather than the app. For example, they were embarrassed to share their eating habits with helpers, had low confidence in their ability to make lifestyle changes, were not very good with technology, or were embarrassed to start using the app again after a long period of non-use:

I haven’t done it for so long and I’m thinking I don’t want to look as though I am just starting this again.

So though even discussing like even putting in just people in the app to me meant eventually I would have to get in touch with them about why I’ve been binging, to not eat and erm like it just felt, no, I just couldn’t and I just couldn’t picture myself doing it.

Helper-related barriers

Participants occasionally reported that it was their helper who was having problems engaging with the app. This was sometimes because of technical problems with the app, or because helpers felt that they had received no incentive to provide support:

. . . she [helper] just thought it [the app] wasn’t really much . . . she didn’t think there was anything about it that would help her, like giving her an incentive to lose weight, or giving her any incentive to help me lose weight. So she just wasn’t impressed, that’s what her words were.

Some participants found it challenging when their helpers were not giving feedback through the app:

I had problems initially . . . so I think maybe that put me off a bit and also the fact that I wasn’t getting any feedback from my friends.

One participant felt that it was difficult to ask the helper to use the app:

Finding a helper is not challenging, but kind of telling the helper to use the app and monitor the app as well it is probably a bit difficult and a bit different to just having a chat.

Other technology-related barriers

Barriers to using the app were sometimes outside the control of the study team, including problems with participants’ phones, such as insufficient memory or needing to replace a phone.

Theme 3: mechanisms of change

Subtheme 3.1: goal-setting and self-monitoring

Two main features of the HelpMeDoIt! intervention were goal-setting and self-monitoring. Most of the interview participants who logged in set goals using either the template or the custom goals feature. Only one participant said that they had not set goals. Participants discussed goal-setting using the app, the kind of goals they had been setting, and what was or was not working for them. Participants made goals for weight loss:

My goal was to be under 20 [stone]. I have been under 20 for the last 3–4 years. So my goal was to be back under 20 by Christmas. By the time of the end of the study I would like to be under 18 stone.

A few participants said that it was easy to forget their set goals as they did not receive reminders from the app to update them. This mainly affected participants early in the intervention when technical issues prevented participants from receiving reminder messages. This issue was resolved by the software company:

I would forget that the goals, because the goals you have to set manually and maybe people because we are busy we will forget, we may forget so it could be good if like the app could have like a reminder.

Most participants liked the template goals that were included in the app, for example ‘stand more – when watching TV I will stand up at each advert break’:

I thought the goals that were already inputted were quite good ideas, so I quite liked them and it was quite easy to add your own if you wanted to.

Most participants set goals and monitored progress towards their goals via the app. They liked being able to monitor their progress towards multiple goals at the same time. They also said that they used self-monitoring outside the app, such as weighing themselves regularly. Feedback from those who did record their weight on the app suggested that progress on this was not displayed in a very engaging way.

Participants frequently made use of other devices, apps and programmes to help them achieve their weight loss goals using goal-setting and self-monitoring. These included scales, the FitBit (FitBit Inc., San Francisco, CA, USA) or other activity tracker, and food diary apps such as MyFitnessPal.

Subtheme 3.2: motivation

Motivation was an element of the intervention that was highlighted by the many participants. Motivation was identified for several different categories.

Motivation for joining the study

Many participants joined the study because they wanted to lose weight, with some explaining that they had hoped that the study would help them get started with the positive changes they wanted to make:

I was at that point where I think I had been to an away day and I felt really overweight and I just thought I need to do something.

Motivation for lifestyle change

Participants talked about what motivated them to begin making healthy lifestyle changes. Some of the reasons included enjoying positive comments from others, wanting to be a healthier person, and avoiding the same health problems as other family members:

People were saying to me, ‘Oh, you’re losing weight, I can see it comin’ off your face’. So that was quite good.

. . . my mum . . . she had to get operated on her stomach because she was overweight or obese I don’t know which. Really overweight and it was really bad so . . . that’s what I think and I don’t want to be like her. And my sister is getting fatter. I don’t want to become like that, I want to . . . yeah, I want to change.

Motivation provided by helper

Participants talked about the helper as a source of encouragement and motivation to keep them working towards healthy lifestyle goals. Some found this particularly helpful when they were struggling to sustain positive changes. Motivation was also discussed by some as being reciprocal:

I would say probably me [I’m my helper’s helper] you know she will say to me, ‘Thanks for motivating me’ or ‘Thanks for saying that’ so we probably motivate each other.

Subtheme 3.3: social support

Social support was the key aspect of the HelpMeDoIt! intervention. In the interviews we discussed helper support and other lifestyle influences within the participant’s wider social network. Participants drew a sociogram (diagram of their social network) at baseline, which illustrated the 5–10 people they were in most contact with (see Chapter 3). Participants also gave information on whether they perceived individuals in their sociogram to be healthy or likely to be a positive (or negative) influence for the participant making healthy changes. Discussion of the sociogram gave us insight into the social support available to participants and the influence of those people in their network.

Broader social context

We asked participants about their broader social network before asking for specific information about the individual(s) they had identified to be their helper(s).

Changes in sociogram over time

We explored whether participants’ social networks had changed during the 6 months since they drew their first sociogram. Almost all participants said that their social network remained unchanged. Only two participants reported some changes, one because of a recent move and the other because of a job change. A change in the sociogram presented a change, either positive or negative, to the levels of social support received by the participant:

The sociogram thing that I done . . . a few of my supports were work colleagues who worked with me an all that, I’m away from three of them right now. But I moved jobs and I wasn’t expecting it, but I moved jobs very quickly.

Lack of, or negative, social support

Although many participants had very good support from friends, partners, or family, about one-third of interview participants struggled to get the help that they wanted or needed. In addition, sometimes friends, families or coworkers showed a lack of support for or interest in what the participant was trying to achieve:

[Interviewer: Did you actually ask, ‘Would you help me do this’?] . . . Yeah . . . I talked to her then a wee bit . . . and then she seemed to . . . [Interviewer: OK, so even though you asked, ‘Will you help me?’ she wasn’t really interested.] . . . Nah [indicating that his wife was not interested in being his helper].

Other times, although rarely reported, there was an active attempt to derail the participant from their healthy lifestyle goals:

They [participant’s parents] would say, ‘Ah, that wee cake, it won’t do you any harm.’ [Interviewer: So they actually encourage you to eat more?] [Laughing] Definitely or they’ll like, I’ll just say, ‘Well, I’ll have a cup of tea’ and then they’ll give me a cup of tea and the cake with it. And they’ll say, ‘Oh just have it we can’t eat all of them’.

Support from helpers

Support from un-nominated or informal helpers

All participants interviewed used a helper to help them achieve their weight loss goals. However, quite a few participants did not use helpers formally nominated through the app. Some participants encountered technical issues when trying to nominate their helpers and some helpers were either not technically minded or did not receive their invitations. Despite not using the app, these participant–helper pairs engaged with the concept of the HelpMeDoIt! intervention:

I didn’t take on the help through the app of a buddy, I think he [helper] were supposed to but he’s just not technology-minded, he’s just no got a clue – knows how to answer his phone and that’s it. He supported me all the way through and obviously he still supports me today.

Yeah my auntie actually, I mean she is one of my helpers I tried to put in the app. She didn’t join, anyway she helped me to send me, we shared some pictures, some healthy food and she helped me a lot but she didn’t join the app.

Reasons for nominating a helper

Participants usually asked someone to be their helper when they felt close to that person. In general, this was a partner, a friend or a family member, but it could also be a coworker with whom the participant got on well. Participants also considered whether their potential helper needed support himself/herself, whether the helper had time to help them, how often they met up, and whether the helper would understand what they were going through:

I think you need somebody who has walked your shoes and has an idea of what you are going through or what the difficulties can be or what you are struggling with when you might just go ‘Aaarrggghhh, I’m just going to have 10 pizzas’ you know what I mean?

Types of support given or offered

Helpers provided different kinds of support in different ways. They gave support through the app (e.g. sending ‘smiles’), by texts or telephone calls or in person. We identified three categories of support given by helpers: (1) informational, (2) emotional and (3) instrumental.

Informational help could take the form of sharing recipes or tips for weight loss and primarily involved giving the participant useful information:

[Interviewer: What would you say was the most helpful things your helpers did for you?] I would say, show me how to eat properly, like quantities of food and discover that you don’t need to be on a diet because you can eat healthy and enjoy the food.

Much of the support that participants received was instrumental, which meant offering support in a tangible or physical way. This could be helping to pay for a gym membership, not buying or offering junk food, or supporting the participant to do more physical activity by doing an activity together:

. . . if it’s a nice day he is like ‘come on, get your shoes on’ and we go for a walk.

Emotional help took the form of encouragement to make and sustain healthy changes. Some participants found this to be the most helpful type of support given by their helpers:

. . . one of my nominees is a health nut and she was good because she kept on at the background, you know? ‘You can do it!’ That’s, I think part of what you need when you’re losing weight is somebody tae say tae you, ‘You know, aye it’s gonnae be hard, but you’re no’ daft. You can dae it’. And that was her.

Life context of helpers

Participants described contextual factors in the lives of helpers that influenced the helper’s ability to provide support. This usually came up when participants were discussing why they might not have received as much support from their helper as they had hoped. Sometimes participants felt that their helpers were too busy or perhaps had their own health issues to contend with:

Well, I did speak with my friend who was going to help me with it. She is quite healthy herself and she was quite interested to do it. But then unfortunately she had kind of health issues herself so I just did it all in my own.

Participant influences their helper(s) or others

We asked participants if there were instances when the healthy lifestyle choices they made influenced their helpers or others. Participants talked about the mutual benefit they often felt from having a helper and that encouragement went both ways in the relationship:

Definitely I think, like, we both [participant and helper] have been trying to eat a bit more healthier and just sort of be a bit more active as well.

Ma wee girl she eats healthier, she tracks, well she tries to keep up with what we are eating as well erm, I’d say it has had a whole effect on the family, like ma partner and ma wee girl.

Negative aspects of helper support

Most participants did not experience any negative aspects of helper support. Of those few who did, some had expected more help but realised that their helpers had too much going on in their own lives to give the desired level of support. Only one participant mentioned that her helper pushed a bit too much:

About the only [negative] thing is the daughter keeps insisting that she knows better than me. Like you shouldn’t be eating this or that. You are eating far too many potatoes! And I say to her, ‘Well I am allowed . . . We have been given a personal plan with an amount of calories’.

Subtheme 3.4: diet and physical activity

All participants talked about diet and physical activity as being an important part of their healthy lifestyle change. Most participants said that they were trying to make small adjustments to their diet. Overall, there was a focus on drinking water rather than sugary or alcoholic beverages and on eating more fruit and vegetables. Participants also discussed how price, convenience and the time of day factored into their dietary choices. Many participants said that they had made small changes around eating more fruit and vegetables:

. . . [reducing] the amount of red meat that I’m eating and trying to improve ma fish and ma fruit and vegetable and that’s it.

Alcohol, fizzy drinks and sugary drinks were regularly part of the discussion about diet:

I have tried to cut down on how much I drink, like, I mean I’m in a pub every week but . . . I’d say I’ve cut down on how much I drink. ‘Cause it used to be that I’d maybe drink, not all the time, but a beer in the house a couple nights a week, like one or two bottles and you know, I’ve stopped doing that for the most part.

Increasing physical activity was an important part of participants’ attempts to make healthy lifestyle changes. Participants frequently increased their walking or cycling but also used classes and gyms to do more physical activity. All participants valued physical activity and believed that it was important to their weight loss goals:

I’ve started cycling to work and I don’t drive.

I am going for walks a bit more and doing some exercise you know using the stairs as an exercise thing.

Theme 4: impact of the HelpMeDoIt! study

Subtheme 4.1: change in behaviour

HelpMeDoIt! inspired participants to do things such as join a weight loss group, get a personal trainer, sign up for a gym, start using a physical activity tracker, and set up a weight loss challenge with family members. It inspired one woman to seek out a helper who gave her the positive support she had been missing before:

I don’t really think I had very much in the way of support. Probably sort of more the negative type, you know from people like my parents kind of nagging me, ‘oh you need to lose weight, you need to lose weight’, but that would be all that they would say really so I think it has been quite different having a helper that . . . he doesn’t ever say it about ‘oh you need to lose weight’ because you are overweight, it is more let’s sort of like try and eat healthily or let’s try and be more active, not in a negative way more in a positive way so I think that’s been a big change just having somebody kind of more positive about it all.

Participants discussed changes had they had made in their efforts to lose weight and be healthier. Reporting actual behaviour change was more common than simply thinking about making a change or reporting a change that they planned to make in the future. Few participants had not yet implemented any actual behaviour change. Most participants had made changes to diet or physical activity, usually both:

I still binge, I mean I still enjoy food because I love food, but I have smaller portions now like and healthy amounts, switched to lentils, changed my diet slightly, things like that.

I was cycling to work, home and back every day and I was doing at least 10 miles a day back and forth to work . . . um . . . I would say on top of that I started swimming once a week and also doing a core strength class which is like, that’s like using a bit of weight and lunges and doing some upper body strength. And then I’ve been doing Zumba on a Sunday because I like it and I’ve also started a spin class, it’s like stationary cycling. Those are kind of the three main activities I’ve added.

Subtheme 4.2: change in weight

We asked participants if they had experienced a change in their weight as a result of making healthy lifestyle changes as part of the HelpMeDoIt! study. Many participants reported losing weight but some had not been able to maintain their weight loss, especially around the holidays. A few had not been able to lose weight and fewer still reported gaining weight:

To date I have probably lost about 2 stone . . . because you know somebody is goin’ to be comin’ out and weighing you and measuring you, so you’ve got to try and achieve something.

I weighed myself . . . But over the Christmas period it was all back on again.

Theme 5: study- and intervention-related insights

Participants were also asked about their views of the study evaluation methods.

Subtheme 5.1: data collection tools

The data collection tools were considered acceptable and even enjoyable. Initially we had concerns about the time it would take participants to complete the questionnaires but none said that this process was burdensome.

Subtheme 5.2: retention strategies

To optimise retention rates at 12-month follow-up, we sent all participants a newsletter at 3, 6 and 9 months post baseline. This included an update on the study, as well as evidence-based tips for weight loss. The newsletter was popular with participants. They also liked receiving thank-you vouchers, but most said that they would have participated without this incentive:

I think if it caught my eye I would have done it regardless of the vouchers but I think the newsletters it was a good way of getting people that are straying off the path to have another wee look at it.

Subtheme 5.3: recommendations and suggestions

Most of the recommendations made related to the intervention rather than the HelpMeDoIt! study methods. Participants gave suggestions to improve the app, mostly about fixing the technical glitches in the initial roll-out. Some participants liked the idea of the app integrating with other popular fitness-related apps. A HelpMeDoIt! community was also suggested:

. . . maybe the only other thing I would say is the level of contact in the beginning was good. But I do think a little bit more, actually would be helpful. I don’t know if you could manage it, but more a sense of community, knowing how others are getting on.

I think what would’ve been good is if you have peer support. So maybe actually rather than asking somebody outwith the study to help you, maybe having somebody else on the study to be a kind of peer support, would’ve been quite good.

Subtheme 5.4: negative aspects of study

Negative aspects related to the intervention have been reported under Subtheme 3.3: social support, Lack of or negative social support and Subtheme 2.3: barriers to using the app, App-related barriers. Participants did not report any other negative aspects of taking part in HelpMeDoIt!. However, a few participants had misunderstood the aim of the intervention when they first joined:

I liked the title, HelpMeDoIt, I didn’t at that time fully appreciate that the ‘help me’ bit had to do with, you know, another person that I needed to find.

Subtheme 5.5: best things about the study

Some of the participants reported that they had really benefited from having a helper:

I think the best thing has probably been my helper getting involved, I think that has been a huge help, you know . . . I think it has been good to have somebody prod you a wee bit.

Many participants said that they liked the baseline questionnaire session at which they received their measurements:

Well the best thing about taking part in the study is when they measure us and all the information about my fat percentage.

Other participants liked knowing that there was a follow-up session in 1 year to help keep them on track. For one participant, joining the HelpMeDoIt! study had helped him realise that he needed to make some changes:

The best thing’s been it was making me more aware . . . that everythin’ in ma life just went . . . haywire so I’d say that’s definitely the best thing.

Findings from interviews with helpers

Interviews with nine helpers provided useful feedback on the helper aspect of the intervention. Thematic analysis identified five key themes and accompanying subthemes (Table 32). Quotations from helpers are identified using their linked participant identification number and gender (M/F).

Theme 6: the helper experience

Subtheme 6.1: helper nomination process

Feedback about the helper nomination process was variable, with some helpers saying that it was time-consuming (which may have been related to the initial technical glitches) and others finding it to be straightforward. Some helpers could not remember what the process involved and others had agreed to be helpers without formally accepting the nomination via e-mail and app.

Subtheme 6.2: guidance provided for helpers

Views on whether or not the app/website provided sufficient guidance to the helper. Many helpers thought that the guidance provided to them by the app and website was sufficient. Not everyone had visited the website so some were uncertain about what guidance was available. However, these helpers also felt that it was easy and intuitive to actually provide help. One helper said that she would have liked more guidance (she did not realise there was a website with information on this topic).

Subtheme 6.3: facilitating change

Helpers primarily facilitated change by providing emotional support, encouraging more physical activity, joining the participant in doing activities and improving healthy eating through recipe sharing or cooking lessons:

She sits just down the corridor and me and my other colleague will say are you coming on the stair walk? We are doing a stair walk and she will usually join us. Yeah, I definitely think there is some motivation there from having some help.

I walk a lot up on the moors and that’s the benefit of having a dog. That’s why today, you know normally I would pick her up at the station but I thought, ‘No, no, it’s dry. Let her walk up’. You know. I was trying to encourage her to do more.

Subtheme 6.4: impact on helper

Helpers said that being a helper influenced them to make healthy lifestyle changes. Some attended new fitness classes or did more walking and others improved their diet. Several helpers said that they were already leading healthy lives and that they had not made further changes as a result of being a helper:

She made me focus, possibly, on the fact that even in this stage it is really possible and it’s really good to set yourself a challenge and a change.

. . . even from the very start this [being a helper] could motivate me as well . . . but I think if I had been able to use the app I’m pretty sure it would have motivated me that little bit more than I have been, so yeah, you know, I definitely think there is a case there of helping the helper.

Subtheme 6.5: negative aspects of the helper experience

Most helpers reported no negative aspects of being a helper. Among the comments made, most were about initial problems with the app (which are described under the ‘Barriers/App/App-related’ theme). One woman said that it was difficult for her and her son to get their participant active and engaged in making changes:

I think that my son and I are frustrated, my son goes to the gym four or five nights a week and he is frustrated with his dad [participant], they were talking about joining the gym and going with him and I think once they sign up for the gym rather than the money going to waste because they’ve already paid for that, I know that will be an incentive for [participant’s name] to actually go to the gym.

Another participant struggled with knowing how to support change in her partner, who experienced depression. She also described the struggle to help her partner eat better. She said that she cooked healthy food from scratch using lots of vegetables but still could not make her partner eat more healthily:

I’m still cooking, I can hear the rustling of the crisp bags cause he’s at his desk at his computer or he’ll eat a bag of Skittles and he’ll eat crap, before I can even get the dinner out. I can’t control any of that.

Subtheme 6.6: positive aspects of the helper experience

Helpers described how happy they were to have supported healthy lifestyle changes in their friend and contributed to their success. They felt good knowing that they had been trusted to help:

I think it’s nice to know that that person kind of trusts you to be supportive and have access to kind of their personal information in that way.

Theme 7: the HelpMeDoIt! software and barriers to use

Subtheme 7.1: the HelpMeDoIt! app

Design and functionality

We received limited helper feedback on the app. Several of the interviewed helpers did not use the app because of initial technical problems in attempting to download or use it; these issues are described in the section ‘Barriers/App/App related’. Most helpers provided support outside the app.

Goal-setting and self-monitoring

This helper liked the idea of being able to see her mother’s goals as it helped her follow up as the helper:

I think it is good to be able to see if they have completed their goals because then you’ve got, you know, if I can see it then I can text her and say, ‘Right mum, you’ve no done this, chop, chop’. Whereas if I couldn’t see it then she could just say, ‘Oh yeah I did that’. I mean, she just might not have inputted it but no I think that’s good to see the goals.

Messaging

Helpers liked the idea of receiving reminders from the app regarding progress and rewards received by their friend. Push notifications went directly to helpers’ phones to notify them of relevant updates. Lack of notifications was an initial technical issue affecting some helpers. This was later resolved by the software company.

Patterns of use

Patterns of use among helpers varied from no use to regular use. Initial technical issues prevented helpers from using it more regularly:

Yeah, it’s hard to say on average. I think the first few weeks I was certainly using it once a day.

Positive aspects of the app

Helpers liked the concept of the app and thought it could help participants if the technical issues could be minimised:

. . . I think the app is still that something, that little extra, you know, you can go that little extra mile with it.

Subtheme 7.2: barriers to using the app

App-related barriers

Helpers cited initial problems with the app, including problems logging on, the app not remembering their assigned unique ID, the app being very slow, problems sending smiles, and push notifications or messages from the app coming in repetitively or sporadically. The helpers who downloaded the app said that they would have used it more if it had functioned better. We did not interview any helpers who used the app after the technical issues had been resolved (this was because of the ethical constraints on contacting helpers):

I couldn’t actually log on, it wouldn’t hold the information and every time I tried to go onto the HelpMeDoIt! app it wanted me to enter my unique ID so unless I had memorised it I’d have to go back to the original e-mail that told me that.

Participant-related barriers

Helpers found it difficult to engage with the app if their friend was not also engaged:

. . . when she wasn’t using [the app] that much then I didn’t use it quite as much . . . Perhaps if I’d seen more activity more progress, em I would have definitely kind of been more active myself I think on the app.

Helper-related barriers

A few helpers admitted to not being very experienced or interested in using technology and apps:

I’m not intae gadgety technology . . . I cannae think of an app, an actual app that I use on my phone. I use it for calling, texting.

Other technology-related barriers

As with participants, a few helpers said that they did not have the storage on their phone to get the app. In some phone models, typically older Android phones, the app did not work well.

Subtheme 7.3: the HelpMeDoIt! website

Most helpers did not use the website, while others used it at the very beginning once or twice. High use of the website was not anticipated, as once helpers had read the guidance they did not necessarily need to revisit. The reasons for not using the website are reported in the ‘Barriers/Website’ section below. Among those who did see the website, comments were neutral or positive, with some helpers admitting that they did not remember much about it:

I went into it initially to look at it and . . . I think the whole concept of it is a really good idea.

Subtheme 7.4: barriers to using the website

There were many similarities between participants and helpers in terms of the barriers to website use. As with participants, low website use was reported by helpers. Some helpers felt that they got the information they needed from the website from one visit. However, there was not a lot of awareness among helpers about the website content or how it could be helpful. If a helper was not engaged with the app, they tended to not use the website. Some helpers said the need for their password, tucked away in an old e-mail, was a barrier to accessing the website.

These two helpers described why they did not use the website:

I think because it’s mostly, or that I felt that it [the intervention] was mostly an app-based exercise if you like.

I didn’t really go back to the website. And I think I understood, I understood what it [the intervention] was all about.

Theme 8: helpers’ impact on participants

Subtheme 8.1: change in behaviour or awareness

Helpers mentioned that they had observed changes in the behaviour or awareness of their friends, such as being more active and making a conscious effort to improve their diets:

We probably did [attempt lifestyle changes] to a certain extent but I think using the app made us both aware of what we do on a daily basis, you know. [Interviewer: So you did a little but it maybe brought it more to the front of your mind?] Yes, and just added that little bit of motivation perhaps.

Subtheme 8.2: diet and physical activity

Helpers reported a number of ways they supported their friends with healthy eating and physical activity, including sharing recipes, teaching healthy cooking, buying fresh fruits and vegetables and avoiding junk food in the house, preparing healthy meals, and going for walks together. Helper and friend accounts were similar.

Subtheme 8.3: motivation

Helpers talked about motivation and the role it played in facilitating change. They believed that their help contributed to their friend’s motivation to make healthy changes. Many helpers found that they were more motivated to eat well and be active themselves because of their role:

Being a helper, I think it kind of motivated me to continue doing my walking and doing my healthy eating in order to get [participant’s name] to go with me.

Theme 9: social support

Subtheme 9.1: ways of interacting between helper and friend

We asked helpers how they preferred to communicate and engage with their friend. Helpers usually used a combination of text, phone, app, and in-person meet-ups. The distance between friend and helper was a major determinant of how they chose to keep in touch.

Subtheme 9.2: types of support given

Helpers reported giving types of help that we categorised as informational, instrumental or emotional. The following quotations are examples of each of those three types of support, respectively:

I was happy to e-mail her recipes.

Yeah, yeah, well, I’d go over to her house and say, ‘Come on!’ and we’ll go for walk.

I tend to usually go into it [the app] kind of after she’d been to the gym or kind of done something along those lines, you know, and send her one of the stickers [smiles]. Kind of a ‘Well done’ or ‘Keep going’ type of thing.

Subtheme 9.3: context of and insights into the helper–friend relationship

There was a fine balance for some helpers as to how much advice they could give their friend, especially when their friend was also their partner. One helper felt that being part of the HelpMeDoIt! intervention made their partner more receptive to gentle encouragement and advice. Part of being a good helper was understanding the person they were trying to help and working within the constraints of that relationship. Helpers also acknowledged that if they lived with the person they were helping that factors into how much and what type of support they can give:

[Interviewer: . . . the first thing you said, was it that sometimes it was difficult . . . to provide help?] Yeah, because you know, let’s not eat this because it is not healthy and not good for us, and he gets fed up of me keep telling him what to do. You have to get a balance.

Helpers had further insights into the relationship between the helper and participant and how this might affect the ability for success:

I was really well supported by my husband and that really showed me that if you are supported by someone it can absolutely make a difference to do something, to have the power to do something to help yourself.

Theme 10: the HelpMeDoIt! study and intervention

Subtheme 10.1: recommendations and suggestions

We received a range of recommendations from helpers. Most of these comments were about the HelpMeDoIt! app. For example, they wanted the app to remember their assigned password, to receive an app notification when their friend achieved a goal, to have more example goals and to have automatic syncing with FitBit or other activity trackers, and one helper suggested that the friend’s weight be hidden and only weight change be visible to helper. Finally, one helper had this to say about the app and encouraging messages:

Almost having somewhere where you can record progress and you can, you know . . . everything or your messaging is kind of captured in the app. Then if somebody is logged in and feeling a little bit low then they can maybe look back and see all the encouragement and support that they’d had from people at one point.

Subtheme 10.2: negative aspects of the intervention

Feedback from helpers was mostly very positive. When helpers described negative aspects of the intervention, these mostly revolved around the initial technical glitches in the app, which were most pronounced at the beginning of the study. One helper said that it could sometimes be challenging to encourage their friend (their partner in this case) who might be negative:

When you are trying to say to him or advise him not to eat certain stuff he would moan you know, ‘But I want to eat it!’ kind of thing.

Subtheme 10.3: impact of the HelpMeDoIt! intervention

Helpers believed that the intervention made them and their friends more aware of their healthy lifestyle behaviours and also influenced helpers themselves to be healthier. One helper said that the intervention had made her partner more receptive to following her advice and encouragement and reported that the whole household was eating more healthily as result of her partner participating in the study:

I don’t know if he [participant] would have listened to me if he hadn’t been taking part in the study, because I have always been a healthy eater and always been very active . . . I think the fact that [participant’s name] was doing the programme with yourself encouraged him to try and be active and do healthy eating and . . . before getting on the programme he wasn’t keen to do it alongside me.

Subtheme 10.4: best things about the intervention

Helpers had many positive things to say about the HelpMeDoIt! intervention. They enjoyed making healthy lifestyle changes along with their friend. They liked the idea of the app and helping their friend make healthy changes. Helpers believed that being part of the intervention helped their friend become and stay motivated to make positive changes. Helper–friend pairs who were also partners felt that the HelpMeDoIt! intervention had helped them become closer:

I think it’s probably brought us close together. I just . . . having her being, I don’t know, I hate using the word ‘journey’ but this kind of ehh kind of following her goals to kind of lose weight and get fitter I think it’s because I’ve been her helper and she’s been doing the same for me as well. It’s . . . I’d say it’s certainly brought us a bit closer.

Further exploratory analysis

For those interview participants with follow-up data (n = 21), we compared those who lost weight (n = 14) with those who had gained weight (n = 7) to explore whether or not there were differences in their accounts. The interview participants who lost the most weight (8–19% of their body weight) reported receiving excellent social support from more than one person in their social network. Many said that they had a strong helper or two but also reported getting support from other family members or friends. They usually described receiving all three types of social support: emotional, instrumental and informational.

Participants who lost the most weight (≥ 5% of their body weight; 7/14) also reported rigorous diet and physical activity-related goal-setting and self-monitoring, usually relying on more than one app (e.g. MyFitnessPal) or device (FitBit or another pedometer) and participating in weekly weigh-ins in a group setting [e.g. Weight Watchers (New York, NY, USA)]. These participants were also more likely to engage with the HelpMeDoIt! app for longer, despite technical problems that eventually led them to taper their use and move to apps that functioned more smoothly. Participants who lost more weight typically said that they had joined the study to be healthier rather than simply to lose weight.

Participants who gained weight (n = 7) also reported some good social support but a few described a lack of, or a change in, social support in some aspect of their life. For example, one woman who gained weight said that her nominated helpers had a significant language barrier and that they did not engage with the app or the idea. One male participant described having great support from his wife and son but said that he had recently changed jobs, which prevented him from walking as much and had removed him from supportive coworkers. Another participant who gained weight reported making goals, monitoring them, and having a helper who was supportive. However, this participant had recently moved to a new city so he did not have as much support as he was used to, had some difficult and unsupportive family members, and said that his goals differed quite a bit from those of his sole helper, who was also a workout buddy. Among participants who gained weight, one said that he never used goal-setting or monitoring, another said that he focused on diet only and not on physical activity, and another said that she regularly forgot to set goals. Participants who gained weight were more likely to say that they had joined the HelpMeDoIt! study because their GP suggested it.

Participants, whether they lost or gained weight, said that they faced barriers to making healthy lifestyle changes, but these were more pronounced in the participants who gained weight, who were less successful in finding workarounds for their barriers. One woman did not like doing things by herself, but her helpers had too much going on to exercise with her and she was unable to find other helpers. Conversely, participants who lost weight said that they tried other ways to find the support they needed, such as joining a weight loss group that met in person or online (e.g. on Facebook). Similarly, both gainers and losers said that motivation to implement and maintain healthy lifestyle changes was a challenge, but participants who lost weight found ways to sustain that motivation, usually by using a supportive helper or community (e.g. a Facebook weight loss group). Similar life contextual factors were identified by weight losers and gainers. These included health issues, habits and past experiences of trying to lose weight.

Mapping the qualitative themes to the HelpMeDoIt! study objectives

We mapped themes from our qualitative interview analysis onto our HelpMeDoIt! objectives (Table 33) to illustrate how the data helped answer the study objectives.

Summary of interview findings

Although there were issues with both helper and, to some extent, participant engagement with the app, partly due to technical issues that were subsequently resolved, overall the social support concept of the HelpMeDoIt! intervention was well received. Both participants and helpers engaged with the idea of having a helper, or being a helper, even if they were unable to do so via the app.

A different level of app engagement was observed between participants and helpers. Participants, who were enrolled into the study, spent more time trying to make the app work and feeding back problems they had with it. Helpers were less likely to try as hard to make the app work and were happy to provide support as helpers even if they did not access the website or download the app.

Helpers enjoyed the role of supporting their friend in making healthy lifestyle changes and felt flattered to have been asked. Different types of support were given by helpers, including instrumental, informational and emotional. Participants seemed to benefit most from emotional support and encouragement. Participant–helper pairings between partners were usually beneficial, although helpers in these situations were more likely to report not always knowing how much to push their partner and dismay over their partner continuing to make less healthy decisions, which they were more aware of because they lived together.

There were differences between interview participants who lost weight and those who gained weight in terms of social support, goal-setting and self-monitoring. In general, the participants who lost the most weight had excellent and varied social support and were enthusiastic about and consistent with goal-setting and self-monitoring. Participants who lost or gained weight had many similarities in motivation, barriers and life context. However, individuals who lost weight found ways to work around barriers, lapses in motivation and life contextual factors, compared with participants that gained weight.

The findings from participants and helpers have identified several key issues for us to consider in a future study. These include ensuring that the app functions effectively on a large scale prior to implementation, having better signposting to the guidance and information on the accompanying website and continuing to provide the positive features that engage participants and helpers with each other. The interview data also addresses questions related to the programme theory and mechanisms of change of the intervention. These are considered further in Chapter 6.