Background
Worldwide, physical inactivity is one of the core risk factors for non-communicable diseases such as diabetes type II and cardiovascular disease [
1,
2]. In the Netherlands, sports and physical activity engagement is lower in socially vulnerable groups than in wealthier groups [
3,
4]. The Dutch Healthy Physical Activity Guidelines (NNGB) set the norm for healthy daily physical activity for adults at a minimum of daily 30 minutes moderate activity at least five days a week [
5]. Socially vulnerable people most at risk of not meeting the NNGB are those of low socio-economic status (SES), or who are unemployed, or of non-Dutch origin, or with chronic disease(s) [
4]. To reduce these inequalities in physical activity behaviour, Dutch health policy focuses on the implementation of community-based health enhancing physical activity (CBHEPA) programs [
6,
7] in order to improve individual health and wellbeing, to reduce inequalities in health and PA behaviour across population subgroups, and to realise public gains in terms of reduced healthcare expenses [
6].
Current theories on enhancing physical activity behaviour and maintenance suggest that physical activity interventions function through individual psychosocial processes (goal-setting, motivation, self-efficacy, and coping with stressors) [
8‐
12], through interactions and group dynamics in exercise groups, and through interactions with the social environment and community [
13‐
19]. Therefore, CBHEPA programs are grounded in individual, group, and community-based theories [
20‐
22].
Dutch CBHEPA programs are built on principles for action for health promotion interventions [
7,
23], as advocated by the WHO and others [
24,
25]. Since the publication of the Ottawa Charter for Health Promotion [
24], professionals are challenged to work explicitly with principles for action important to modern health promotion [
25]. A principle describes the code of conduct or a rule of action and is generally action oriented [
26]. Principles for action encompass a continuum of values emerging from health promotion research and practice. At one end of the continuum, more conventional health and physical activity promotion principles are found, reflecting traditional health education based on biomedical, behaviourist, and reductionist approaches to health. Usually, these programs address a specific topic or lifestyle, with an emphasis on targeting at-risk people with behaviour change strategies [
25]. At the other end of the continuum, health promotion is guided by principles for action based on an ecological perspective on human health [
27,
28]. This perspective on health and physical activity promotion emphasises the need for actions that are empowering [
29], participatory [
30‐
32], intersectoral, equitable, and sustainable, and that use multiple strategies [
33]. The focus is on health as a resource for meaningful living [
34‐
37].
From this latter perspective, it is expected that using principles for action contributes to the effectiveness of CBHEPA programs. Principles for action leave scope for adjustment to contextual needs on the one hand, and are the program’s constituents which can be implemented in different contexts and settings on the other hand [
38]. Usually, the effectiveness of CBHEPA programs is based on measuring physical activity outcomes at individual level, using standardised self-report instruments [
39], but how defined or ideal principles for action emerge in practice is largely dependent on contextual factors, knowledge, or the skills of the local professionals involved. Whether or not principles for action are recognised and valued by participants in exercise groups in on-going CBHEPA programs, and how they contribute to effectiveness, is rarely investigated.
As part of an on-going evaluation study of a Dutch CBHEPA program, Communities on the Move (CoM) [
21], we wanted to explore particularly group-based principles for action, since CBHEPA programs in the Netherlands are generally group-based. CoM was developed and disseminated (2003–2012) by the Netherlands Institute for Sports and Physical Activity (NISB) and targets socially vulnerable groups. CoM defined a set of principles for action at individual, group and program level. This current study aims to evaluate CoM’s group-based principles for action in group settings. It addresses the question which of the identified group-based principles for action are perceived as important by CoM participants. We thereby hope to contribute to the knowledge base on the use and impact of principles for action in group-based physical activity programs, using a practice-based evaluation approach.
Methods
We studied how participants appreciated the group-based principles for action applied in CoM: active participation, enjoyment, and fostering group processes. An exploratory evaluation design was used. The principles for action were operationalised on the basis of the literature on social cognitive theory [
40‐
42], social learning theory [
43], and social capital and participation [
30,
31,
44], alongside interviews (
n = 11) and expert consultation (
n = 2).
Scientific [
45‐
49] and grey literature [
50,
51] were explored to identify data collection techniques suitable for low literate and culturally diverse socially vulnerable groups. Focus group techniques were identified, alongside cultural sensitive techniques actively engaging the target group, facilitating dialogue and providing immediate feedback. The principles for action were operationalised as follows:
-
Active participation: 1) participation in group formation [
19,
52,
53], 2) participation in physical activity program content decision making [
54,
55], and 3) participation in community initiatives [
54,
56,
57].
-
Enjoyment of physical activity: 1) expressions of enjoyment (physical, verbal and nonverbal) [
58‐
60] and 2) safe and supportive environments [
27,
52,
61,
62].
-
Fostering group processes: 1) social support, looking at group composition (size, [cultural] diversity, boundaries, phase) and group structure (roles, norms, social support, and cohesion) [
13,
63], 2) role of the exercise trainer [
17,
62,
64], and 3) learning achievements [
40,
43].
Based on these operationalisations, a semi-structured interview protocol was developed: the active participation, enjoyment, and fostering group processes (APEF) tool, to assess participant appreciation for each of the group-based principles for action (Table
1). For each principle, two or three statements were formulated, allowing data to be collected on individual points of view, as well as probing theme-driven dialogue between researcher and respondents and dialogue among respondents. The development of the APEF tool for group-based principles for action will be described in detail elsewhere (Herens, Wagemakers, Vaandrager, Van Ophem, Koelen, in preparation).
Table 1
Outline of the interview protocol (APEF tool)
Active participation | Group formation | 1. We, as exercise group, choose who participates in the exercise group. | Since when have you been exercising together? |
How are participants recruited? |
Do you ever bring a friend or a neighbour? |
| Content activity class | 2. We, as exercise group, choose the activities for the exercise class | What does your physical activity program look like? |
Were you involved in the choice of activities, and if so, how did that work? |
How important is that for you? |
| Community initiative | 3. Some participants within the exercise group take the initiative to exercise together elsewhere | Can you give an example of somebody taking the initiative? |
Enjoyment | Enjoyment of physical activity | 4. Exercising in the exercise group ensures that I like being physically active | What physical activity do you like most? |
Is the program consistent with your preferences? |
How do you ensure that everybody can enjoy the physical activity class? |
| Feelings of safety | 5. The exercise group offers me safety to be physically active | What comes to your mind if we talk about safety? |
How does the group support safety? |
Fostering group processes | Social support | 6. Exercising in the exercise group offers me support to be physically active | What comes to your mind if we talk about group support? |
In what way does the group offer support to physical activity behaviour? |
How do you deal with factors that make physical activity difficult? |
| Role exercise trainer | 7. Within the exercise group, the exercise trainer is an example for me to be physically active | In what way is the exercise trainer an example? |
| Learning achievements | 8. By exercising in the exercise group, I learn how to be more physically active in my daily life | Can you give examples of what you learned in the exercise group? |
What have you discovered since you joined the exercise group? |
What is your benefit or achievement? |
Data collection
From May 2013 to May 2014, ten focus groups were conducted in Dutch CBHEPA programs, including exercise groups participating in the CoM evaluation study (convenience sampling). The APEF tool was used in ongoing exercise groups, except for two. In these latter groups, participants still came together as part of an educational scheme (groups 1 and 2). Group members were asked to participate in a focus group. In all ten groups, a number (range 6 to 11) of group members were willing to participate (
n = 76).
Table 2
Characteristics of CBHEPA programs
1. | Womena (n = 6) | Amsterdam | A | Fixed (10 weeks) | Community centre | Weekly (1.5 h) | Walking/running (Embedded in language class) | Socially vulnerable women (non-Dutch) |
2. | Women (n = 6) | Enschede | B | Fixed (13 weeks) | Sports club canteen | 2 x week (3 h) | Introduction to various sports activities (Embedded in education trajectory, including follow-up meetings once every 6 weeks for 18 months) | Socially vulnerable women (non-Dutch and Dutch) |
3. | Women (n = 8) | Helmond | C | Continuous | Playground outdoor fitness | Weekly (1 h) | Outdoor group fitness | Socially vulnerable groups (non-Dutch and Dutch) |
Men (n = 1) |
4. | Women (n = 6) | | C | Continuous | Playground outdoor fitness | Weekly (1 h) | Outdoor group fitness | Socially vulnerable groups (non-Dutch and Dutch) |
Men (n = 2) |
5. | Women (n = 6) | Rotterdam | D | Continuous | Community centre | Weekly (1 h) | Group exercise to music | Socially vulnerable women (non-Dutch) |
6. | Women (n = 10) | | D | Continuous | Community centre | Weekly (1 h) | Group exercise to music, incl. fall prevention | Socially vulnerable women (non-Dutch and Dutch) |
7. | Womenb (n = 11) | | D | Continuous | Community centre | Weekly (1 h) | Group exercise to music | Socially vulnerable women (non-Dutch) |
8. | Men (n = 7) | | D | Continuous | Residential care home | Weekly (1 h) | Group fitness class | Socially vulnerable men (non-Dutch) |
9. | Women (n = 4) | Tilburg | E | Continuous | Community centre | Weekly (1 h) | Group exercise class, incl. fall prevention | Socially vulnerable elderly women and men with a chronic condition (Dutch) |
Men (n = 3) |
10. | Women (n = 6) | | E | Continuous | Community centre | Weekly (1 h) | Group exercise class | Socially vulnerable elderly women, some with a chronic condition (Dutch) |
The focus groups were conducted in rather open settings, using the sports venue (a community centre, sports club canteen, or class room) as meeting place. In four focus groups, outside listeners were present, who were told not contribute to the discussions since they were not participating in the CBHEPA program.
Prior to each focus group, members gave oral consent for their participation and for the proceedings to be audio recorded. The aim and procedure was explained by the researcher (first author). Dutch was the language of conversation in all groups.
Statements were presented during the focus groups, written on flipcharts. Each statement was read out aloud. Respondents were asked to individually score each statement with coloured voting cards carrying both text and symbols: ‘agree’ (green card with ☺); ‘neither agree nor disagree’ (yellow card with
) or ‘disagree’ (red card with ☹). Group scores were reported on the flipcharts during the focus group and further discussed in-depth. The researcher acted as facilitator to generate the free flow of information among respondents. Assistance was provided by one or two junior researchers.
The duration of each focus group ranged from 50 to 70 min. Some women left before the end of one focus group because they had to collect their children or grandchildren from school.
Ethical considerations
The authors declare that the study was conducted in accordance with general ethical guidelines for behavioural and social research in the Netherlands, stipulating that behavioural research falls outside the scope of the Act on review of medical research involving human subjects (WMO) when a study is not of a medical nature, and subjects do not receive a particular treatment or are asked to behave in a particular way [
65]. Furthermore, the study design was peer-reviewed and approved by the review board of the Wageningen School of Social Sciences. All participants entered into the research with voluntary consent. They were provided with information about the purpose and contents of the study. Guarantees of confidentiality and anonymity were given prior to each focus group. Moreover, participants were able to withdraw from the study at any time for any reason.
Data analysis
Our analytical strategy to identify respondents’ appreciation of group-based principles for action was thematic and data driven [
66]. We followed a stepwise procedure [
67]: 1) To assess respondents’ individual appreciation, the scores for each statement were counted (one vote, one point) and added up. For final analysis, all scores were added up across the ten groups. 2) All focus group discussions were transcribed ad verbatim. 3) Respondents were de-identified in the transcript. 4) Transcripts were read by at least two researchers. 5) Top-down coding was developed, based on elements identified in the literature, for each group-based principle for action. For example, codes used for a group dialogue on social support were: (group) commitment or engagement, ownership, motivation, task orientation, and collective faith. 6) Coding was extended with codes for ‘responsive leadership’, an additional theme emerging from our data [
64,
68]. 7) All transcripts were coded by at least two researchers using Atlas.ti 7.0. Codification differences between researchers were discussed until consensus was reached. 8) For each statement, codes, e.g., size, culture, closed/open groups, were clustered into themes (group composition). Duplicate coding across statements, indicating interrelatedness, was regrouped under one statement. For example, respondents’ views on social support, which were expressed in discussions following the statements both on safety (statement 5) and on social support (statement 6), were regrouped under the statement on social support.
For consistency, the order of statements presented in the results was rearranged compared to the order during interviewing, thus clustering our findings for each principle more concisely. Citations were used to carefully reflect respondents’ language and meanings. Finally, respondents’ views on principles for action in CBHEPA programs were summarised in terms of group-based driving and restraining forces, following Lewin’s group dynamic theory on force fields, to identify what forces matter most in group-based principles for action [
69,
70].
Discussion
Our study on respondents’ appreciation of group-based principles for action in Dutch CBHEPA programs – active participation, enjoyment, and fostering group processes – revealed some interesting new insights. Relating to the principle of active participation, our findings indicate that group members’ active participation in group formation occurs only after they have participated for some time and happens primarily through sharing beneficial experiences in personal social networks. Initial group member recruitment is perceived as a task for the exercise trainer, through seeking publicity and mobilising key persons.
According to respondents, active participation in the development of content for the CBHEPA program is mostly directed at tailoring activities to individual needs. Tailored programming is highly appreciated; this is in line with other studies [
52,
55], endorsing its importance for on-going engagement of socially vulnerable groups in physical activity programs. In addition, our findings make explicit that tailored programming happens provided the exercise trainer knows the sort of participants with whom he/she is dealing and takes the initiative to act on that. This emphasis on the need for exercise trainers to be responsive in physical activity programs has also been found in other studies [
62,
64].
Dutch CBHEPA programs aim to empower socially vulnerable groups by improving participants’ health and wellbeing through physical activity. They are developed on the assumption that socially vulnerable groups will become more self-reliant in organising their physical activity behaviour and participate more often in community initiatives. According to our findings, joining a CBHEPA program is respondents’ distinct way of becoming engaged in community initiatives. Only a few of them are engaged in additional sports or community-related activities. One explanation might be that people take part in a CBHEPA program primarily for individual satisfaction, e.g., enjoyment and relaxation, without a desire to pursue collective goals [
71,
72]. Another explanation might be that, in practice, Dutch CBHEPA programs use rather conventional health education principles for action, targeting at-risk groups and using a behaviourist and reductionist approach to health, rather than health promotion principles for action, based on an ecological perspective on health [
25,
27,
28].
Relating to the principle of
enjoyment of physical activity, our findings indicate that having fun together is perceived as an important principle for action for program adherence in socially vulnerable groups. The relationship between leisure-time activity and health is a growing area of research, with a particular focus on affective responses, mood and emotions. Experiencing positive affective states through leisure-time (physical) activities is one of the important factors that maintain and promote individuals’ psychological, social, and physical health and wellbeing, by direct strengthening of their health and wellbeing, and as a means of moderating stress or stress effects [
73]. In physical activity interventions, enjoyment is found to be a moderator of efficacy [
74]. Studies indicate that not only self-control and discipline, but also enjoyment, pleasure and ‘not worrying’, are key values in maintaining an active and healthy lifestyle [
58,
75,
76]. In discussing enjoyment, respondents mentioned predominantly individual experiences, described by Jallinoja et al. as ‘negotiated pleasure’, referring to the process of balancing between health-seeking and pleasure-seeking behaviour. Because of a potential discrepancy between these two aims, pleasure is constructed not simply as a spontaneous experience, but often as a planned and disciplined event [
46]. ‘Negotiated pleasure’ regarding physical activity, as found in our study, evolves around: 1) pushing oneself, or using someone else as an external push, to overcome the temptations of remaining inactive; 2) the instrumental values of physical activity, such as health or psychological benefits; 3) the satisfaction of physical activity goal achievement; and 4) the physical sensation that is felt during and after being active [
46].
Our findings relating to group experiences of enjoyment, expressed as feelings of safety, safe environments, and social support, show that (changes in) affective responses at individual level are strongly linked to group-based experiences, which can be facilitated [
77]. This is consistent with the self-determination theory, indicating that, alongside perceived autonomy and competence, relatedness (with fellow participants as well as with the exercise trainer) is an important medium for change and internalisation of physical activity behaviour [
8,
9,
78].
Our findings relating to
fostering group processes illustrate the importance of group support. In discussions on the statements on safety and social support, very similar views emerged, showing an interrelatedness of (emotional) safety and social support. This highlights the important role of interpersonal factors in group-based CBHEPA programs, such as mutual trust, interdependency, respect, attractiveness, integration and sense of belonging. Our findings are supported by other studies on group dynamics in physical activity programs [
13,
19,
79]. Group dynamics in CBHEPA programs are, however, often implicit and left unaccounted for. CBHEPA programs are usually group-based for organisational reasons (cost-covering), rather than for behavioural change reasons. Nevertheless, some studies indicate that group dynamics strategies, explicitly applied in group-based physical activity interventions, are more effective in establishing physical activity behaviour change than individually targeted interventions with social support, which, in turn, are more effective than individual interventions without additional social support [
16,
22]. At the same time, a lack of standardisation across the literature in relation to how group dynamics strategies are applied in physical activity programs is also reported [
16,
18].
Our findings indicate that an exercise trainer acts as a role model in being fit and healthy, as well as in being kind and responsive. Respondents attribute great value to the fact that the exercise trainer is an expert as well as a friend, facilitating learning processes in various domains. Exercise trainers use the exercise group as a relatively convenient environment to bridge (cultural) diversity, using exercises to enhance both verbal and nonverbal communication and cooperation.
Responsive leadership thus emerges as an additional principle for action in group-based CBHEPA programs. Alongside the role model aspect, exercise trainers’ responsive leadership skills are emphasised by respondents. Our study illustrates the need for ‘enabling’ professionals in exercise groups targeting socially vulnerable people [
80]. Based on the literature, three areas of expertise can be defined for responsive leadership to facilitate learning processes for behavioural outcomes in such groups: first, the responsibility to ensure that the demands of the organisation are satisfied (satisfactory group size, cost-covering level), and that group members’ needs and aspirations are satisfied [
17,
64]; second, the leadership skills to manage resources (ensuring secure physical activity environments, monitoring adherence, fostering group processes), personal reputation and image (being a qualified and enthusiastic role model), and development of relationships (based on [cultural] knowledge, prior experiences, and responsiveness to participants’ performance styles) [
68]; third, teaching skills to adapt exercise classes to participants’ knowledge, skills, and (cultural) dispositions: this is probably best described as ‘culturally responsive teaching’ [
81].
There is need to further explore the reciprocal relationship between experiential learning within groups (who learns what, when, and from whom), the development of group norms, group cohesion, skills and collective efficacy, and individual behavioural outcomes, such as increased physical activity behaviour and maintenance [
16,
82]. This calls for a more systematic approach to determine underlying causal mechanisms of group-based CBHEPA programs [
83,
84], to determine how to measure important variables consistently, such as group environment in terms of process and structure, and to compare and contrast across studies [
16].
Our study reveals that the group-based principles for action, as defined in CoM, are not demarcated entities, but rather represent a range of intertwined values and principles to organise (group) processes [
25,
37]. Fostering group processes seems an overarching principle, conditional for the spin-off in terms of enjoyment and active participation, which, in turn, leads to (the development of) perceived sense of ownership and to participants taking responsibility for the exercise group’s as well as their own physical activity behaviour. Scientific literature on the use and appreciation of group-based principles for action in CBHEPA programs seems fairly limited [
25,
33]. Also, in practice, the use of group-based principles for action is rarely made explicit within and across CBHEPA programs, seemingly driven by tacit knowledge and common sense [
13,
79]. With our study, using a practice-based evaluation approach, we aim to contribute to the knowledge base on the use of group-based principles for action in CBHEPA activity programs. Our study thus contributes to the on-going discourse on how to improve health-enhancing physical activity interventions [
39,
83].
Implications for future research are that proxy indicators or indirect measures need to be identified to assess transformative changes within the group or community [
85,
86], and that responsive evaluation strategies should be used, e.g., two-way methods (including group discussions and face-to-face engagement) in order to pick up differing kinds of views, including the use of peer-led questioning [
87]. The strength of our study is that we have developed a systematic way of assessing participant appreciation of group-based principles for action. This adds to existing methods of measurement, e.g., individual questionnaires, which are most commonly used to assess outcomes of group dynamics in exercise groups [
18,
88,
89].
Methodological considerations
Some comments on this research relate to data collection and processing. Focus groups varied in composition and size. In some groups, all members were of Dutch origin; in others, a large ethnic and cultural diversity was found. The fact that it was necessary to use Dutch as the common language hindered some respondents from expressing themselves freely in their mother tongue, but challenged others to practice their skills in the Dutch language. Occasionally, those who spoke Dutch fluently translated for others. Therefore, we cannot rule out the possibility that socially desirable responses entered our data set, also because the focus groups were held in existing group settings.
Furthermore, literature on culturally appropriate health and physical promotion offers several strategies to address socio-cultural differences within and between groups [
90], such as soliciting input from population members, linking intervention content with values, addressing language and literacy challenges, incorporating population media figures, using culturally relevant forms of physical activity, and addressing specific population linked barriers to activity [
91]. Our findings reflect examples of these strategies being used, except the use of media figures. Nevertheless, we cannot rule out possible influences of different beliefs about health concepts across cultures, lack of health literacy or skills in reading, leading to differences in understanding and interpreting the statements [
92,
93], despite our positive experience of getting respondents engaged in a meaningful dialogue about group-based principles for action in CBHEPA programs in all focus groups.
The APEF tool, based on statements and subsequent group discussions, proved useful for engaging respondents in a meaningful dialogue. On the positive side, it allowed all respondents to participate. It enabled the researcher/facilitator to reach out to those who kept silent. It also kept respondents alert throughout the focus group. The voting procedure itself was, however, sometimes hard to manage as respondents started discussing as soon as they heard the statement, without using their vote cards and casting their votes only after discussion. Two statements, those addressing social support and group safety, generated considerable debate. It might be that the concepts were too generic and abstract for this target group. In future, safety should be addressed more explicitly in two statements: one addressing environmental safety and the other addressing emotional safety.
Our findings are based on a volume of ten focus groups, including 76 respondents, generating a fairly solid basis for interpretation of our data. The APEF tool also generated data for comparison between groups; this is an indication of its generalisability (external validity).
Competing interests
The authors declare that there are no competing interests.
Authors’ contributions
MH developed the design and coordinated the study, carried out data collection and drafted the manuscript. MH and AW performed the qualitative analysis. AW, LV and MK conceived the study, participated in its design and coordination, and helped to draft the manuscript. All authors read and approved the final manuscript.