This article presents a practitioner-based approach to identify key combinations of contextual factors (C) and mechanisms (M) that trigger outcomes (O) in Dutch community-based health-enhancing physical activity (CBHEPA) programs targeting socially vulnerable groups. Data were collected in six programs using semi-structured interviews and focus groups using a timeline technique. Sessions were recorded, anonymized, and transcribed. A realist synthesis protocol was used for data-driven and thematic analysis of CMO configurations. CMO configurations related to community outreach, program sustainability, intersectoral collaboration, and enhancing participants' active lifestyles. We have refined the CBHEPA program theory by showing that actors' passion for, and past experiences with, physical activity programs trigger outcomes, alongside their commitment to socially vulnerable target groups. Project discontinuity, limited access to resources, and a trainer's stand-alone position were negative configurations. The authors conclude that local governance structures appear often to lack adaptive capacity to accommodate multilevel processes to sustain programs.

BackgroundAs interventions are not yet successful in substantially improving physical activity levels of low socioeconomic status groups in the Netherlands, it is a challenge to undertake more effective interventions. Participatory community-based physical activity interventions such as Communities on the Move (CoM) seem promising. Evaluating their effectiveness, however, calls for appropriate evaluation approaches.ObjectiveThis paper provides the conceptual model for the development of a context-sensitive monitoring and evaluation approach in order to (1) measure the effectiveness and cost-effectiveness of CoM, and (2) develop an evaluation design enabling the identification of underlying mechanisms which explain what works and why in community-based physical activity programs.MethodsA cohort design is proposed, based on multiple cases, measuring impact, processes, and changes at each of the distinguished levels. The methods described in this paper will evaluate both short- and long-term effects, costs, and benefits of CoM.ResultsTesting of the proposed model began in October 2012 and is on-going.ConclusionsThe design offers a valid research strategy for evaluating the effectiveness of community-based physical activity programs. Internal validity is guaranteed by the use of several verification techniques such as triangulation. The multiple case studies at the program and community levels enhance external validity.

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BackgroundPhysical inactivity is a core risk factor for non-communicable diseases. In the Netherlands, socially vulnerable groups are relatively less active than groups with higher socio-economic status. Community-based health-enhancing physical activity (CBHEPA) programs aim to empower socially vulnerable groups by improving participants’ health and wellbeing through physical activity. CBHEPA programs often revolve around group-based principles for action, such as active participation, enjoyment, and fostering group processes. As such principles are rarely made explicit, our study aims to identify which of the group-based principles for action are considered important by participants.MethodsRespondents (n = 76) from ten focus groups scored their individual appreciation of group-based principles for action – active participation, enjoyment, and fostering group processes – on a three-point, statement-based scale. Opinions were further discussed in the focus group. Focus group discussions were transcribed and analysed by a team of investigators. The coding procedures, identifying elements appreciated in group-based principles for action, were thematic and data driven.ResultsStatements about participatory programming generated much less consensus in appreciation among respondents than statements about enjoyment and fostering group processes. To some extent, group members participated in the development of program content. Participation in group formation or community initiatives was less frequently perceived as something within group members’ control. Enjoyment, expressed as physical and emotional experiences, was found to be an individual driver of group exercise. Fostering group processes, expressed as social support, was found to contribute to enjoyment and learning achievements. Responsive leadership, ensuring responsive guidance, by an enthusiastic exercise trainer acting as a role model, were identified as additional necessary principles for action.ConclusionsGroup-based principles for action in CBHEPA programs are not clearly demarcated. Fostering group processes is an overarching principle, conditional for the spin-off in terms of enjoyment and active participation. This, in turn, leads to a sense of ownership among participants, who take up responsibility for the exercise group as well as their individual activity behaviour. CBHEPA programs thrive on participants having fun together and exercise trainers’ leadership skills. A professional, competent, responsive exercise trainer plays a key role in the organisation and maintenance of CBHEPA programs.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-015-2515-6) contains supplementary material, which is available to authorized users.

Physical inactivity is most commonly found in socially vulnerable groups. Dutch policies target these groups through community-based health-enhancing physical activity (CBHEPA) programs. As robust evidence on the effectiveness of this approach is limited, this study investigated whether CBHEPA programs contribute to an increase in and the maintenance of physical activity in socially vulnerable groups. In four successive cohorts, starting at a six-month interval, 268 participants from 19 groups were monitored for twelve months in seven CBHEPA programs. Data collection was based on repeated questionnaires. Socio-economic indicators, program participation and coping ability were measured at baseline. Physical activity, health-related quality of life and on-going program participation were measured three times. Self-efficacy and enjoyment were measured at baseline and at twelve months. Statistical analyses were based on a quasi-RCT design (independent t-tests), a comparison of participants and dropouts (Mann-Whitney test), and multilevel modelling to assess change in individual physical activity, including group level characteristics. Participants of CBHEPA programs are socially vulnerable in terms of low education (48.6%), low income (52.4%), non-Dutch origin (64.6%) and health-related quality of life outcomes. Physical activity levels were not below the Dutch average. No increase in physical activity levels over time was observed. The multilevel models showed significant positive associations between health-related quality of life, self-efficacy and enjoyment, and leisure-time physical activity over time. Short CBHEPA programs (10–13 weeks) with multiple trainers and gender-homogeneous groups were associated with lower physical activity levels over time. At twelve months, dropouts' leisure-time physical activity levels were significantly lower compared to continuing participants, as were health-related quality of life, self-efficacy and enjoyment outcomes. BMI and care consumption scored significantly higher among dropouts. In conclusion, Dutch CBHEPA programs reach socially vulnerable, but not necessarily inactive, groups in terms of socio-economic and health-related quality of life outcomes. Our findings suggest that CBHEPA programs particularly contribute to physical activity maintenance in socially vulnerable groups, rather than to an increase in physical activity behaviour over time.

The PNMT contributes to the facilitation of coordinated action in health promotion networks by making positions and roles of network partners visible. In combination with dialogue and reflection the PNMT helps to elucidate factors influencing coordinated action and outcomes. The PNMT is valuable in grasping intangible aspects between actors by stimulating collective learning. These insights can be used by researchers and network actors to achieve more successful coordinated action for health promotion.

This study was carried out by Wageningen University & Research and was commissioned and financed by the Dutch Ministry of Agriculture, Nature and Food Quality within the context of KB-motif 'Feeding cities and migration settlements', in KB-35 Food Security and the Water-Food Nexus.

In community-based health enhancing physical activity (CBHEPA) programmes, group-based principles for action such as active participation, enjoyment, and fostering group processes are widely advocated. However, not much is known about participants' perceptions of these principles as there are no assessment tools available. Therefore, this article describes the development of the APEF (Active Participation, Enjoyment, and Fostering group processes) tool and reports on its implementation in a Dutch CBHEPA programme. Indicators for the principles have been identified from literature research, interviews with professionals, and secondary analysis of three group interviews with 11 practitioners. To address the identified indicators, the APEF tool was developed, pretested, and used in 10 focus groups with 76 participants. The APEF tool consists of eight statements about group-based principles for action, on which CBHEPA participants vote, followed by in-depth discussion. The voting procedure engages participants. Spider diagrams visualise participants' perceptions of group-based principles. The APEF tool addresses the challenge of relating group level outcomes to individual outcomes such as physical activity behaviour. The tool facilitates as well as evaluates group-based principles for action, it stimulates dialogue and is culturally sensitive, but it needs strong facilitating skills to manage group dynamics.