This study aims to understand the behaviour changes men who attended a weight loss programme engage in during weight maintenance. Understanding the needs of men in the context of weight loss maintenance is important, as they are underrepresented in this body of literature.Given its focus on personal experience, this study adopted a qualitative design. Semi-structured interviews supported by participant-generated photo-elicitation techniques to explore the behavioural changes 12 men engaged in 6 months after attending a men-only weight loss programme. Data analysis was undertaken through thematic analysis and Gleeson’s polytextual thematic analysis.This study suggests that the key behaviours men engaged in to maintain weight loss can be classified into four categories: (1) ‘Small’ changes, (2) Informed decisions, (3) Monitoring of behaviours, and (4) Dealing with ambivalence.This study makes an original contribution to knowledge and can have important implications for practice in the area of men’s health, particularly with regard to the long-term impact of weight loss interventions. For example, the prevalence of diabetes is greater among obese men (14%) compared to women (11%).1 However, most men are underrepresented in hospital admissions related to obesity, in traditional weight loss interventions and in weight-related studies.2 To illustrate, in a recent systematic review on weight loss maintenance, 78% of participants were women.3 Similarly, in Garip and Yardley’s4 review of weight management studies, at least 224 out of 290 participants were women. Likewise, Pedersen et al.5 undertook a qualitative study to understand the complexity of self-regulating food intake in weight loss maintenance among short- and long-term weight loss maintainers. Their sample was also predominantly women, with only 4 males out of 18 participants. In addition, only 10% of patients receiving a primary care referral to commercial behavioural weight-loss interventions are men.6 However, current evidence and practice on weight loss and weight loss maintenance is still biased towards women’s needs.In the UK, the rates of obesity have increased since the 1980s, and this rise is expected to continue. The majority of adults in England are overweight or obese, with more men (67%) than women (62%) being classified as such.7 This suggests that regardless of gender, current obesity treatments are dissatisfactory in the long term, but little is known about the reasons for this.8 While previous studies have highlighted the behavioural issues that are important for long-term weight loss maintenance, such as self-regulation, problem solving and increased Physical Activity (PA),9 these intervention approaches are often just a replication or an extension of those used for initial weight loss.3 Furthermore, it is unclear how these intervention strategies are maintained in the longer term.Although little is known about men’s experiences of weight loss maintenance, there is a trend in the literature suggesting that weight regain is common after participation in weight loss interventions, with people regaining on average a third of the weight lost within a year.10 approaches to weight loss and weight loss maintenance should be designed with the needs of men in mind. Men’s perceptions of weight loss interventions as feminized may explain their underrepresentation in weight loss interventions.2 Promising evidence has demonstrated some intervention approaches that may be particularly appealing to men, such as the use of sports-based and homosocial environments.1113 While these male-friendly approaches have been effective in increasing men’s uptake and adherence to weight loss interventions, understanding how men incorporate intervention strategies into their daily lives post intervention is still needed.5Given that masculinity is a culturally normative ideal of male behaviour, and it is constructed as the opposite of femininity,With these thoughts in mind, this study aims to understand how men translated and incorporated intervention strategies and behaviour changes into the context of their daily lives in the 6 months after completing a weight loss intervention. In particular, this study explores how complex social, contextual, cognitive and emotional factors influence men’s attempts to maintain weight loss and health-related behaviour change in the longer term.This research is part of a larger project aiming to understand men’s health-related behaviours before, during and after attending a men-only weight loss intervention, called Tackling the Pounds [TtPs] (pseudonym). TtPs aims to help men lose 5% of their body weight in 12 weeks (one session of 90 min per week) through exercise and education. The findings of this study refer to men’s experiences of weight loss management during the 6 months after completing TtPs. Ethical approval was gained from the Research Ethics committee at Leeds Beckett University and by NHS REC [13/WA/0187]. Pseudonyms have been used throughout.14 qualitative research is ‘a situated activity that locates the observer in the world. It consists of a set of interpretive, material practices that make the world visible’ (p. 4). This definition emphasizes the role of the researcher as an interpretive instrument that uses different practices to understand the life experiences of people. As qualitative researchers, we subscribe to the view of multiple realities, where reality is subjectively constructed by each person depending on context. Therefore, the philosophical assumptions guiding this study include a constructivist epistemology and a relativist ontology.Given the focus of this study on understanding lived experience, a qualitative approach was used. According to Denzin and Lincoln,1517This study draws on semi-structured interviews and participant-generated photo-elicitation to explore men’s health behaviours in the 6 months following TtPs. Combining photographs with interviews was deemed an appropriate way of exploring the social, contextual, cognitive and emotional factors that influence weight loss maintenance, as this methodological approach can help generate vivid and personally meaningful accounts, some of which could have been overlooked through interviews alone.the impact of the intervention on participants’ health behaviours; (2) barriers and facilitators for weight loss maintenance; (3) social support related to weight loss maintenance; and (4) participants’ motivation towards weight loss maintenance. In total, 12 men agreed to participate in this follow-up phase of the research, and interviews lasted between 40 and 130 min.Participants were invited to provide or generate photographs for the specific purposes of this research. To do this, L.L.-S. contacted participants by phone to arrange a follow-up interview and she invited them to produce a personal photographic diary over a week about any behaviours they felt they had changed as a result of attending TtPs. They were asked to provide photos from their own personal archive or to take new photographs. Although L.L.-S. offered a disposable camera to take the photographs, all participants preferred to use their smartphones to complete this task. Then, they were asked to email L.L.-S. the photographs they had taken prior the interview. L.L.-S. printed the photographs and brought the hard copies to the interview, and/or participants brought photographs from their own personal archives to the interviews. During the interviews, L.L.-S. incorporated prompts to explore the participants’ visual and narrative-based accounts, such as: ‘Why did you take/bring this particular photograph?’, ‘What is this photograph showing and why does this matter to you?’, ‘In what context was this photograph taken and what makes it meaningful?’ and ‘What elements of this photo are related to your weight loss journey, and why?’. Data generated through discussion of visual materials were also supported by the use of a semi-structured guide, which explored (1) 18 approach to thematic analysis and Gleeson’s19 polytextual thematic analysis. This means that while following the phases of thematic analysis proposed by Braun et al.,18 we assumed that both sets of data  were linked. After transcribing each interview verbatim, each participant’s transcript and set of images was scrutinized for themes following an iterative process that involved moving back and forth from text to images. During analysis, L.L.-S. first familiarized herself with the data by conducting the interviews, listening and transcribing within 7 days of being produced, and making notes. After this, L.L.-S. started to develop themes by hand using a thematic map. Every time a new code was found, she added it to the map. Subsequently, she searched and identified potential clusters of patterned meaning on the mind map, which became tentative themes. These were then reviewed by the co-authors. Subsequently, the report was written.Data analysis aimed to capture both the verbal and the visual data. Therefore, analysis was guided by Braun et al.’sTwelve men agreed to participate in this study, all of whom completed the 12 sessions of TtPs. All participants were White British and self-reported being heterosexual, most (83%) participants had children and self-rated their health as ‘poor’ or ‘average’ (67%), of whom only a few (17%) ‘sometimes’ used health services. Ten participants reported maintaining the weight lost during TtPs and two (Milt and Lewis) continued to lose weight at follow-up. Information about participants’ sociodemographic profiles and health-related behaviours at baseline is provided in In line with the constructionist epistemology that underpins this research, the accounts shown in this study are a result of a process of interaction between participants and L.L.-S., who collected the data informing this study. The following paragraph, written in the first person by L.L.-S., shows how her own subjective experiences may have shaped this research.am a heterosexual female with an athletic body shape. My BMI is 20 kg/m2and I am a long-distance runner. I am White, middle-class and from Spain, so English is not my mother tongue. I was 28 years old at the time of data collection. I believe that my gender, nationality, body shape and age influenced my interactions with participants, the information they shared with me and their engagement in this research. For example, participants did not talk about intimacy with me, even though male authors found that sexual frequency increases among men post weight loss.20Furthermore, due to a limited linguistic and cultural understanding, I was unable to participate in gendered talk such as jokes and banter. To overshadow this limitation, I engaged and excelled at other gendered social practices during the sessions, such as football and some exercises such as push-ups, where I tried to achieve the highest number of repetitions within the group. According to Alexander et al.,21banter is integral to social cohesion among British males, and it allows men to bond with each other. It also helps facilitate discussions of sensitive topics such as weight and health.11For these reasons, I had to find other acceptable ways of building trust and rapport with participants, such as showing a caring attitude, giving them information about myself and my country when requested , and making sure I participated in the activities when they invited me to do so, instead of intruding at times when I may not have been welcomed.In total, five men used visuals to support their talk. Conan took two photos about food; Milt brought 10 photos to the interview, about the weather, exercise, snacks at work, illness and Do It Yourself (DIY) activities; Abraham provided 14 photos, all of them about food; Ralph brought photographs of his car, his grandchildren and the hospital; and Lewis was the only participant bringing photographs to the interview that would enable him to compare his lifestyle pre TtPs with the behaviours he engaged in during weight loss maintenance. The most common reasons participants gave to explain their lack of participation in photo-elicitation included: (1) a preference to rely on verbal accounts, (2) the extra perceived burden of taking photographs, and (3) lack of confidence using this methodology. Findings from verbal and visual data can be categorized in four key themes: (1) ‘Small’ changes, (2) Informed decisions, (3) Monitoring of behaviours and (4) Dealing with ambivalence.Participants stressed the importance of adopting small lifestyle changes for long-term weight loss maintenance, and they developed their own strategies to fit in PA and healthy eating within their daily lives and identities. These strategies related to the introduction of active ways of living and the consumption of healthier foods.While increasing daily PA can be difficult for people with multiple commitments (e.g. work and family), participants used strategies to increase PA without this compromising other commitments. For example, some participants reduced their sedentary behaviours by introducing active ways of doing activities that are typically sedentary, such as TV watching and reading. In some instances, these changes resulted from a process of transferring lessons from TtPs into creative responses in daily life. Lewis:Extra work equals extra benefits, so I’ve got my own stretch bands, so I can do some of the exercises that we did with [lifestyle coach]. And me exercise bike, which lives in the conservatory […]Researcher:Did you have this before TtPs?Lewis:I had that yeah, and it was used as a clothes horse. Basically, [wife] used it to dry the washing on it, because that’s all the use it ever got.Researcher:When did you start to use it?Lewis:I started to use it probably after a month, when I had been here [TtPs] for about four weeks, and I was beginning to get used to the level of physical activity and I was seeing some benefits from losing weight as well, and I thought, well, why not, give it a go […] so I am there and my wife is here [pointing at the photograph of the bike], and we can still have a conversation, still watch the TV and get generally warm, a bit of sweat on and then go and have a shower and exercise done.By suggesting ‘we can still have a conversation, still watch the TV’, Lewis is implying that the incorporation of more active ways of living in his daily routine is only an addition to what he used to do, not a disruption. Other small lifestyle changes some men introduced in their daily lives to increase their PA levels included, for example, walking instead of driving. These changes brought about several benefits beyond increased PA levels and fitness, such as saving money:Researcher:Do you have any examples of the things that you do now that you didn’t do before?Charles:So if I am going into town then I won’t park in the middle, I’d park at a cheap car park that is further into town and walk into town and I wouldn’t get the lift or the escalators, I would take the stairs. I walk to football if I go to the stadium, even though is 45 min walk. It’s probably just as long in the car with all the traffic, so I’d take that, I’d rather walk again just listen to my music and so it saves money, it’s a better exercise.Besides reducing sedentary time and increasing PA at home, Lewis also talked about having active breaks during work. After showing the following photographs  to illusLewis:That’s me coach potato [laughs] so I am not sat there watching the TV anymore, and now I’ve got me walking shoes. I spend a lot of time in those […] I don’t just kind of walk around the home. I took the opportunity when I’ve been out and I’ve been working, in my lunch hour, I’ll maybe get my rucksack, and I’ll get my bag, pop me sandwiches in the bag, change into my walking shoes, park the car and maybe walk 25-30 min up the hills, sit down up the hills, have my lunch, and walk back down. So it’s a break in the day, it breaks the day up for me, and it gives me that added bit of boost.I got into a routine where I was eating quite a lot. I had quite big plates. But now my portion sizes are similar to probably one of my kids, to be honest […] The hardest part for me was leaving food, if I felt full. I was always brought up I had to eat the whole plate, and I got into that routine. I’d eat my plate, and if the kids left theirs, I’d eat theirs. But now, if I am full, I’ll stop, I’d actually leave food. That was a difficult lifestyle change I made, because I don’t like seeing waste, so I wanted to finish it.Participants adhered to healthy eating habits during weight loss maintenance. This process was not always straightforward, and involved breaking with some ‘bad habits’, as Malcolm explained:Before coming to [TtPs], on a Saturday night, I used to make a curry and rice, and we’d eat all of it. But now probably because of TtPs we cook the same amount, we eat probably half of it, and save the rest.Arguably, during the intervention, men like Malcolm learned to bring overeating back into consciousness, and reflected upon their unconscious tendency to ‘eat the whole plate’. Echoing this point, and showing a picture of one of the meals he made , AbrahamBeing consciously aware of ‘how much’ extra food was being eaten not always resulted in an increased self-control of eating behaviours. In many cases, structural changes were needed, as explained by Milt:Researcher:Do you think you have control over your intake?Milt:I think if you gave me a big table full of food, there’s a bit of a programme on me that would eat that, that could eat that, so the only thing is I’ve gotta find ways of not doing that, like using a smaller spoon, slowing down the eating, things like that.down, instead of cutting off, the pleasurable unhealthy foods they still enjoyed:From this, it appears that mindful regulation of food intake was difficult for participants. Hence, Milt changed his food environment to more effortlessly manipulate his consumption in a less disciplined way, which facilitated his adherence to weight loss maintenance. Some men also talked about cutting Researcher:Does your diet now differ from what it was before coming to TtPs?Ralph:Yes. I would say I am eating healthier than I was. I am not saying it’s perfectly healthy, but I would say it’s a lot more of a healthy diet than it was. And especially lately, I’ve gone back into the salads again, and I am quite enjoying the salads. But my favourite has always been chips, and that’s been my downfall, these chips. I mean I can eat them no matter where I go, it doesn’t matter. But I do try now to not have them like three or four times a week, in fact to be honest with you, I may be lucky if I get them once a week these days.This is my best friend, the fella that comes shopping with me, and he makes a big difference to what goes in the basket. So I read labels now, I drive my wife mad, ‘What are you doing, just put it down!’ ‘No, no, hang on a minute, I just need to have a look! No we don’t want that one, we want this one’. But yeah, I am very conscious about what to buy and what I put in the basket and what we shop for […] I look at the low content, I look at the low one, trying to look at the green one if I can. If it’s in the red, then I don’t buy it at all. If it’s in the yellow, it is acceptable. But my preferred choice would be to go through the green, always.In this study, some men used the simple and tailored supportive materials they were given during TtPs. These resources facilitated men’s attempts to become active agents in their health choices. Many of the weight loss maintainers referred to a traffic light shopping guide that was delivered to them during TtPs. This tool provided flexible guidance for food choices, and it was central to men’s sense of autonomy when making decisions about what to buy. Lewis took a photograph of it  and descgood foods, whereas he avoids foods that are in the red column, because they are bad. This easy-to-do evaluation of the goodness of different types of food helped participants transform complex data into meaningful information. As a result, the cognitive effort required to make healthy choices was lowered, and the simplicity of approach like this may contribute to maintaining long-term health behaviours.For Lewis, foods that fit in the green column are Participants used different approaches to keep track of their progress towards their health-related goal(s). Some of these included using mobile apps, spreadsheets, self-monitoring of weight and experiential feelings, particularly with clothes. ‘Visualizing’ and ‘feeling’ weight changes enabled the men to bring habitual behaviour into conscious awareness, and these became key mechanisms of self-surveillance. For example, Conan talked about a spreadsheet, which he designed to monitor his weight loss/gain across time:Conan:I keep a tab of how often I’ve been to the gym, what exercises I’ve done, what I’ve achieved, that sort of thing. I keep a sort of record in my book and on a spreadsheet.By deliberately self-recording his weight over time, Conan portrays a type of self-regulation style that could help him control his weight. Although other men did not record their weight as thoroughly as Conan, they became more aware of experiential cues such as assessing the tightness of their clothes. These cues were less premeditated than self-monitoring, but still provided relevant information. Milt demonstrated such a self-regulatory approach:Researcher:Do you have any specific targets in terms of weight loss?Milt:Yeah. The trousers I’ve got on now are size 40, up until a few years ago I was in a 38, and I’ve been able to tighten the belt for the last few months, and I am almost where I can get to a size 38. So I think I wanna be able to get into a size 38, I mean once I get there obviously the next goal. But I heard somewhere, for a man, if you are a 40 inch waist you are much more likely to get diabetes […] So that’s probably, that’s my ultimate aim. It’s like each Monday when I put my work pants on, it’s like, are they tight, or are they comfortable?good according to a medicalized regime of self-control, and the men’s personal health needs. In this process, men became reflexive subjects who were ‘willing to undertake self-reform but at the same time rationally manage the experiential conflicts produced by that reform’ (p. 231).22 In this context, the consumption of the occasional treat was normalized, as explained by Matthew:I’ve noticed it myself really, I do like to for four to five days eating healthy, pasta, chicken, broccoli, etcetera, I just need that sugar rush in me, because I’ve not had it for a bit. But as soon as I’ve had that sugar rush, I can’t stop, and that’s when… one and a half days, two days, I think, I need to stop. I need to get to that gym and get it all out of me, then I’ll carry on eating healthy, etcetera, and then I may go to 5 days, 6 days, and then I need another boost of sugar.Dealing with ambivalence involved men making decisions between what is thought to be Additionally, Liam, whose wife had a stroke a few weeks before the interview, mentioned drinking as a coping strategy. However, he realized that he was not ‘going anywhere’, and he planned to reduce his alcohol consumption to a limited number of days:Liam:I don’t think I will ever say I will never drink again. Because there are occasions when it’s social and I enjoy it. So, I think my target would be to increase alcohol-free days […] Like not touch alcohol Monday, Tuesday, Wednesday and Thursday, but you can go out for a couple of pints Friday and maybe one on Saturday. So you are actually reducing your units, but not denying yourself the complete pleasure.Others learned how to compensate for unhealthy behaviours: for example, Abraham adjusted his health behaviours as follows:Researcher:What did you do last week that you think has helped you to lose one kilo?Abraham:Nothing out of the ordinary really; I just carried on with the same regime. And I am quite happy this is working, I don’t, I’ve not, I mean say we went to a wedding and that: ‘Oh God, I did knock a few back there and I had a big meal’, you know what I mean? But I thought: ‘Well, I’ll get it off when I get back’, you know? That type of thing. ‘Coz you don’t want to go backwards, you know, you’ve got that goal when you do set your mind to it.Some men were able to make ‘personal assessments of risk’, meaning that instead of conforming to a medicalized regime of self-control, which depicts those who do not conform to its logic as ‘ignorant’, ‘apathetic’ and ‘lacking self-efficacy’; participants (un)consciously transgressed biomedical interdictions by enacting independence and autonomy:Researcher:Did you learn anything in TtPs about fizzy drinks?Abraham:Oh yeah, I understand what they are saying, I accept everything what they are saying but I don’t know, I seem to want to break the rules if you know what I mean, because I don’t want to go down such a path where I think people’s got getting to a situation where they say: ‘Oh I would love to eat that but I can’t’. You know I shouldn’t eat that. I am not going down that avenue. I don’t want to do that, if I want to eat it I’ll eat it.I used to go and buy a packet of biscuits, I would just sit there in front of the TV and eat the biscuits and eat lots of them. But now I’ve got a biscuit barrel and I say to her [girlfriend]: ‘Take three biscuits out of the barrel, have them with a cup of tea, and then that’s it’. And the barrel stays there in the kitchen, and it’s easier, a pack of biscuits lasts two weeks now, whereas before lasted two days at the most.Despite coming across as transgressive, this does not mean that Abraham was careless about his health. For him, subordination to a medicalized regime of external control, which did not account for his personal needs, undermined his self-control and was alienating. As a result, he developed his own mechanisms of self-control, as this approach was more aligned with his identity. Charles also talked about deploying portion control strategies as a way to behaviour change:17 of weight loss maintenance. In doing this, this study shows how men incorporate behavioural changes into their lives and accounts for the cognitive, emotional and contextual influences on weight loss maintenance.3The uniqueness of this study lies in its capacity to understand the behaviours that men engage in to maintain weight loss after completing a weight loss intervention. This knowledge matters because men have been unfairly underrepresented in this area of research. Besides the sample being unique, the use of visual methods in this study is also innovative in an area where most qualitative studies have privileged verbally transmitted knowledge. The combination of interviews with photo-elicitation methods enabled some participants to better express themselves and illustrate resources for engaging in long-term behaviour change, thus allowing for the emergence of ‘localized understandings’ (p. 685)3 and, unsurprisingly, often fail.8 The findings of this study have highlighted the different types of behaviour change strategies that are feasible for men to apply in the context of their lives to sustain weight loss after attending a weight loss intervention and include: maintaining small changes that do not disrupt with the normal course of their lives; using simple tools to guide their decisions about diet; developing own strategies to control portion sizes; and monitoring of behaviours and having a healthy lifestyle while still accounting for their own personal needs. This information can be used by policy makers and practitioners to design and implement interventions that are not only successful but also sustainable in the long term, even post intervention.The knowledge generated in this study has important implications for practice, as it can be used to support the development of effective weight loss interventions for men. This includes both the design of interventions to help men lose weight and the implementation of strategies to help men maintain weight loss in the long term. This is important because most intervention approaches to maintenance replicate those used for initial weight loss23 men also have a degree of expertise comparable to women when it comes to weight loss maintenance. Participants in this study showed an ability to make rational and informed decisions about their behaviours, which favourably contributed to weight loss maintenance. However, instead of adhering to a medicalized regime of self-control, many men talked about the strategies they had developed to be healthy in a way that was aligned with their identities. This is a new insight in the literature on weight loss maintenance and suggests that men can and do change their behaviours during a weight loss intervention, but the successful maintenance of these internalized behavioural regulations are more likely to occur when these changes are in harmony with the normal development of their lives. Instead of internalizing neoliberal constructions of the responsible healthy citizen, men in this study prioritized their own identities over other societal pressures.24This study adds new insights to the literature on masculinities and health. It suggests that, far from being unconcerned about their health, men who attended a weight loss intervention rely on a complex web of skills to maintain healthy lifestyles. While it has been suggested that women are the ‘experts’ in the feminized realm of dieting – a feminine activity that is about looking slim and pretty, linked to vanity,8 these findings provide a reflection of modern society. It is interesting to note how the findings from this study differ from studies on weight loss dominated by, or exclusively focused on, female samples. Many of these studies report participants feeling a tension between the obese past and the present day and used negative words like ‘battle’ to refer to their weight loss maintenance efforts.8 Additionally, in relation to diets, previous studies have found that sustaining diets was experienced as a state of ‘effortful vigilance, requiring considerable personal strength and commitment’,25 but again these were dominated by female samples. However, there seems to be a different type of societal pressure on women’s bodies compared to men’s, which inevitably influences how women and men experience weight loss and weight loss maintenance. Men in this study did not use those war-like, negatively framed words and moral overtones when discussing behaviour change. For them, flexibility and enjoyment were the key to success.Given that discussions on obesity, dieting and weight loss are related to our ideas about beauty, normality and acceptable behaviour,While this study makes a significant and original contribution to the literature on weight loss maintenance, it is important to highlight some cautionary notes when interpreting these results. Most of the theory used to underpin our understanding of participants’ experiences of weight loss maintenance draws on psychological understandings of health behaviours. While we do not see this as a limitation, we believe that understanding the complexity of human life is perhaps out of reach of psychologically orientated approaches. Thus, there remains a need to draw on sociological thought, in particular with regard to health practices to understand how men are able to negotiate and navigate through the sociocultural health world. This could help understand why interventions like TtPs help some men at certain times of their lives, but not others.26 Some of the reasons mentioned by some participants for not providing photographs also suggest that clear instructions and appropriate support is required when undertaking qualitative studies using visual methods.Some lessons can also be learned from the use of photo-elicitation techniques with men in the area of weight management. In this study, only 5 out of 12 men used visuals to support their talk, meaning that most participants preferred to privilege verbally transmitted knowledge. This is, in itself, an important methodological finding, as it problematizes and challenges the idea that men are verbally inexpressive.27 future research should also investigate the impact behaviour change and weight loss may have on men’s identities. This call for future studies was already proposed nearly two decades ago by Sarlio-Lähteenkorva,8 but it is still an underexplored area.Given the homogeneity of the sample in terms of ethnicity and sexuality included in this study, future research should explore the experiences of weight loss and weight loss maintenance among other groups of men, such as gay men, men from ethnic minority groups, as well as the experiences of those men who do not complete interventions. Furthermore, since the body is a core part of the reflexive project of self-identity,Although more men than women are overweight or obese in the UK, and more likely to experience obesity-related comorbidities, current practice on weight loss interventions and weight loss maintenance is biased towards women’s needs. Furthermore, weight regain is common after participation in weight loss interventions, suggesting that the current obesity approaches are dissatisfactory in the long term. For these reasons, this study aimed to understand how men who attended a weight loss intervention incorporate intervention strategies within the context of their lives post-intervention.18 thematic analysis and Gleeson’s19 polytextual thematic analysis.Adopting a qualitative approach which drew on semi-structured interviews and participant-generated photo-elicitation, this study explored men’s health behaviours in the 6 months after attending a community-based men-only weight loss intervention. As observed in our study, the behavioural changes men implemented in the weight loss maintenance phase were aligned with their identities and fitted within the context of their lives. The ‘localized understandings’ of weight loss maintenance we have found in this study have been possible due to the use of innovative methods of data collection, such as participant-generated photo-elicitation and sophisticated methods of analysis, including a combination of Braun et al.’sAccording to the men interviewed, maintaining weight loss was a result of introducing changes that were small and fit within the contexts of their lives and identities, such as active living and healthy eating; being able to make informed decisions by using the information and tools provided and learned within the intervention; adopting different strategies to monitor their health behaviours and weight; and developing personal strategies to deal with ambivalence, by allowing themselves treats and compensating for unhealthy behaviours.Our research has shown the ways in which intervention strategies that support weight loss maintenance may differ from those that promote initial weight loss, particularly among men. Notably, interventions could promote long-term effectiveness if they account for the context of people’s lives, for example, by identifying and addressing the cognitive, emotional and contextual factors that influence people’s attempts to maintain weight loss. Additionally, our study has shown the complex web of skills men rely on to maintain healthy lifestyles. This knowledge may help policy makers and health practitioners to design and implement interventions that not only lead to successful and sustainable outcomes but could also help address the unique health needs of a population group that has traditionally been overlooked in this area of research and practice.


Polymedicated older patients are at greater risk of suffering from adverse events. For this reason, the detection of both inappropriate polypharmacy and polypharmacy-associated Drug-Related Problems (DRPs) are essential to improve the health and wellbeing of older adults and to reduce healthcare costs. This work aims to explore health professionals’ perceptions and opinions about polypharmacy and the handling of medicines by polymedicated older adults.Thirteen focus groups with 94 health professionals  were conducted in primary healthcare centers of the center region of Portugal. Participants were asked to discuss their perceptions and beliefs concerning DRPs in polymedicated older adults. The sessions were audiotaped. After the transcription and coding of focus group sessions, a thematic analysis was done.The following four main themes emerged from the 13 focus group sessions: poor compliance and polypharmacy- A perpetuated vicious cycle, organization of the healthcare system, interaction and communication between the health professionals, and strategies to prevent inappropriate polypharmacy.The lack of both an efficient network of information and Interaction and communication between Health professionals makes the detection and/ or prevention of polypharmacy in older adults difficult. The implementation of new models to manage and/or prevent polypharmacy based on health professional perception and beliefs is essential to prevent DRPs and improve compliance among older adults.The online version contains supplementary material available at 10.1186/s12877-020-01972-3. The world population is aging, and it is expectable that by 2050 one in six people will be over the age of 65 . Age-relensure healthy lives and promote well-being for all at all ages” [United Nations defined as a worldwide priority “ll ages” , 5.According to a recent study, although being one of the most aged countries in the world, only 9% of the Portuguese older adults were considered healthy and, almost 50% of them had difficulty complying with their medication regime , 7.In the last decade, the studies on Drug-Related Problems (DRPs) have focused on medication errors committed by HPs and attributed medication errors to mistakes in prescribing, preparation, or dispensing . To our FG studies can be a valuable tool because they allow the identification of all dimensions of a problem, even those that are unexpected , 10. AccThis study provides valuable data for the implementation of a new healthcare model of polypharmacy management in primary healthcare systems.An exploratory qualitative study using an FG approach was designed to explore the perception of primary care HP, community pharmacist (CP), general practitioner (GP), and nurses about polypharmacy in older patients. It was asked the collaboration of healthcare center directors to participate in the study collaborating in the invitation of HPs. FG sessions were moderated by a PharmD/ Ph.D. researcher (FR), following a guide based on a systematic review study and drawn up by a group of experts in pharmacology and epidemiology  and encompassing a total of 40,835 registered older patients (age ≥ 65 years).For each FG session were invited at least 2 CP, 2 nurses, and 2 GP. FG sessions were conducted from May to October 2018 and lasted for 60–90 min. They were carried out until saturation of information was reached on the research questions. Before the beginning of each session, the moderator reminded the participants of the study goals and the fact that audio records were being made of the sessions. The moderator ensured the participants that the content matter would remain confidential at all times and that the data would be processed without the identification of participants. All participants signed an informed consent form before participation. The participation of the HPs was voluntary, without any incentives.a method for identifying, analyzing and reporting patterns (themes) within data”. “It minimally organizes and describes data set in (rich) detail” [. In a first approach, and to allow a better understanding of the content of FG all the transcripts were read multiple times by two researchers. After that, initial codes were generated and grouped into themes. Then themes were revised, and data interpreted and discussed by the team, before emerging the overarching concepts. NVivo qualitative data analysis software  was used to help with the organization and analysis of the data.All the sessions were transcribed and coded by a researcher (AIP). Each session was codified with the acronym FG followed by an alphanumeric character. The participants of each session were also codified with the acronym of their FG followed by the acronym CP for community pharmacists, GP for general practitioner, or N for nurses and an alphanumeric character (e.g. FG1CP1). To guarantee trustworthiness, one month after the last hearing, the tape was listened, once again, and the transcription content was revised. A thematic analysis was done, following the methodology described by . Braun a detail” . In a fiOverall, 13 FG were conducted with a total of 94 HPs enrolled (40 GP 20 CP and 34 nurses). The sociodemographic characteristics of the participants are summarized in Table Qualitative analysis resulted in four major themes: “poor compliance and polypharmacy- A perpetuated vicious cycle”, organization of the healthcare system, interaction and communication between health professionals, and strategies to prevent inappropriate polypharmacy Table .Table 2The presence of multiple comorbidities is a normal consequence of ageing and for this reason polypharmacy in older patients is common practice”, FG5GP1.“According to HPs, aged-related comorbidities prone older adults to multiple prescriptions, and, for this reason, polypharmacy is an unavoidable consequence of aging.“Polypharmacy leads to poor compliance and the poor compliance conduce to polypharmacy …. Because if they do not adhere to a therapeutic regime … we prescribe for one situation, after that for another problem”, FG13GP1.HPs also perceive that polypharmacy and poor compliance are two faces of the same coin, because polymedicated older adults have difficulties to comply with the therapeutic regime, hampering the achievement of clinical outcomes and leading GPs to prescribe one more medicine.“Polypharmacy is closely related to literacy”, FG11GP1.Because older adults value medicines and admit that they are essential to promote wellbeing, HPs believe that most of the time, medication errors are unwitting and committed due to the lack of knowledge of older adults.“The problem of polypharmacy is the loneliness of the older adults that do not have any young familiar near to help” FG2CP2.From this point of view, lack of literacy, sociocultural factors, such as the absence of family and/or relatives to take care and help with the management of medicines are the main contributors to medication errors.“One older woman brought to the healthcare center, both their medicines and the medicines of their husbands because they do not recognize their pills”, FG6N3.“There are several generic medicines for the same active substance (from different holders) and older patients identify the medicines by the color of the tablet … /if a doctor prescribes to him another medicine or deprescribes a medicine if they have the pill at home, they will continue to take it”, FG1CP1.During their daily routine, HPs perceived that because older patients recognize medicines by the color and/or shape of the pill, duplication mistakes, mainly due to generic medicines confusion, or taking medicines, which belong to others, can easily happen.“After an emergence visit, we frequently observed that older patients, come to the pharmacy with a specific medicine, and at a certain point they do not know if they should stop or not take that medicine, and for this reason, they continue taking it” FG1CP1.During FG sessions, it was also perceived that older adults have some difficulties to understand the duration of treatments, and for this reason, they tend to prolong the treatments for more time than is recommended by the GP. These mistakes are frequently detected in medicines prescribed for an acute episode that requires an emergency room visit.“There is a lot of confusion, for example, inhalators, they have difficulties, the device has a counter but they don’t know, and sometimes they arrive at the pharmacy and told us that the inhaler is empty but is new, they do not use it”, FG2CP1.According to HPs, difficulties related to the use of some medicines, such as inhalators, can influence the efficacy of treatments.They are easily influenced by their neighbors, which say: I took this pill and I am feeling very well” FG3GP1.“Hide a lot of information, sometimes there is no medical prescription, it was a recommendation of the neighbors” FG1CP1.“Several patients buy on TV calcium pills” FG1FGP1.According to HPs, the desire of older adults to achieve wellbeing makes them easily influenced by the neighbors or even by television commercials, potentiating the consumption of over-the-counter (OTC) drugs, supplements, or even herbal products. These substances besides interfering with chronic medication might be contraindicated for their health problems.Sometimes some patients complain that they take more medication than food”, FG1CP1.“HPs believe that polypharmacy per se is a contributor to poor compliance because older adults take so many medicines that they easily withdraw some that they believe to be less important.“Polymedicated patients always try to remove one or another pill that they believe does not affect”, FG3GP1.“If someone refers to the side effects of statin, patients automatically stop taking”, FG8GP1.According to HPs perception, the huge number of pills throughout the day prompts older adults to skip a dose, to give up some medicines that they undervalue, or that they believe might cause adverse effects.“Deprescribing some medicines it was almost impossible, for example, trimetazidine is very, very hard”, FG3GP1.If I want to deprescribe pills that the patient is taking to 30 or 25 years, with which they felt good … we understand that it’s causing more harm than good … it is very difficult”, FG5GP2.“During their practice, GPs perceived that fake beliefs of older adults make the deprescription of medicines difficult.price of the medicines also contributes to poor adherence” FG1GP1.“The Another important compliance-influence factor that emerged during the FG discussions was the price of medicines.… a large number of older adults that take oral anticoagulants, the new ones that are more expensive, sometimes instead of taking two pills only take one” FG4GP3.“According to HPs, patients with economic problems, adjust the therapeutic regimen to spend less money.price of some medicines, namely insulin promotes the wastage of health resources because patients tend to open new insulin before the first finished, and put the older on the garbage” FG2CP1.“Low However, some HPs also pointed out that the Portuguese National Health System (NHS) is predominantly financed by taxes and some out-of-pocket payments that include co-payment for a wide range of services, though there are income-based exemptions population groups . Portuguese older adults with an average salary of 1.5 times below the value of the social support index are exempt from co-payment for any publicly provided services. For these reasons, some HPs affirms that sometimes the low price of medicines promotes the wastage of health resources.older adults do not report their specialist/ emergency room visits to the GP, for these reasons’ GP has difficulties in detecting this inappropriate polypharmacy” FG1GP5.“… “Teas herbal products and other blend beverages that patients buy here or there because of their health problems... One for the gallbladder, one another to the head, other to the kidney, and all of these substances have an active substance. All of them can cause drug interactions …. That we cannot control” FG5GP1.During FG sessions, it was perceived that the lack of communication between patients and physicians is not only an important polypharmacy-related factor but also an influencer of compliance. Because patients do not report to their GP either the specialist appointments that they had or the new prescriptions or other products that they take, inappropriate polypharmacy is harder to detect.HPs perceived that the organization of the healthcare centers doesn’t simplify the identification of DRPs. Within this theme, two subthemes emerged, i.e. “Medication management directives” and Clinical appointments.“The lack of centralization of chronic medication management is a problem, because we have many vulnerable older patients … , who have several physicians’ appointments, consequently to many prescribers, both in the public and private sector. These physicians have very great freedom to prescribe, which makes that the physician where all the information should converge, theoretical the GP, have difficulties in handling and evaluate all the prescribed medication …. And this then generates situations such as polypharmacy, adverse reaction, drug interaction”, FG1GP1.HPs believe that the lack of centralization of patients chronic medication compromises clinical outcomes and promotes duplication mistakes.must privilege the use of electronic means to support the processes of prescribing, dispensing and billing of all types of medicines, as well as health products” [. For this reason, the prescription and the treatment guide are sent by SMS (short message service) to the mobile phone. According to HPs, these directives make the empowerment of patients on medication management difficult.“I think, there is some pressure for physicians to stop printing the treatment guide …. The older population needs the guide treatment written in a paper”, FG5N1.“Into the older population that has a cell phone, some do not know how to use it, and when they want to see the treatment guide sometimes, they press the wrong button and once upon a time a treatment guide, they delete all”, FG5N2.NHS guidelines recommend that HPs “roducts” . For thiThe 15 minutes of clinic appointment turns out to be little to explore these issues”, FG13GP2.“According to HPs, the short time of the clinic appointments’ hampers not only the therapeutic review process but also the review of the handling of medicines by older adults..“It takes time to see all … and we do not have time” FG2GP5.HPs also refer that the lack of time during clinic appointments is an important polypharmacy-related factor that sometimes is undervaluedWithin this theme, two subthemes emerged, i.e. lack of time to communicate and external responsibilities.“… yesterday, a pharmacist called to tell me that a patient bought a statin different from what I had prescribed, I appreciate that”, FG4GP3.HPs believe that in some healthcare centers the interaction among HPs promotes the detection of DRPs.There are units that make protocols with local pharmacies … the problem is the lack of time” FG1GP1.““… must-have big management of medicines, and for this is necessary do therapeutic revisions and presently GP, perhaps because they lack time, they are not doing it”, FG2CP3.However, when managing patients’ therapeutics, this is not always a reality.we are obliged, and even if we were not, we always send complete information with the medication with everything, and then we never get the return”, FG4GP1.“… Sometimes happens patients are taking an active substance for hypertension prescribed by the GP, therefore prescribed by myself, in the meanwhile, for any reason they go to the emergency service and comes to the home with other hypertensive medicines from another chemical group, which must not be taken with the previously prescribed hypertensive. Because physician, that works at the emergency service, did not take the trouble to see the chronic medication of the patients, the patients take the pills”, FG10GP1.“In Portugal, primary healthcare centers are the gatekeeper of the NHS, so, whenever a patient needs a specialist appointment, the GP requests the appointment and sends all the clinical processes of the patients to the specialist. During FG sessions, it was perceived that it is hard to obtain the return information, suggesting that there is a lack of communication between GPs and the other physicians.“I do not feel comfortable to remove some medicines, a cardiologist appointment, patients expect eternity, so they go to a private clinic and, if I call the cardiologist, he will say if you want to remove the medicine do it, but is your responsibility”, FG10GP5.This lack of time to communicate becomes more demanding in circumstances such as the deprescribing process.If patients have, doubts are pharmacist faults …. They must explain well because they sell the medicines, they have all the material”, FG10GP3.The lack of time to communicate promote misunderstandings among HPs and they tend to assign responsibility to others. According to GPs, CPs are not doing their job because before selling a medicine they should ensure that patients know how to use the medicines.“What happens is that GP does not have the perspective of the price of medicines, and they prescribe medicine and, when the patient came to the pharmacy they ask us if we do not have a cheaper medicine, “I do not have money to buy this …” / we are not changing the therapeutic, we are first helping the patients” FG10CP2.GPs also affirm that some duplication mistakes occur, because CPs replace the original medicines, which they prescribed, with generic medicines. On the other hand, CPs feel undervalued by physicians who tend to forget their role and the fact that their proximity to older patients makes them know patients’ needs better. Moreover, CPs affirm that when selling a generic medicine, they do it responsibly and because they know the economic context of the patient.“All the prescription must have to be authorized and validated by the GP, that managing and planning the health of the patient”, FG1GP1.According to HPs, polypharmacy could be reduced if GPs were able to act as the manager of all prescriptions, i.e. GP should have the opportunity to validate/ or not a prescription, prescribed by other physicians, before the dispensing.During FG sessions it was perceived that HPs admitted that the introduction of the.“If the PEM allows the update of chronic medication and if pharmacists could access the PEM, the pharmacist can make the renewal of the chronic medication and, this in turn, relieve the burden that physicians have in terms of patient appointment” FG1GP1.Electronic prescription of medicines (PEM) promotes the managing of medicines; however, this platform had some gaps that make the detection of DRPs a hard task. GPs affirmed that when using PEM, they find difficulties in updating chronic medication. They also believed that all HPs should have access to this platform. HPs believe that the limited access of PEM to the nurses hampers their role in DRPs detection. Moreover, CPs could also have a more active role in DRPs detection, if they could access PEM. CPs could relieve the burden of primary healthcare centers in terms of time and duration of clinical appointments, through the opportunity to renew the chronic medication.To avoid DRPs related to duplication of medicines, HPs suggested that the pharmaceutical industry should agree to standardize the boxes of medicines and even, if possible, the color and form of pills by active substance.“The boxes of the same active principle should have the same color …” FG1GP2.“the pills should also be standardized in terms of shape and color, FG1N1.“The ideal would be to have a support team not only to make the dressings and emergencies but also to visit the needy patients that live alone. Older adults often do things on their way because they don’t want to ask for help and they don’t have support either... The support would be to try to understand if the medication is being well managed”, FG5N1.“The user comes to the health center, takes the prescription I can even know if he raised the boxes in the pharmacy, but on the home visit, I can find a warehouse of boxes of medicines”, FG5GP1.“Promote health literacy”, FG3GP2.“The awareness campaigns could be a good help to patients and healthcare professionals”, FG5N1.Lastly, health professionals believe that to decrease DRPs it is essential to support, empower the patients and promote health literacy.Worldwide, one of the consequences of the demographic trends in ageing was the increasing number of ageing-related comorbidities. Because of that, the implementation of new models to deal with the consequences of polypharmacy is fundamental not only to ensure the welfare of the older population but also to guarantee the efficacy of healthcare systems. From this point of view, understanding HPs perceptions and beliefs is fundamental.To our knowledge, this is the first FG study that encompasses a multidisciplinary team of HPs , who daily take care of polymedicated older adults, to explore their perception and opinions regarding polypharmacy-associated DRPs in older adults.HPs believe that the economic/ social context of older adults influences their behavior, and, in cases of low literacy, low mensal incomes, and lowliness, it can trigger the occurrence of DRPs. The short time of clinical appointments, the lack of time to communicate and network between all HPs, the poor communication between HPs and patients were identified as the main gaps in the healthcare system that difficult for both the managing of polypharmacy and the detection of DRPs. The decrease of the gaps mentioned above and the empowerment of polymedicated older adults can have positive effects on patient health outcomes through the improvement of compliance and the reduction of DRPs.During FGs sessions, we perceived that overall; the different HPs have complementary and frequently similar answers. However, HPs tend to assign responsibilities to other HPs, CPs affirm that GPs are not doing their work on the therapeutic review, and GPs believe that CPs are not due to their work on counselling patients. CPs also affirm that they do their best the managing their patients, and they make an effort to manage each patient according to patients’ socio-economic reality and argue that GPs do not value their work.Due to the overload of the Portuguese NHS, patients wait months or even years for a specialist appointment. This waiting time together with the overwhelmed that Portuguese physicians’ feelings are, according to our perception, the main reasons for the inappropriate communication between physicians and a source of misunderstanding. This situation becomes more demanding because, in some situations, patients instead of waiting for a specialist appointment opt to go to a private clinic and, they do not report these appointments to GP.Our study participants consider that the presence of multiple comorbidities associated with the fact that the guidelines are based on single chronic diseases makes polypharmacy a recurrent issue among older adults. Moen et al.  reportedSafran et al.  reportedWe believe that the development of health policies directed to polypharmacy as well as the implementation of computerized clinical decision support systems  will notThis study has some limitations linked to the chosen methodology. FG participants were invited/ selected by healthcare center directors, the results cannot be generalized to the whole population, timid participants have more difficulty to share their perceptions, and participants may follow the general trend to give similar answers. This methodology’s generalizability is best judged in both exploring the perception of the participants and to favor the arising of a new topic . This mePortuguese GPs feel overwhelmed and for this reason, they do not have time to revise the therapeutic of their patients. To minimize DRPs-associated polypharmacy in older adults, GPs, nurses, and CPs should interact to facilitate the therapeutic review. The strengthening of communication among HPs, between HPs and patients and the improvement of literacy of older adults regarding the managing of their medicines is essential to enhance health outcomes among polymedicated older adults.In 2018, our group initiated the MEdElderly project to improve drug managing among the older population of Portugal’s center region. The results of this FG study were useful to design an educational intervention that aims to address the main DRPs observed in older adults, demystify false beliefs and promote the correct management of medicines.Additional file 1.


Although cash transfers (CT) are hypothesized to reduce AGYW’s HIV risk, little is known about the mechanisms through which CT empower AGYW. We explored the impact of a CT intervention on AGYW’s sexual decision-making in order to describe the pathways through which the cash may influence risk behavior. The study employed qualitative methods involving: 20 longitudinal in-depth interviews (IDIs), 40 cross-sectional IDIs, 20 narrative IDIs, and two focus group discussions with AGYW ages 15–23 participating in a CT intervention. AGYW’s conceptualized empowerment as: “independence”, “hope and aspiration”. Potential pathways through which CT empowered AGYW were: economic, hope and aspiration for a better future, and access to knowledge. As a result of this empowerment, AGYW reported reductions in transactional sex, experiences of intimate partner violence, and risky-sexual behaviour. A sense of responsibility developed through economic empowerment, enhanced participants’ self-esteem and confidence in decision-making leading to changes in AGYW’s sexual risk behaviors. Adolescent girls and young women (AGYW) in sub-Saharan Africa make up 10% of the total population, yet they account for 25% of the new HIV infections –5. SpeciAlthough there has been some progress towards addressing economic vulnerabilities and gender inequalities in Tanzania, many AGYW still live in poverty and have limited decision-making power in their households and sexual relationships , 10. ResCash transfers (CT) are encouraged as an intervention that may empower women to make their own decisions and support themselves financially . They arSauti project. The Sauti project is one of the implementers of the Determined, Resilient, Empowered, AIDS free, Mentored and Safe (DREAMS) initiative package, a PEPFAR-funded program that combines biomedical, behavioral, and structural interventions to reduce new HIV infections among vulnerable populations. We specifically recruited participants who were recipients of one of the Sauti project’s structural interventions, a combined CT and economic empowerment program. This intervention aimed to reduce economic vulnerability among AGYW by enabling them to reduce sexual risk behaviours such as transactional sex, age-disparate sex, concurrent partnerships, and inconsistent condom use.This qualitative study was conducted with AGYW enrolled in the Sauti project. The economic empowerment intervention that accompanied the CT, called WORTH+, included financial literacy education, individual and group savings and loan, and entrepreneurship skills training such as soap making. WORTH+ groups were led by a trusted mentor and met on a weekly basis. In order to receive CT, participants were also required to attend 10 h of behavior change communication (BCC) sessions led by trained peers and designed to address the major determinants of HIV risk, gender-based violence, and reproductive health. The BCC package provided education on HIV and other STI prevention, gender-based violence prevention, family planning, condom use, negotiation skills, self-efficacy/agency skills, and promoted health-seeking behaviors.CT of Tanzanian shillings (TZS) 70,000 (~ USD 31) were provided to program participants every three months over an 18-month period. Cash was delivered via SIM cards on mobile phones, both provided by To be eligible for the CT, participants had to be: female; between the ages of 15 and 23; resident of the intervention villages; out of school; completed BCC sessions; and, willing and able to give voluntary, informed consent/assent to all study procedures including HIV and HSV-2 testing and receipts of test result. Participants under 18 years of age required the consent of a guardian unless they met criteria for emancipated minors .Sauti project sites in the Shinyanga region of Northwest Tanzania, including Bulungwa, Kahama, and Shinyanga municipal. Shinyanga is a primarily agricultural area and is among the poorest regions of Tanzania. We used a multi-methods qualitative approach that included longitudinal in-depth interviews (n = 20), cross sectional in-depth interviews (n = 40), and narrative timeline interviews (n = 20).We recruited participants (n = 80) from We conducted longitudinal interviews (n = 20) to examine patterns of CT use and their impact over a 1-year period. Participants were interviewed in June 2017 just after the first round of CT, then again in June 2018 after they had received three or more payments. All longitudinal interviews were conducted with participants from Shinyanga municipal, since initial CT had only reached this area by June 2017.We conducted additional cross-sectional interviews (n = 40) in June 2018 in all three recruitment areas with AGYW who had received three or more payments. Interviews broadly assessed how participants spent their CT, to whom they disclosed cash receipt, how those people reacted to the program and any advice they provided, and how this cash may have impacted their relationships. Towards the end of our research, we conducted a community-engaged activity where AGYW (n = 10) who had participated in the CT intervention joined three participatory focus group discussions (FGD) involving reflection on benefits and drawbacks on the CT intervention, with a direct focus on empowerment.Finally, we conducted narrative timeline interviews with women n = 20) in all three recruitment areas. Narrative timeline interviews are a participatory research method wherein participants develop visual timelines depicting relationships over a specified amount of time. Timelines have been used as a tool to provide more in-depth discussion of relationship qualities, as well as to allow for comparisons of relationships across time , 20. In  in all tSauti project and near the homes of some participants. All interviews and FGDs were audio recorded, transcribed verbatim in Kiswahili, and translated by trained research assistants. Participants were compensated TZS 5000 (~ USD 2) for transportation costs to the interview. We obtained ethical approval from the institutional review boards (IRBs) of The University of North Carolina and the National Institute for Medical Research in Tanzania. Informed consent was obtained prior to any interview or FGD.All interviews and FGDs were conducted in Kiswahili by trained female research assistants. Individual interviews and FGDs were conducted in private locations at the civil society organizations implementing the All interviews and FGDs were transcribed verbatim in Kiswahili, and then translated into English. Interview and FGD transcripts were reviewed for quality of transcription and translation. Six researchers coded transcripts using Dedoose, an online qualitative software. We applied thematic analysis to analyze data. For each interview type, one transcript was coded by all analysts, and then coding consistency was compared across analysts. Upon reaching consensus and modifying code definitions, transcripts were coded by multiple analysts. Approximately 20% of the remaining transcripts were quality checked for coding by another analyst. Analysts took notes on any discrepancies in coding found, and then resolved with the group in team meetings. After coding was complete, we used coded transcripts to create matrices summarizing major topical areas, including the impact of CT on relationships and sexual risk. We reviewed matrices to identify patterns within and across interviews.The results are structured in three broad themes: emic conceptualization of empowerment, levels of empowerment and their impact on AGYW’s lives, and pathways of empowerment.I can afford all I want”, “we depend on ourselves”, “look towards ourselves to sort our financial issues”, “make our own decisions”, and “move from one point to another”. Expressions depicting empowerment as a state of being were: “self-reliant”, “self-aware” and “moved out of the box”.AGYW described empowerment in varied but sometimes overlapping ways. These ranged from the act of doing or performing certain activities to a state of being. The majority of AGYW emphasized economic empowerment over sexual empowerment. They linked empowerment to affording material needs, a shift from depending on parents and/or sexual partners for material needs to depending on self, the ability to make decisions in sexual relationships, and having sex on AGYW’s terms. When conceptualizing empowerment as performing certain activities, AGYW used expressions such as: “If we say that we’ve been empowered… we’ve moved from dependency to independence… if you depended on a parent for even a small amount of money you would fail to get money for even needs like sanitary pads...but the coming of this organization has really empowered us by giving us this money and us starting these businesses…we now have our own money…We have that ability to be independent, to do what you want without depending on any one. (FGD)Despite such variation in their descriptions, AGYW consistently saw “dependency” in contrast to empowerment:The perception of girls has changed. The community disrespects those without jobs, the idlers. The CT has helped me…When I got that money, I entered into business. I am now busy with my business. So, other people [community] see that… I mean if you depend on yourself, the community wouldn’t disrespect you. AGYW reflected on the impact of empowerment at three levels: community, interpersonal (family and intimate relationships), and intrapersonal. At the community level, empowerment was linked to social standing and was demonstrated by ownership of property, ownership of other material things, and access to money. Not being able to meet one’s needs led to community disrespect; AGYW reflected on past experiences depending on others as de-humanizing. According to the majority of AGYW, the community disrespected people without a job but respected those with a source of income.Now if you have your own business the man must respect you, that my wife has got money. …Now that I have my money, even if the man doesn’t provide, you are able to take care of that. At the interpersonal level, CT seemed to have empowered AGYW economically and improved their interactions, both in families and in intimate relationships. Some married participants reported feeling exploited by their spouses prior to the CT, saying that some male partners previously refused to provide for the needs of their families even though they were the only ones in a position to do so. However, with the introduction of CT, this exploitation reduced. Since CT enabled women to contribute some income to the household, AGYW’s relationships with their spouses improved. AGYW further described how income from CT addressed their difficult economic situations, empowering them economically.On the issue of using a condom, it is now upon you to decide as we have now been empowered…you don’t depend on him anymore. Previously, they (men) would refuse to use a condom while you (girl) want to use it…he knows that even if you refuse to have sex, you will eventually go back to him with your problems (needs)…. He then reminds you, ‘I told you to do that thing (sex) but you refused’…Now it becomes like a revenge and it is upon you to agree or refuse…but now you know that you have your own business (income), you don’t depend on him for needs… So, if you tell him to use a condom and he refuses, you also refuse (to have sex with him). (FGD)Within the context of intimate relationships, the majority of AGYW (married and unmarried) talked about previously being unable to make decisions in sexual relationships, for fear of losing a partner and his economic support. They reported that they found it difficult to question their partners or suggest to use condoms, even in situations where they knew they were at risk. However, by participating in the CT, they felt empowered to make decisions such as using condoms, reducing number of partners, abstaining from sex, accessing HIV testing, and reducing their engagement in transactional sex. Reflecting on her confidence to negotiate for condom use, one participant stated:After the cash transfers our abilities have widened…we have received phones so we have been given the ability of becoming strong and confident., CT have also enabled us to believe in ourselves. (FGD)At the intrapersonal level, AGYW reported increased confidence, self-esteem, and reduced stress as a result of being able to provide for their economic needs. They mentioned that they felt confident about their voice in their families, were self-reliant, and were able to afford and own things they could not previously possess such as mobile phones:Most married women, such as myself, didn’t have a voice in our families. I didn’t even know how to stand up to a man or how to talk to him because I was afraid of him. But after this project, I am no longer afraid of him. If there is an issue we discuss. Further, describing how CT had given her a ‘voice’ and confidence to engage her partner in discussions, a married woman reported:Based on the themes that emerged on the impact of CT on the lives of AGYW, we developed a framework Fig.  that proFor example, you find that she needs a smart phone but she does not have the money to afford it…Previously, she would go to her partner and talk to him using nice words, so that she can get that money…but since we received money from the CT project and started small businesses and have been getting profit from it…that money multiplied…so now she can do anything that she desires to. (FGD)Regular access to cash and freedom to spend was something that AGYW valued. The majority of AGYW reported that, prior to the introduction of the CT intervention, they did not have access to regular cash and struggled to meet most of their needs. CT enabled them to purchase items they desired without depending on sexual partners.It was like I was balancing…I saw it was better to use a large amount of money on something valuable like a business, rather than playing with it…going to buy clothing or maybe you use it on luxury, like eating and drinking. Since they now had access to cash, AGYW discussed how they were now able to plan their expenditures and use money wisely on investments, rather than items like clothing. When asked how she made her decision to spend different amounts of CT on different things, an 18-year-old, single woman reported:Sauti project.This CT program has helped us. Apart from helping me and my husband it helps me at home. Life at home isn't bad now…Before, I was just a housewife, but the money and the entrepreneurial lessons from this programme like making soaps has helped us. AGYW reported that they increasingly participated in economic production as a result of the entrepreneurial skills (e.g. soap making) they had learned from the In the beginning I was depending on sex, but now I depend on myself…At first girls had about three to four partners. It is not that they loved them all…but it is just that they meet your needs …they (partners) give you little funds…if you need this or that they would give you…but when we received this money (CT funds), even these issues of relationships reduced…because you realize that even the money he gives you, you can also get it on your own. So, you decide to reduce the partners to just one. (FGD)Another key feature of empowerment observed in the narratives of AGYW was the mention of a shift from dependence on parents and/or partners to self-dependence. The majority of girls did not have their own income and thus were unable to meet their own personal basic needs. This led them to engage in sex, sometimes with multiple partners, some of whom they did not feel emotionally attracted to. Reflecting on their sexual lives, many AGYW talked about how prior to the introduction of CT they had multiple partners but have now reduced this to one partner because they can now meet their own economic needs.Now we are totally self-aware… we can work for ourselves and can look good on our own without depending on someone else…We are doing different activities…Even the community appreciates that this organization has greatly educated our daughters. (FGD)AGYW talked about self-awareness and having discovered their potential and ability to look good without depending on men.…Some of us never imagined we could become financially independent because we depended on men… But right now, my sister, I can’t hide it from you, right now I am with my business, I don’t depend on a man it really helps us. While expressing worry that the CT were soon coming to an end, married women described the independence that the CT program had brought to their lives by enabling them to take care of some of the family needs and not necessarily ask husbands for everything:Since I started receiving money my relationship with my partner has improved. Before the introduction of the CT, we were fighting because of my needs. We could fight when he has no money. I had a hard time before I started receiving that money. AGYW reported that depending on partners for their needs was stressful, and that financial empowerment through CT improved the quality of their relationships with their partners. AGYW attributed their experiences of increased respect, reduced spousal violence, reduced sexual harassment from sexual partners, and increased control in sexual relationships to their participation in the CT programme. Specifically, many married AGYW reported being respected and experiencing reduced spousal conflict after they started contributing to the economic functioning of the household.The reality is that it [CT programme] has given us the bravery to search/find because we have our capital and are searching/looking; we are doing businesses and are satisfying our small needs. They have given us the courage to run different businesses. (FGD)AGYW described feeling confident and believing in themselves. They reported being able to do what they could not usually do and had never imagined possible for themselves. They were able to spot and utilize opportunities available to them, and engaged in activities that were usually outside their imaginary domains.The good things about this project is that it has made things easier for me, so right now I am an entrepreneur…this is something good because before I didn't imagine myself having a business. One young woman talked about her experience and enhanced hope:Sauti Project, and were now able to save, lend, and borrow money at some interest.Honestly, I am grateful for this program, firstly I didn’t know how to save and borrow money, but now, I monitor myself, honestly, I was also dependent like my fellow here. After entering the CT, I got money and started rearing livestock. (FGD)Prior to the introduction of the CT and accompanying financial management training, most AGYW did not know the options available to them in terms of lending and borrowing money from existing structures in their communities. With the introduction of CT, many opted to join saving and lending groups that were managed by Eeh, many young women did not know the meaning of savings and economic issues. But they are now part of groups. They can both save and borrow money to start businesses or for other family needs (FGD)AGYW reported that they had realized the value of belonging to savings groups because they had a place to go back to in emergency situations.This income generation is helping me. I want to put more effort into it so that I can be successful, so that I can be able to have my own family, build my family and my home and have my good life…those are my dreams. Many AGYW described the way their hopes and aspirations for the future had been enhanced. They talked about the CT as a stepping stone to a much bigger business investment, a “good life” and a “good future.” Many aspired for financial independence, a big business, and having their own family and home. One 17-year-old adolescent girl reported:As indicated in the above excerpt, AGYW felt confident about reaching their goals in life. They expressed changed aspirations, from previously aspiring for very little things such as clothing to now aspiring for things they had never thought about such as owning land. As a result of the success they had in their business investments, AGYW aspired for a “good future”. Many talked about moving from one business to another with an intention of doing something that was profitable.When I joined the CT, I started a business and I was able to support myself with my needs. I can now buy my own body lotion, dresses and shoes because I generate profit from the business and my capital is always there… I have now reached my goals and only left with buying a piece of land. My plans are that from doing this business, I will buy a piece of land build a house of my choice in future. Doing my business, I believe I will buy land and then build a house of my choice… I have started paying for the land by installment. The decision to save was motivated by the desire to invest in the future. Savings goals included expanding business investments, increasing livestock holdings, purchasing a plot of land, and eventually building a house. One unmarried young woman described her plan for building savings towards personal goals:For example, through that behaviour change education that we received from the programme…we have been empowered to a large extent. For example, a person like me did not understand the meaning of gender violence…when I heard of gender violence, I assumed that this was only serious things such as a person being slaughtered. But I have now realized that even if a woman is beaten by her partner, that is also gender violence...because he has been cruel to her…he has abused her, he has spoiled her body. (FGD)AGYW reported that the CT intervention had empowered them through provision of education on safe sexual behaviour, recognizing violence in sexual relationships, and understanding the need for HIV testing.We’ve been empowered concerning our big disease (HIV). People are now getting tested; they are really volunteering to get tested than before. In the past it wasn’t that easy for one to tell the other to get tested but now people are getting tested in large numbers. (FGD)Describing the knowledge acquired on the importance of HIV testing, AGYW reported:We set out to explore AGYW’s understanding of empowerment, manifestations of empowerment, and pathways through which CT works to empower AGYW economically as well as in sexual decision-making. The three key defining elements of empowerment were access to cash, ability to be independent, and having future aspirations. Our results show that AGYW’s knowledge and understanding of empowerment very much revolved around financial independence, economic achievement, and decision-making in different spheres of their lives. The ways participants described empowerment resonated with the conventional definition of empowerment, which lays emphasis on independence and autonomy , 22.Economic empowerment was linked to AGYW’s ability to participate in economic production, savings groups, and taking care of their needs. Evidence points to AGYW being at high risk of sexual and reproductive health (SRH) problems as a result of their economic vulnerability , 23–30. Empowerment manifested at three interlinked levels: community, interpersonal (family and intimate relationships), and intrapersonal levels. AGYW’s access to resources and participation in community savings groups enhanced their solidarity and elevated their social standing at the community level. Inasmuch as a woman’s economic empowerment depended on her position in the family, it determined her control over resources, what she could do outside the family, and ultimately the decision-making power she wielded in her sexual relationships. Increasing women’s social standing in the community could potentially lead to less exploitation and more investment in women. Future studies should examine community-level impacts of CT programmes.At the interpersonal level, CT influenced AGYW’s intimate relationships with many reporting reduced spousal conflict, partner respect, and increased agency and decision-making power. Economic stressors have been found to increase risk of gender-based violence at the family level . The facInasmuch as some AGYW received material support from their families, this was not always sufficient leading to AGYW’s dependence on sexual partners to supplement this. Some studies have noted that it is not easy for low-income households to meet all the needs of AGYW, as some needs may be regarded as luxuries in comparison to other competing household needs , 36. PovAt the intrapersonal level, CT gave AGYW a sense of future orientation that encouraged them to aspire for bigger developmental goals such as owning land, a home, enlarging their business; these are things many had never imagined possible prior to the introduction of the CT. As noted in this study, aspirations and feelings of independence are non-tangible benefits that are important to adolescent social growth. Evidence shows that attributes such as independence and social growth are important components of adolescent development, as they are associated with transitions from childhood to adulthood and could lead to improved future aspirations .Whilst all AGYW talked about a feeling of independence after receiving CT, the extent to which this independence influenced economic decision-making varied by marital status. Married AGYW talked about being currently able to make expenditure decisions in the household. Women’s control over resources has been found to affect their control over decision-making in households . While oSauti programme, there is potential for social desirability bias. It is possible that participants may have reported more positive influences of the programme than negative. This was, however, minimised by having the research done by an organisation independent of the implementing organisation/team. The research team also spent some time with the study participants building rapport and trust in order to encourage participants to give honest responses.A key strength of this study is the longitudinal nature that allowed for exploration of change over time and the use of multiple qualitative methods to triangulate findings. However, similar to any research, this study has limitations. Since this study recruited participants from an ongoing economic empowerment intervention, the CT empowered AGYW by fostering more independence and giving them hope and aspirations for the future. The feeling of independence allowed AGYW to use money the way they wanted, participate in economic production and save in ways that made sense to them. A sense of responsibility developed through engagement in business activities, enhanced participants’ self-esteem and confidence in decision-making. This empowerment led to changes in AGYW’s sexual risk behaviors, giving women more authority to negotiate safe sexual behaviors, reduce their number of partners, and not rely on transactional sex.