Care to move! A mixed-methods evaluation of care–physical activity initiatives for citizens with a low socioeconomic status

Introduction

The overweight and obesity rates of today are unfavourable, have increased over the past years and are expected to further increase in the future. Overweight and obesity appear more among citizens with a low socioeconomic status (SES) compared with citizens with a higher SES, leading to health inequalities. Therefore, care–PA initiatives have been developed, in which the healthcare sector and the PA sector collaborate to improve the health and lifestyle of citizens by increasing daily PA and improving dietary behaviours. However, much is still unknown regarding the effectiveness and funding of care–PA initiatives for citizens with a low SES. Therefore, X-Fittt 2.0 has been developed, which is being studied in this thesis.

X-Fittt 2.0 is a 2-year programme consisting of two phases: a 12-week intensive programme and a 21-month aftercare phase. During the first 12 weeks, participants receive intensive guidance in developing a healthy lifestyle, which consists of four parts: per week two sports sessions in a group guided by a sports coach and one individual sports session; dietary advice and monitoring by a dietitian; coaching by a lifestyle coach; and two appointments with a physiotherapist. The remaining 21 months comprise the aftercare phase, during which participants receive coaching by a lifestyle coach to work on their personal goals and to encourage behavioural maintenance regarding a healthy lifestyle.

Aim

The aim of this thesis is to contribute knowledge and insights about care–PA initiatives for citizens with a low SES, so that existing and future initiatives can better suit this group. In the light of this aim, seven research questions were addressed:

1. What are the short- and long-term outcomes of participation in X-Fittt 2.0, in terms of health, quality of life (QoL) and societal participation?
2. What is the impact of participation in X-Fittt 2.0 on the healthcare utilisation of citizens with a low SES?
3. What are the experiences of the participants in the combined lifestyle intervention X-Fittt 2.0?
4. What are the effective elements of X-Fittt 2.0, a combined lifestyle intervention for people with low SES?
5. What are the effective elements of care–PA initiatives for adults with a low SES in the Netherlands, based on the experiences of health promotion experts?
6. What are citizens’ preferences regarding the public funding of projects that promote a healthy body weight among people with a low income, and do these preferences differ between people with different incomes?
7. Why do citizens prefer certain projects that promote a healthy body weight among people with a low income over others?

Methods

This study adopted a mixed-methods approach. To study the short- and long-term impact of X-Fittt 2.0 on health, quality of life (QoL) and societal participation, data from 208 participants were collected using questionnaires and body measurements, 17 group discussions (n=71) and 68 semi-structured interviews over a 2-year period. In addition, to study the impact of X-Fittt 2.0 on healthcare utilisation, healthcare claims data of 44 X-Fittt 2.0 participants were used, comparing the 2 years before the start of X-Fittt 2.0 with the 2 years after the start. The 17 group discussions (n=71) and 68 semi-structured interviews with participants were also used to evaluate the experiences of participants with X-Fittt 2.0. To unravel the effective elements of X-Fittt 2.0 and care– PA initiatives for citizens with a low SES in general, two concept mapping studies were conducted, using nine public health practice professionals and one participant, and 19 health promotion experts. Additionally, to explore citizen preferences regarding the public funding of projects promoting a healthy body weight among people with a low income, to identify whether such preferences differ between citizens with a low income and those with a higher income and to identify the reasons underlying these preferences, a participatory value evaluation among 1,053 Dutch citizens was used.

Conclusions and recommendations

This thesis has extended the understanding of care–PA initiatives for citizens with a low SES, which resulted in three important insights. First, support and guidance from professionals appears to play an important role in learning and maintaining new health behaviours, motivating participants and overcoming barriers to a healthy lifestyle, such as being physically active. Second, highly accessible initiatives are needed that address different barriers experienced by citizens with low SES. For example, an initiative that is offered at low cost, at a location close to the participants’ homes where participants feel comfortable, and that participants can easily combine with their daily activities. Third, offering group-based initiatives also seems valuable for motivation and support and for sharing knowledge and experiences, which might help in improving participants’ lifestyles. These insights led to implications for policy, practice and research.

Implications for policy include for example: prioritising health promotion programmes for citizens with a low SES, such as care–PA initiatives; and including the PA portion of care–PA initiatives in the basic healthcare insurance scheme or offering the PA portion at an affordable price.

Regarding practice, implications include: providing a long and intensive period of support and guidance in care–PA initiatives, followed by a long period of aftercare; and involving citizens with a low SES in the development of care–PA initiatives.

Recommendation for future research are: to include a larger study population and, regarding healthcare utilisation, a longer study period as well, to study the effectiveness of care–PA initiatives for citizens with a low SES; to study whether overweight and obese citizens with low SES who start a care–PA initiative after a long period of physical inactivity are more at risk of developing PA-related injuries.

We need to care to move citizens with a low SES to a healthier lifestyle. This means governments that care about the health of citizens; policies that encourage healthy behaviour; healthcare and PA sectors that move towards an integral approach to health promotion; and governments and practitioners that acknowledge the barriers that limit citizens with a low SES to live healthily. And then, if accessible care–PA initiatives exist, people with low SES can care to move.