Background: In the Netherlands, inequalities in physical activity behaviour go hand in hand with socioeconomic inequalities in health. To promote physical activity effectively and equitably, participatory community-based physical activity interventions seem promising and are supported by the Dutch government’s policy. Although many strategies have been developed to increase physical activity levels in general and in socially vulnerable groups in particular, most evaluations show only small to moderate effects. To date, the evidence base rests mainly on correlational, cross-sectional studies at participant level, lacking insight into causal relationships and interaction patterns between factors influencing physical activity. In addition, in line with Dutch health promotion policy, there is a general demand for community-based health-enhancing physical activity (CBHEPA) programs to be evaluated for impacts and (cost)effectiveness.
Aim: The aim of this PhD research was to assess the effectiveness of these community-based physical activity programs at different impact levels (individual, group, and program), including the mechanisms generating outcomes. This study aims to contribute to the evidence base of programs targeting socially vulnerable groups, by applying systematically a multilevel and realist perspective in order to generate recommendations about how to evaluate physical activity promotion interventions targeting socioeconomic inequalities in health and physical activity.
Methods: The research used a mixed methods design, grounded in an ecological perspective on human health, enabling the identification of underlying mechanisms at multiple levels which explain what works and why. A total of 268 participants in 19 groups in seven ongoing CBHEPA programs were monitored between 2012 and 2015. At individual level, a sequential cohort design was used to acquire longitudinal data on developments in physical activity behaviour and health-related indicators, and to assess participants’ willingness to pay for sport and physical activity. At group and program level, qualitative techniques of measurement and analyses were used, thus linking outcomes at multiple impact levels from different datasets over a period of time, adding contextual and time-related value to our findings building a realist synthesis protocol.
Results: Based on a multilevel analysis, our findings showed that the CBHEPA programs reach socially vulnerable, but not necessarily inactive, groups in terms of socioeconomic and health-related quality of life outcomes. No increase in physical activity levels over time were found, but the findings suggest that ongoing programs contributed to physical activity maintenance in the target population. Significant positive associations were found between leisure-time physical activity, and health-related quality of life, self-efficacy, and enjoyment.
Furthermore, participants’ willingness to pay (WTP) for sports and physical activity was explored in terms of money and time in relation to WTP predictors. The average monetary WTP amounted to €9.60/month, exceeding the average monthly program fees actually paid by €2.64, and was positively associated with income and sport and physical activity experiences. The average WTP in travel time was close to18 minutes and was positively associated with income and age. Indications are that short-term program satisfaction is probably more decisive for willingness to pay than long-term perspectives of improving health-related quality of life.
At group level, fostering group processes was found as an overarching principle, conditional for spin-offs in terms of enjoyment and active participation, which, in turn, lead to a sense of ownership among participants, who take up responsibility for the exercise group as well as for their individual activity behaviour. CBHEPA programs thrive on participants having fun together and on exercise trainers’ leadership skills.
The issue of physical activity maintenance was explored in the case of women of non-Western origin. The factors influencing physical activity maintenance at individual level were: perceived (health) benefits, self-regulation, and learning outcomes regarding physical activity and social participation. At group level, mutual support, security, sharing stories, and trust were important factors. At program level program, quality, staff responsiveness, continuity, and accessibility were important factors. Individual perceived benefits and factors at group and program level, aimed at an appropriate mix of exercise and social activities, contributed significantly to physical activity maintenance by women of non-Western origin.
At program level, outcomes of interest, identified by local stakeholders, related to community outreach, program sustainability, intersectoral collaboration, and enhancing participants’ active lifestyles. Supportive contexts were municipal policies in support of community-based programs, established collaborative structures and community networks, and alignment with other health and welfare projects. Stakeholders’ past experiences with sport and physical activity projects and commitment to the target group were strong additional supportive contextual factors. Supportive mechanisms were entrepreneurship, leadership, responsiveness, deployment of professional exercise trainers, and ensuring the implementation of tailored and accessible program activities. Local governance structures, however, appeared often to lack adaptive capacity to accommodate multilevel processes to realise the sustainment of CBHEPA programs. Policy volatility often results in discontinuity of project funding and collaborative processes, and a reduction in the availability of professional expertise, thus hampering program development and sustainability.
Conclusions: CBHEPA programs, if supported in their performance and sustainability, succeed in generating physical activity maintenance in socially vulnerable groups. Two parallel tracks of value co-creation were identified, reflecting value-in-social-context shaped by social forces and reproduced in social structures through interaction and dialogue: the institutional track, involving the collaborative processes at institutional level, and the exercise group track, involving the collaborative processes in the exercise groups. The exercise trainer is usually the only linchpin responsible for connecting these parallel tracks. Strong evidence was found on how contextual dynamics shape local CBHEPA initiatives and on the need for responsiveness and adaptive mechanisms in the institutional track as well as in the exercise group track, in order to realise sustained CBHEPA programs.
We suggest future research on physical activity behaviour and maintenance to focus not only on how individuals act, but also on how individuals, groups, and environments interact. This calls for evaluation strategies which align accountability with learning through evaluation.