Unravelling mechanisms underlying the action principles of a community-based health promotion programme: a realist evaluation

The setting of this study is the community health promotion programme Voorstad on the Move (VoM). This local programme was one of 46 small-scale projects under the umbrella of the Healthy Futures Nearby (HFN) programme funded by the private funding organisation, FNO, with the aim of reducing health inequalities within the Netherlands [35]. From September 2016 to the end of 2019, VoM was developed and implemented in a socioeconomically deprived city district of 10,750 inhabitants in a city in the eastern part of the Netherlands. In this city district, both the SES and the health status of inhabitants are relatively low compared with other parts of the city [36]. The VoM programme pursued multiple goals. On the one hand, it aimed to improve Voorstad inhabitants’ perceived health and achieve changes in the social and physical environment in order to support healthy behaviours. At the same time, it focused on finding keys to reducing health inequalities [37]. VoM is a local programme developed and implemented with the active involvement of low SES citizens, who – in the view of health professionals – are usually hard to reach and not very interested in health promotion activities. The programme was innovative, as it differed from usual health promotion programmes in which health and lifestyle themes and activities are set by professionals. Instead, this programme shifted from being a predetermined health promotion programme with a set of health behaviour interventions to being an open approach with a focus on the action principles, citizen participation and intersectoral collaboration. The VoM programme was guided by participatory action research (PAR) [13, 37]. During the programme, stakeholders were continually involved, and different perspectives of citizens and professionals were captured and used to optimize consequent actions. As such, the development of capacities, learning, and empowerment was facilitated [38, 39].

In September 2016, the VoM programme started as a collaboration of five organisations, all part of the existing social infrastructure: the municipal health service, the Voorstad social support team (SST), the welfare organisation, the neighbourhood viability coalition, and the local sports service organisation. The programme’s driving and leading force was the VoM coalition, with representatives of the five organisations, all community workers, along with a health broker, who was an inhabitant of Voorstad, working in a self-employed capacity. The benefits of a broker role, especially in health promotion, lie in connecting stakeholders from health and non-health sectors with citizens, and subsequently stimulating an integrated community approach to address health inequalities [40]. The coalition members built a communitywide network of organisations, workers, and citizens based on the existing social infrastructure and the contacts that each of them brought in. The health broker role was essential in connecting the VoM coalition with the broader network and in facilitating citizen participation [38]. Citizens’ perspectives on health were explored with existing community groups – consisting of Voorstad inhabitants (e.g., a walking, a yoga, and a knitting group) and volunteers at a community centre and a play garden – in two group sessions with each group [39]. These community groups were actively involved in the VoM programme from the start.

Based on the literature on community-based approaches and evaluation studies of complex community health promotion programmes [41‐44], we composed an initial programme theory, represented by the a logic model (Fig. 1). This model was used for the development, implementation, and evaluation of the VoM programme [37].

The assumption is that developing and implementing health activities at different levels – i.e., citizens, community workers, and community – will result in the long term in improved perceived health, a health-supportive environment, and sustainable local health policy, and ultimately lead to a reduction in health inequalities. These long-term expected outcomes will be preceded by short-term outcomes, defined as outcomes of interest such as health literacy, healthy alliances, and changes in the physical environment. Besides intended short-term and long-term outcomes, there might be unplanned outcomes that sometimes have a greater influence on the health determinants for a community than the more narrowly focused outcome goals of projects [45]. Programme outputs that precede and generate short-term outcomes include, for example, insight into citizens’ perception on health, new health-promoting activities, an extended community network, new coalitions of primary care professionals and social support workers, and municipal involvement. Another assumption is that, by applying the citizen participation and intersectoral collaboration action principles, programme outputs will be generated, leading to short- and long-term outcomes as already explained.

As part of the PAR that accompanied the VoM programme, a range of qualitative data was collected throughout the programme between 2017 and 2019. In addition, data collected by researchers from the overall evaluation of the FNO HFN programme were analysed [52]. Data used in this study originated from multiple sources and methods to ensure validity. Sources and methods include for example midterm and end evaluation sessions with coalition members; individual interviews and group sessions with community workers, the health broker, and citizens; semi-annual progress reports prepared by the programme coordinator; and minutes of the VoM coalition meetings (Table 1). In addition, an activities database, in which characteristics and reports of the activities that were part of the VoM programme were registered and monitored, was consulted. All sources were used to study both action principles, except the data from the sub study ‘Benefits of participation’ (V), which was only used for the action principle citizen participation. The photo-voice study (IV), the semi-annual reports (VI) and minutes of coalition meetings (VII) were also used to clarify the context.

Interviews and group sessions were anonymised and transcribed ad verbatim. The analysis was stepwise, data driven, and thematic [56], using Atlas-ti 22. Coding was developed based on a realist synthesis protocol with the focus on CMO configurations, looking not only at what worked, but also for whom and why it worked [46‐48]. The operationalisation of the concepts – context, mechanisms, and outcomes – is illustrated in Table 2.

In 2017, the VoM programme started by exploring perceptions of health with existing community groups (C1), leading to insights into how citizens perceived health (O1) (Fig. 2). Social relations and interaction, physical activity, and a positive life attitude were mentioned as the most important perceptions of health.

If you keep on moving, you experience: I feel healthy. (Yoga group participant)

To stay healthy, you need to think positively about all problems. (Language group participant)

The results of these group sessions caused awareness among community workers (O2) about the significance and perceptions of health and resulted in new health-promoting activities (O3). The health broker (C2) managed to involve the community groups by utilising personal contacts (people knew her) (M1) and by taking the presence of community centres as a base (C3). New health-promoting activities (O3) resulted from these contacts and from connecting the ideas of participating citizens with existing citizens’ initiatives (M2).

The development and implementation of new health promotion activities (O3) were also facilitated and supported by community workers (M3) and often took place in the community centres located in the city district (C3). These community workers, including the health broker, built the collaboration with citizens on personal contact (M1).

Most important is building trust. Take your time to get to know people and show your face from time to time. (Health broker)

Citizens who participated or volunteered in activities felt connected and involved as a result (O4).

At the course [‘Looking for sense’], I am included in the group. (Participant).

Knitting connects us. (Knitting group participant).

In the first 1.5 years, the health broker was responsible for the achievement of most of the activities, always in cooperation with citizens and other community workers. Because of changes in local health and social support policies and organisational choices resulting from that, community workers found that they had limited possibilities to support citizens’ initiatives (C5). Cutbacks on welfare work and policy prioritising individual support measures meant that no designated budget for health promotion activities was available (C6). The activity budget provided by the externally funded VoM programme (M5), together with community workers’ motivation to facilitate and support (M3), helped to

The organisation of the social support teams is turned upside down, which means that our role is unclear, which makes collaboration difficult. (Social support team member)

Within the existing procedures and regulations, group activities are very difficult to organise. (Social support team member)

Later, community workers, especially the SST members, became more and more involved in the programme, eventually taking over the health broker role (C2). They anticipated the termination of the contribution of the health broker, who was temporarily subsidised as part of the VoM programme. By taking over this role, the SST members, financed by the local government to execute the social support law, were able to foster the sustainability of the activities. Several years of working together closely with Voorstad citizens, and listening to the citizens’ perspectives about health, resulted in a shared view on health and well-being (O5).

… that health is so much more than healthy eating and physical activity, or stop smoking, but that it is mainly in the social environment and interactions. (Health broker)

According to the coalition members, one of the most important outcomes was the strengthened and extended collaboration within the VoM coalition (O6) (Fig. 3) and with a variety of stakeholders, citizens as well as workers, in the community. Important outcome-generating mechanisms identified by the coalition members were clarity about roles and tasks within the VoM coalition (M6), the programme coordinator’s leadership and persistence (M7), and sharing vision and ambitions regarding brokerage and health promotion strategies (M8) (Fig. 3).

I am proud of the obvious collaboration. We contact one another more easily; that’s how we do it here. We know how to find one another and that yields a lot for the neighbourhood. (Social services team worker)

The combination of supportive context conditions like a steering group (the VoM coalition) (C7), the existing social infrastructure (C8), and a history of collaboration (C9) together with personal contact (M1) and patience (M4) resulted in the involvement of new community groups, organisations, and individuals in the coalition’s network (O7). In addition, a new coalition, named ‘Well-being or not to be?’ was formed (O8).

A restraining context condition was the unstable (policy) context in which the VoM programme was implemented because of transitions of policy responsibilities from the national to the local government (C11). Partly because of this, coalition members were confronted with cutbacks and uncertainty at the start of the VoM programme, because of the limited support from their organisations (C12) and changes in their own organisation and coalition members (C13) that diverted attention from collaboration. The implementation of action research activities (M9) helped the coalition members to recognise the processes that evolved within the coalition and made it possible to act upon them.

I put lots of time and energy into it and then sometimes you ask yourself: does anything come out of it? The research provides the insight that it really does! (Coalition member)

In the final year of the VoM programme, no new activities were initiated; instead, the focus of the VoM coalition and community workers was on the continuation of health promotion activities, participation by citizens and community groups, and sustaining the collaboration and the broader network. The PAR (C10) that accompanied the VoM programme increased awareness of the coalition’s achievements, like for example the organisation of the training programme ‘Leader recreation and physical activities’ that eight citizens completed successfully. Subsequently, coalition members paid more attention to creating visibility (M10) for their achievements. Visible achievements, among other things, presented in a ‘Keep Voorstad moving’ movie, contributed to the involvement of the municipality in the VoM programme and the allocation of a bridging budget (O9) by the end of the programme term, when the funding budget ended (C4). This was promising for sustaining the VoM coalition and communitywide collaboration into 2020 and beyond. With the bridging budget, two successful health promotion activities – the ‘Looking for sense’ course and chair gymnastics – could be continued in 2020.

Our study indicates that using a critical realist perspective delivers an in-depth analysis of the CMO configurations and contributes to a better understanding of the workability of the citizen participation and intersectoral collaboration action principles. The insights into the mechanisms in this study concern just one case, which is both a strength and a limitation [65]. On the one hand, it has created a thorough understanding of the CMO configurations in a real-life setting, and provided a way to understand the nature of the relationship between the VoM programme and the context in which the programme is situated [46]. On the other hand, it may be hard to generalise the findings, because every CBHPP has its own characteristics and is implemented in a different context. In order to gain broader insights into the mechanisms that underly these two action principles and to make adjustments to the (initial) programme theory, more practice-based studies are needed.

The focus in this study was on two action principles mentioned in the Ottawa Charter of Health Promotion [30]. Our results indicate that citizen participation and intersectoral collaboration are crucial action principles in CBHPPs and reveal outcomes that relate to the other action principles. For example, new health promotion activities and sustainability of the programme through the municipal involvement shape healthy public policy and action. In addition, the skills and competences stakeholders require for collaboration and citizen participation need to be developed, as made explicit in one of the other Ottawa Charter principles.

One of the limitations of this study was the selection of stakeholders represented in the research. Community workers, especially the VoM coalition members, were actively involved in focus group sessions, interviews, and coalition meetings and thereby contributed to a large extent to the research. Recruitment of citizens was challenging, and this may have created bias in the total group of citizens involved in favour of those most involved in, and enthusiastic about, the VoM programme. Compared to the community workers, citizens were less represented in the study. In addition, the analytical processes used to develop the CMO configurations, although gone through with different researchers, were inherently vulnerable to subjectivity. This may have resulted in misattributions about the importance of mechanisms and the CMO configurations applied.