Background
Participation in regular physical activity can bring a wide range of health benefits that impact upon the population. These benefits go beyond physical health to include other benefits, such as improved cognitive function, quality of life, personal wellbeing and social functioning [
1‐
7]. To receive these health benefits, adults should undertake a minimum of 30 min of moderate-intensity physical activity on five days per week or 20 min of vigorous-intensity physical activity on three days per week. Also, an equivalent combination of both moderate- and vigorous-intensity physical activity is possible [
5,
8]. However, research suggests that 31% of adults worldwide and 34% of Dutch adults do not meet these levels of health-enhancing physical activity (HEPA) [
7,
9]. These people are at higher risk of developing chronic diseases and premature death [
1‐
7].
Participation in sports activities at a sports club can contribute considerably to HEPA levels of individuals [
10]. In Europe, 12% of the population is a sports club member. This percentage is even higher in the Netherlands (27%) [
11]. Due to their wide reach, social and informal educational nature, sports clubs have great potential to promote a healthy and active lifestyle in the population [
12,
13]. Indeed, health professionals and policy makers see the sports club as a new relevant setting for programs and strategies to increase HEPA among inactive population groups [
14‐
18].
More traditional institutional settings, like universities and workplaces, have already been used for health promotion. Settings-based health promotion is based on the idea that health behaviors of individuals are influenced by the places in which they live, work and play and the factors interacting in those places (i.e. environmental, organizational and personal factors). Important aims of this approach are among others: 1) creating supportive and healthy environments in order to make ‘the healthy choice, the easy choice’ and 2) integrating health promotion in the daily strategies and activities of the setting [
19‐
22]. However, health promotion in general, and the promotion of HEPA among inactive groups in particular, is still a relatively new concept for sports clubs. Their focus is mainly on providing training, competition and elite sports [
14,
16].
Nonetheless, a few examples of HEPA promotion strategies and activities in sports clubs can be found in the literature. In Australia, for instance, they focused on the development of healthy (e.g. healthy eating, responsible serving of alcohol) and welcoming sports club environments as a means to increase sport participation by less active population groups. Also, the implementation of sporting programs that involved cross-sectoral partnerships (i.e. between sports clubs and other sectors, like health, education and recreation) was advocated [
14‐
16]. In the Dutch context, National Sports Federations received funding within the National Action Plan for Sport and Exercise (NAPSE) to develop sporting programs adapted to the needs and abilities of inactive people [
23]. These programs had to be integrated in the daily activities of their affiliated clubs. In this regard, the Netherlands Tour Cycling Union (NTFU) initiated Start2Bike, a six-week training program for inactive adults and adult novice cyclers. Participants are learned the basic skills of mountain biking or road cycling. Subsequently, they are encouraged to continue cycling in a beginner’s group at the club or as a member of the NTFU.
To date, research concerning HEPA strategies and activities in the sports club setting focused predominantly on implementation matters, like organizational readiness, partnership and capacity-building strategies and factors influencing implementation [
14‐
16,
23]. However, still little is known about the effectiveness of these initiatives on increasing HEPA levels [
24]. There is a request for an evaluation of activities in controlled studies, assessing both short- and longer-term effects [
25,
26]. Until now, the only answer to this request was the evaluation of the Start to Run program, a six-week training program for novice runners, initiated by the Dutch Athletics Organization and implemented by local athletics clubs [
27]. It proved to be effective in increasing HEPA levels of participants, with 69.0% of participants still engaged in running 4.5 months after they finished the program. However, it was stated that further research was needed to determine whether these results could be generalized to other sports and sporting programs. Therefore, this study aimed to investigate the short- and longer-term effects of the Start2Bike program on HEPA levels of participants in a controlled study design.
Methods
Study design
To determine the effects of Start2Bike on HEPA levels of participants, a controlled study design was used. For comparability purposes, this study used the same data collection and analyses methods as those applied in the Start to Run study [
27]. Start2Bike participants subscribed for the program on a voluntary basis. Subsequently, they were asked to participate in this study. They were not subjected to procedures, nor were they obligated to follow certain behavioral rules. Therefore, consistent with Dutch legislation, medical ethics committee approval was not required [
28]. This study was performed according to ethical guidelines (i.e. with regard to principles like informed consent, enabling participation, avoiding adverse consequences, avoiding undue intrusion, confidentiality and data protection) [
29]. Privacy procedures were conform Dutch Data Protection Authority regulations. For reporting of results, the Transparent Reporting of Evaluations with Nonrandomized Designs (TREND) group reporting standards were used as a guidance [
30].
Study population
Start2Bike participants
Start2Bike is aimed at inactive adults and adult novice cyclers (i.e. mountain biking or road cycling). Dutch sportive cycling clubs offer the program twice a year (in spring and autumn) at 83 different locations. Recruitment of participants is done by the clubs in different ways, namely by the distribution of leaflets and posters, advertisements in local newspapers and word of mouth. This study included 260 adults (from the different Start2Bike locations) who had subscribed for the Start2Bike program in spring 2009, with email addresses provided by the NTFU. These persons received an email with study information and a link to an online baseline questionnaire. The Start2Bike participants provided consent for participation in this research by completing this questionnaire.
Control group
To control for possible changes in physical activity behavior in the Dutch adult population (i.e. physical activity changes caused by other factors than the Start2Bike program, like seasonal influences), members of the Dutch Health Care Consumer Panel served as control group. This panel consists of approximately 3000 adults (≥ 18 years) and forms a representative sample of the Dutch adult population. The panel is used to record views about and experiences with health care and other related topics [
31]. In this study, initially 1328 panel members were included. Control group participants did not receive any intervention. Furthermore, it was questioned whether they had participated in the Start2Bike program or any of the other NAPSE sporting programs before or during the research period, because this could bias the results. Consequently, panel members who had done so were excluded from this study. In addition, the mean age and percentage of females was higher among questioned panel members compared with Start2Bike participants. Age and gender are known to influence physical activity levels [
11]. Therefore, an age and gender matched control group was formed.
Start2Bike program
The program was aimed at riding a mountain bike tour of 30 km or a road cycling tour of 70 km. In Table
1, a description of the training program can be found. The program lasted for six weeks. Each week consisted of a group session led by professional coaches and two individual cycling sessions, whereby rest days were scheduled after training days. For individual training sessions, it was advised to cycle at least with one other person. A group session (± 2 h) included an introductory part (± 30 min), core 1 (30 min), core 2 (45 min) and closure part (15 min). The introductory part consisted of a welcoming and explanation of the training, an equipment check (e.g. cycle, helmet) and warming-up (30 min). The warming-up was a combination of cycling, stretching and repeating of technical skills of the previous training. In core 1, a new technical skill was practiced and, in core 2, this was done with increasing cycling intensity and duration. Practice was ended with a cooling-down (10 min), which consisted of cycling at a slow speed and stretching. At the closure part, the training was discussed, the bicycle was cleaned (when possible) and the coach(es) provided instructions for the individual training sessions to the participants. Theory items, like the risks and (health) benefits of cycling, prevention of injuries and physiological outcomes of training, were discussed before or during practice items. During individual training sessions, participants had to practice previous learned technical skills, whereby cycling distance was gradually increased during the training period. At the sixth guided training session, participants could practice and test their cycling skills in a test tour, before participating in a real NTFU mountain biking (30 km) or road cycling tour (70 km) (one week thereafter). Participants trained in a group of maximum twelve people. When there were more than twelve participants, the group was split. There were at least two professional coaches per guided training session and one coach per group of twelve people. The NTFU provided trainer courses, especially for the Start2Bike program. At the end of the program, participants were encouraged by their coach(es) (both verbally and through email) to continue mountain biking or road cycling in a beginner’s group at the club through club membership. They were also informed about the option to continue cycling through an individual membership of the NTFU. Participants brought their own bicycle and equipment. In some locations, it was possible to lend materials.
Table 1
Content Start2Bike sporting program
Introduction (± 30 min): ▪ Welcome and discussing program of the day. ▪ Check of equipment (helmet, bicycle, clothes). ▪ Warming-up (30 min): cycling, stretching and repeating the technical skill from the previous training. Core 1 (30 min): ▪ Practicing a new technical skill. Core 2 (45 min): ▪ Practicing technical skills while increasing intensity and duration of cycling. ▪ Cooling-down (10 min): cycling and stretching. Closure (15 min): ▪ Discussing the training of today. ▪ Coach prescribes homework for the upcoming week. ▪ When possible: cleaning of bicycle. Theory items are discussed before or during practice items. | 1 | ▪ What is mountain biking/road cycling? ▪ Risks and (health) benefits of cycling. ▪ Tuning of bicycle and helmet. ▪ Equipment (clothes, saddle, helmet, shoes, sun glasses). ▪ Safety during cycling. | Braking, how to use your gears | Practicing previous learned skills: braking, using gears. Mountain biking: two times cycling 10 km. Road cycling: two times cycling 25–45 km. |
2 | ▪ Proper foods and drinks before, during and after training. | Balance | Practicing previous learned skills: braking, using gears, balance. Mountain biking: two times cycling 10 km. Road cycling: two times cycling 25–45 km. |
3 | ▪ Physiological processes during exercise. | Riding curves | Practicing previous learned skills: braking, using gears, balance, riding curves. Mountain biking: two times cycling 15 km. Road cycling: two times cycling 30–50 km. |
4 | ▪ Prevention of injuries. | Overcoming obstacles (mountain biking) or cycling in a group (road cycling) | Practicing previous learned skills: braking, using gears, balance, riding curves, overcoming obstacles/cycling in a group. Mountain biking: two times cycling 20 km. Road cycling: two times cycling 40–55 km. |
5 | ▪ Physiological outcomes of training (e.g. improving strength, endurance, physiological adaptations to training). ▪ Training with a heart rate monitor. | Climbing & descending | Practicing previous learned skills: braking, using gears, balance, riding curves, overcoming obstacles/cycling in a group, climbing and descending. Mountain biking: two times cycling 25 km. Road cycling: two times cycling 40–60 km. |
6 | ▪ Stimulating continuation of cycling (e.g. at a sports club). | Test mountain biking or road cycling tour | Practicing all previous learned skills. Mountain biking: cycling 25 km and the last training 15 km. Road cycling: cycling 60 km and the last training 25 km. |
Outcome measures
Demographic data (i.e. age and gender) were collected from all study participants. To measure physical activity, the
Short
QUestionnaire to
ASsess
Health-enhancing physical activity (SQUASH) was used. This tool is considered to be sufficiently reliable and valid to measure physical activity levels in an adult population [
32]. The applied SQUASH procedure has been described in more detail elsewhere [
27]. In short, the SQUASH contains questions about five domains of physical activity: 1) commuting activities, 2) leisure-time activities, 3) sports activities, 4) household activities, and 5) activities at work and school. The amount of time participants spent in each of the domain-specific activities was measured for an average week in the past month, using three main queries: days per week, average time per day and intensity (light, moderate, vigorous). Whether participants met Dutch physical activity norms was the main outcome measure derived from the SQUASH (i.e. meeting HEPA levels). According to these norms, adults should undertake a minimum of 30 min of moderate-intensity physical activity on five days per week (Dutch Norm for Health-enhancing Physical Activity: DNHPA) or 20 min of vigorous-intensity physical activity on three days per week (Fit-norm) for health benefits. Someone who meets at least one of the two norms adheres to the so-called ‘Combi-norm’, the third norm used in the Netherlands (see also Table
2). Dutch physical activity norms are based on international physical activity guidelines [
5,
9]. Secondary outcome measures calculated included: total minutes of physical activity per week; and minutes of physical activity per week per domain and intensity category.
Table 2
Dutch physical activity norms for adults
Dutch Norm for Health-enhancing Physical Activity (DNHPA) |
Adults (18–54 years):
Thirty minutes or more of at least moderate-intensity aerobic (endurance) physical activity (≥ 4 MET) on at least five days each week.
Adults (55 years and older):
Thirty minutes or more of at least moderate-intensity aerobic (endurance) physical activity (≥ 3 MET) on at least five days each week. A moderate-intensity aerobic physical activity requires a moderate amount of effort and noticeably accelerates the heart rate, e.g. brisk walking, gardening. |
Fit-norm |
Adults (18–54 years):
Twenty minutes or more of vigorous-intensity physical activity (≥ 6.5 MET) on at least three days each week.
Adults (55 years and older):
Twenty minutes or more of vigorous-intensity physical activity (≥ 5 MET) on at least three days each week. A vigorous-intensity physical activity requires a large amount of effort and causes rapid breathing and a substantial increase in heart rate, e.g. running, fast cycling. |
Combi-norm | Meeting the DNHPA and/or Fit-norm. An adult is physically active enough to improve and maintain health when he or she meets at least one of the above mentioned norms (i.e. the DNHPA or Fit-norm). |
Physical activity measurements of Start2Bike participants were performed at baseline (t = 0), six weeks (t = 6 weeks: i.e. directly after they finished the program) and six months after baseline (t = 6 months: i.e. 4.5 months after they finished the program) using an online questionnaire. To enhance response for comparisons with the control group, all Start2Bike participants who returned the baseline questionnaire were invited to fill in the questionnaire at six months, irrespective if they had returned the questionnaire at six weeks. Physical activity measurements of control group participants were performed simultaneously at baseline (t = 0) using a postal questionnaire and six months (t = 6 months) using a postal or an online questionnaire. When necessary, a reminder was sent after a week (online forms) or two weeks (postal forms).
Sample size
The sample size in this study was based on finding a change in HEPA. Mountain biking and road cycling are vigorous-intensity physical activities. Therefore, the Dutch Fit-norm (see Table
2) was used as reference. A sample size of 74 participants per group was needed to find a 20% difference between the Start2Bike group and the control group at the six-month measurement, assuming an alpha of 0.05 (two-sided) and a power of 0.80. With 260 and 1328 participants included in the study for the Start2Bike group and control group, respectively, it was assumed that an adequate number of participants was approached.
Statistical analysis
The software program Stata (version 10.1, Stata Corporation, College Station, Texas) was used to perform statistical analyses. The main features of each group were described using descriptive statistics. A chi-squared test and an independent t-test were used to test between-group differences with regard to gender and age, respectively. McNemar tests (dichotomous measures) and paired t-tests (continuous measures) were performed to examine within-group changes in physical activity. Multiple logistic (dichotomous measures) and linear (continuous measures) regression analyses were used to test between-group changes in physical activity. In the regression analyses, physical activity level at six months was the dependent variable and group (Start2Bike group vs. control group, with the control group serving as reference category) the independent variable. To adjust for baseline physical activity, this variable was also added to the regression model as an independent variable. For instance, to test changes in meeting the Fit-norm between groups, the following variables were added to the logistic regression analyses: meeting the Fitnorm at six months (yes/no, dependent variable); group (Start2Bike vs. control group, independent variable); meeting the Fitnorm at baseline (yes/no, independent variable). In addition, more robust regression procedures were performed to examine whether the results (continuous measures) were influenced by outliers: this included the use of robust standard errors (i.e. bootstrap and Huber-White robust estimates of the standard errors). These latter procedures did not alter results and conclusions of this study significantly. Therefore, these results are not described in this article. The significance level for all analyses was set at p < 0.05.
Conclusions
The study results show that the six-week Start2Bike program positively influences HEPA levels of participants by increasing participation in sport. In addition, the results support previous research that a relatively short sporting program, offered by sports clubs, can encourage less active people to engage in and continue sport at HEPA levels. Overall, sport can contribute to health through increased HEPA and the sports club can serve as a setting to stimulate this. Consequently, these results are of value to policymakers and sports practitioners who acknowledge the possibilities of sports clubs in health promotion. Future research should investigate whether sport behavior is maintained and if and under what conditions participation in club sport can support this. Also, the suitability of sporting programs for different less active population subgroups should be examined. In this way, policy makers and sports practitioners can make well-informed choices regarding the contribution of this setting to a healthy and active lifestyle.
Acknowledgements
We thank the study participants for their contribution to this research.
Ethics approval and consent to participate
Start2Bike participants received an email with study information and a link to an online baseline questionnaire. By completing this questionnaire, participants provided consent for participation in this research. Consistent with Dutch legislation, medical ethics committee approval was not required, because participants were not subjected to procedures, nor were they obligated to follow certain behavioral rules [
28].