Evaluation and Program Planning 65 (2017) 54–68

Contents lists available at ScienceDirect

Evaluation and Program Planning

journal homepage: www.elsevier.com/locate/evalprogplan

Assessing participants’ perceptions on group-based principles for action in MARK

community-based health enhancing physical activity programmes: The
APEF tool
⁎
Marion Herens1, Annemarie Wagemakers
Wageningen University & Research, Health and Society, Hollandseweg 1, PO Box 8130, 6700 EW, Wageningen, The Netherlands

A R T I C L E I N F O A B S T R A C T

Keywords: In community-based health enhancing physical activity (CBHEPA) programmes, group-based principles for ac-
Health enhancing physical activity tion such as active participation, enjoyment, and fostering group processes are widely advocated. However, not
Community health promotion much is known about participants’ perceptions of these principles as there are no assessment tools available.
Principles for action Therefore, this article describes the development of the APEF (Active Participation, Enjoyment, and Fostering
Measurement instrument
group processes) tool and reports on its implementation in a Dutch CBHEPA programme. Indicators for the
Participatory evaluation
principles have been identified from literature research, interviews with professionals, and secondary analysis of
Group dynamics
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 par-
ticipants 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 sti-
mulates dialogue and is culturally sensitive, but it needs strong facilitating skills to manage group dynamics.

1. Introduction In the Netherlands, community-based health enhancing physical

Since the publication of the Ottawa Charter for Health Promotion
(WHO, 1986), professionals are challenged to work explicitly with
principles for action considered important to modern health promotion
(Gregg & O’Hara, 2007). The principles for action for health promotion,
defined by WHO (1986), highlight empowering, participative, holistic,
equitable, intersectional, sustainable and multilevel strategies, emer-
ging from health promotion research and practice, ranging across a
continuum (Gregg & O’Hara, 2007). At one end of the continuum,
characteristics of ‘modern’ health promotion principles are found:
holistic, ecological, constructionist, egalitarian, and salutogenic, em-
phasising participatory processes and health as a resource for living. At
the other end, characteristics of more conventional health promotion
principles are found, based on biomedical, behaviourist, and reduc-
tionist approaches to health, targeting ‘at risk’ people with behaviour
change strategies.
activity (CBHEPA) programmes aim to reduce inequalities in health and
promote physical activity behaviour (Ministry of Health Welfare and
Sports, 2011). Socially vulnerable groups, e.g. people with low socio-
economic status (SES), people who are unemployed, of non-Dutch
origin, with chronic disease(s), or overweight (Hildebrandt,
Bernaards, & Stubbe 2013), engage less in sports and physical activity
compared to high SES groups (Wendel-Vos et al., 2009). CBHEPA
programmes promote physical activity to improve individual health
and well-being, to realise public gains in terms of reduced health care
expenses, and to reduce inequalities in health and physical activity
behaviour across population subgroups (Herens, Wagemakers,
Vaandrager, van Ophem, & Koelen, 2013).
Dutch policy for CBHEPA programmes builds on at risk as well as
participatory and egalitarian principles for action. Principles for action
take effect at multiple levels and in different programme phases (Herens
et al., 2013). At the individual level for example, health education is

Abbreviations: APEF, Active Participation, Enjoyment, and Fostering group processes; CBHEPA, Community-Based Health Enhancing Physical Activity; CoM, Communities on the Move;
FG, Focus Group; HEPA, Health Enhancing Physical Activity; SCT, Social Cognitive Theory
⁎
Corresponding author.
E-mail addresses: marion.herens@wur.nl (M. Herens), annemarie.wagemakers@wur.nl (A. Wagemakers).
1
Present address: Wageningen University & Research, Centre for Development Innovation, PO Box 88, 6700 AB Wageningen, The Netherlands.

http://dx.doi.org/10.1016/j.evalprogplan.2017.07.002
Received 21 January 2017; Received in revised form 17 June 2017; Accepted 2 July 2017
Available online 04 July 2017
0149-7189/ © 2017 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
M. Herens, A. Wagemakers
directed at vulnerable groups to increase physical activity and reduce
weight. At the group level, principles for physical activity and health
promotion in use are community participation, empowerment, enjoy-
ment, and learning processes (Hagberg, Lindahl, Nyberg, & Hellénius,
2009; Laverack, 2006a; Saan & de Haes, 2008). These group-based
principles for action are expected to contribute to the success and ef-
fectiveness of CBHEPA programmes because they leave room for ad-
justment to contextual needs on the one hand, and, as the programme’s
constituents, can be implemented in different contexts and settings on
the other hand (Kok, Vaandrager, Bal, & Schuit, 2012). The relevance of
group-based principles for action in the field of physical activity and
health promotion is widely recognised and reported. As far as we know
however, there is a lack of evidence on their contribution to the ef-
fectiveness of CBHEPA programmes, e.g. increase in physical activity at
the individual level. The assessment of principles for action at the group
level is not yet clearly operationalised, and tools for addressing this
issue are lacking, as we have found in our literature search (see Section
3.2). Consequently, little is known about how CPHEPA programmes
address the group-based principles for action and how they are valued
by stakeholders. Therefore, in this study, we developed a tool to assess
participants’ perceptions on group-based principles for action. In line
with modern health promotion principles for action, we took a con-
structionist and participatory stance, engaging stakeholders in the dif-
ferent steps to develop and test the new tool. In this paper, we describe
the development of the tool and guidelines for its implementation.
First, we set the scene for developing the tool for group-based
principles for action in Dutch CBHEPA programmes by presenting the
case of Communities on the Move (CoM), which has been subjected to
an effectiveness study (Herens et al., 2013; Herens, Bakker, van Ophem,
Wagemakers, & Koelen, 2016). Next, we describe the explorative
strategy to develop an instrument to assess participants’ perceptions on
the group-based principles for action: Active Participation, Enjoyment,
and Fostering group processes (APEF). Thereafter, we describe the re-
sults of the APEF tool in 10 focus groups and the experiences of both
participants and researchers regarding implementation of the tool.
Detailed results obtained on groups’ evaluation narratives on the
principles for action have been published elsewhere (Herens,
Wagemakers, Vaandrager & Koelen, 2015). We discuss the APEF tool
and conclude with lessons learned on implementing it for CBHEPA
programmes targeting socially vulnerable groups.
2. Setting the scene for assessing principles for action at the group
level
CoM was developed and disseminated (2003–2012) by the
Netherlands Institute for Sports and Physical Activity (NISB) – since
2016 the Dutch Knowledge Centre Sports – and targets socially vul-
nerable groups. CBHEPA programmes, such as CoM, use an ecological
perspective on health (Sallis et al., 2006), emphasising the interaction
between factors within and across the different levels of intervention
(Glanz, Rimer, & Viswanath, 2008; Herens et al., 2013). CoM defined a
set of principles for action at individual, group and programme level. As
part of an on-going evaluation study of CoM, we sought to evaluate
group-based principles for action.
Group-based principles for action, defined in CoM, are active par-
ticipation, enjoyment, and fostering group processes (Herens et al.,
2013). At group level, CBHEPA programmes build on social cognitive
theory (SCT) (Bandura, 2004), social learning theory
(Bandura & McClelland, 1977), and the concepts of social capital
(Putnam, 2001), participation (Pretty, 1995), and enjoyment (Hagberg
et al., 2009; Raedeke, 2007). SCT explains behaviour as a product of the
interplay of individual, behavioural, and environmental influences and
underlines that individuals learn from one another by observing and
operating collectively to achieve change (Bandura, 2004). Social capital
enables people to share information, to provide social support, and to
collaborate in order to achieve certain goals that cannot be achieved
55
Evaluation and Program Planning 65 (2017) 54–68
working alone (Morrens, 2008). Active participation, or level of en-
gagement of participants in a group, (Hyyppä & Mäki, 2003; Lindström,
Hanson & Östergren, 2001; Pretty, 1995) and social engagement, or
level at which participants participate in activities and social connec-
tions, are related to social capital (De Leon, Glass, & Berkman, 2003).
Involving the target group, and making programmes culturally
sensitive, are actions that thrive on a participatory and egalitarian
perspective inphysical activity promotion (Gregg & O’Hara, 2007), in
which target groups are actively involved in decision making
throughout the programme (Aldridge, 2014; van der Deijl, Etman,
Kamphuis, & van Lenthe, 2014; Withall, Jago & Fox, 2011). In addition,
participatory processes facilitate the development of capacities,
learning, and empowerment (Rice & Franceschini, 2007), and enable
and empower people to gain control over their lives and the determi-
nants of their health (Koelen & Linström, 2005; Wagemakers et al.,
2008).
Monitoring real-world interventions and improving the engagement
of socially vulnerably groups inphysical activity research suggest con-
structionist (Patton, 2002), participatory, and action-oriented research
(Green, Glasgow, Atkins, & Stange, 2009; Wagemakers, Vaandrager,
Koelen, Saan, & Leeuwis, 2010; Wallerstein et al., 2011). Therefore,
primarily constructionist evaluation criteria need to be used in asses-
sing principles for action at group level, such as engaging those with
less power respectfully and collaboratively, respecting multiple per-
spectives, reflexivity, doing justice to the integrity of unique cases, and
contributing to deepening understanding and dialogue (Patton, 2002).
Thus, our study fits with the key principles for action for physical ac-
tivity promotion strategies in socially vulnerable groups as defined by
the WHO: 1) involve target groups in all stages of programme devel-
opment, 2) make programmes culturally sensitive, 3) develop and
maintain partnerships and adopt an ecological approach, 4) monitor
real-world interventions, measure long-term adoption and main-
tenance, and 5) improve the recruitment of the target group in physical
activity research studies (WHO, 2013, pp. 7–8).
3. Development of the APEF tool
We used an iterative, exploratory design to identify indicators and
measurement instruments of group-based principles for action.
Scientific and practice-based evidence on group-based principles for
action were combined to develop the APEF tool in three phases (Fig. 1):
a) to identify indicators of principles for action, b) to search for mea-
surement instruments to assess principles for action, and c) to oper-
ationalise the group-based principles for action into statements.
3.1. Identifying indicators of group level principles for action
Expected output and outcomes of group-based principles for action
in CoM are programme adherence (active participation), programme
satisfaction (enjoyment), and group learning (fostering group pro-
cesses) (Herens et al., 2013). First, to define and operationalise these
concepts, we conducted a literature search to identify indicators, based
on existing theories, for group-based principles for action in sport and
physical activity. The Scopus database was used (Appendix A). Inclu-
sion criteria were professional discipline (e.g. health, social science)
and language (English). Group-based principles for action and theore-
tical concepts were included as search terms in combination with the
inclusion criteria physical activity, sport, full text availability, and a
focus on team or group level. Second, using purposive sampling in order
to collect practice-based information, we conducted semi-structured
interviews, with the two NISB professionals providing CoM training.
They were interviewed about CoM group-based principles for action
and known instruments to assess indicators for principles for action in
sport and physical activity groups. The Appreciative Inquiry technique
(Cooperrider, Whitney, & Stavros, 2005) was used to stimulate an open
and positive interview. Third, we conducted a secondary analysis to
M. Herens, A. Wagemakers
Fig. 1. Overview of methods used to develop the APEF tool.
further identify practice-based indicators for group-based CoM princi-
ples for action of respectively: a) full transcripts of three group inter-
views with in total 11 CoM exercise trainers and coordinators, con-
ducted at the start of the CoM evaluation study and b) full transcripts of
two duo-interviews, with a coordinator and an exercise trainer, at two
CoM locations. Exercise trainers and coordinators were sampled from
all CoM locations included in the evaluation. Fourth, we observed ex-
ercise classes in three groups participating in the CoM evaluation study
(convenience sampling) in two different municipalities. Detailed ob-
servation reports were written. The interview transcripts and observa-
tion reports were coded top-down in Atlas.ti (7.0), based on the three
group-based CoM principles for action: active participation, enjoyment,
and fostering group processes, by two researchers. The results were
discussed with a third researcher.
For each group-based principle for action, indicators based on sci-
entific literature and on empirical data (interviews and observations)
are described in Table 1. Literature-based indicators on active partici-
pation reflected the programme planning and organisational perspec-
tive, mainly about participation levels and decision making (three
publications: Pretty, 1995; Rifkin, Muller, & Bichmann, 1988;
Wagemakers, Vaandrager, Koelen, & Leeuwis, 2010), and participant-
driven implementation (four publications: Rinne & Toropainen, 1998;
Snyder & Stukas, 1999; Vernon & Ross, 2008; Wagemakers et al., 2008).
Indicators based on empirical findings describe active participation in
terms of participant involvement, group formation, or programme
content.
Literature-based indicators on enjoyment of physical activity showed
individual and group-related (verbal and non-verbal) experiences and
expressions of enjoyment as perspectives for measurement (seven
publications: Kuroda, Sato, Ishizaka, Yamakado, & Yamaguchi, 2012;
56
Evaluation and Program Planning 65 (2017) 54–68
Legrand, Bertucci, & Thatcher, 2009; Lomax, Brown, & Howard, 2004;
Løvoll & Vittersø, 2014; Mullen et al., 2011; Parastatidou, Doganis,
Theodorakis, & Vlachopoulos, 2012; Sim, Bartlam, & Bernard, 2011).
Indicators based on empirical findings identified factors related to
participants’ experiences such as satisfaction and feelings of safety and
positivity.
Literature-based indicators of fostering group processes showed dif-
ferent group characteristics as perspectives for measurement: group
structure, composition, norms, roles, social support, and leadership.
Three publications were found for group dynamics in sport and physical
activity settings (Pescosolido & Saavedra, 2012; Spink,
Wilson, & Priebe, 2010; Zucchermaglio, 2005). Indicators based on
empirical findings identified factors that largely overlapped with the-
oretical indicators, emphasising the role of leadership and aspects of
group support and safety.
3.2. Identifying measurement instruments for group-based principles for
action
To identify measurement instruments for indicators of group-based
principles for action, a second literature search was conducted, using
scientific (Scopus) and grey literature (CoM documentation). First, in-
itial search terms combined sport and physical activity with tools, in-
struments, or methods (Appendix B). Inclusion criteria were profes-
sional discipline (medicine/health professional/psychology/social
science/nursing science/multidisciplinary), language (English) and
published later than the year 2000. Second, the identified CoM prin-
ciples for action and theoretical concepts were added. Inclusion criteria
were full text availability and a focus on physical activity settings and
behaviour. Third, criteria for evaluation in socially vulnerable groups
M. Herens, A. Wagemakers Evaluation and Program Planning 65 (2017) 54–68

Table 1
Overview of indicators for group-based principles for action.

Principle Indicators based on literature Indicators based on (group) interviews and observations

Active participation [1]
Enjoyment [2]
Fostering group processes
[3]
Participation levels and decision making:
■ Problem solving
■ Mission, strategy, goals, action plans
■ Ownership, dedication, task motivation, ownership
Programme activities:
■ Frequency, time, intensity
■ Expectations, competences, skills, knowledge
■ Emotions regarding physical activity challenges and skills
■ Degree of enjoyment
■ Physical expressions of joy (e.g. laughing)
■ Non-verbal expressions of joy (e.g. smiling)
■ Sense of revitalisation and relaxation
■ Value attribution to physical activity activities
■ Group composition (e.g. size, (cultural) diversity, development
phase, power relations)
■ Group structure (interdependence, ownership, commitment, self-
organisation)
■ Group roles (formal and informal)
■ Group norms (shared beliefs, collective goal setting and task
motivation, responsibility, and cooperation)
■ Group cohesiveness (sense of belonging, confidence, respect,
integration, interpersonal and group attractiveness)
■ Social support (commitment, motivation, collective faith)
■ (Typology of sport) Leadership styles
■ Degree of participation in group formation
■ Degree of participation in programme content
■ Participant involvement in programme decision making
■ Participant involvement in recruitment and group formation
■ Participant involvement in follow-up of absenteeism
■ Participant involvement in initiating new health enhancing
(physical activity) initiatives within group or wider community
■ Participants’ satisfaction with physical activity activities
■ Role of safety
■ Role of learning
■ Percentage of participants expressing positive feelings about
organised activities
■ Conditions and experiences that make physical activity fun
■ Group processes
■ Closed versus open group structures
■ Role of exercise trainer
■ Role of group leader
■ Power relations
■ Cultural diversity
■ Programme components that enhance group dynamics and group
cohesion
■ Programme components that enhance involvement of the social and
physical environment in group activities

1 Pretty, 1995; Rifkin et al., 1988; Rinne & Toropainen, 1998; Snyder & Stukas, 1999; Vernon & Ross, 2008; Wagemakers et al., 2008; Wagemakers, Vaandrager et al., 2010. 2 Kuroda
et al., 2012; Løvoll & Vittersø, 2014; Legrand et al., 2009; Lomax et al., 2004; Mullen et al., 2011; Parastatidou et al., 2012; Sim et al., 2011. 3 Pescosolido & Saavedra, 2012; Spink et al.,
2010; Zucchermaglio, 2005.

were added, e.g. target group involvement, providing immediate
feedback, cultural sensitivity. Techniques for individual interviews or
questionnaires were excluded. Finally, the search term ‘focus group’
was added, resulting in one publication for participation (Wagemakers
et al., 2008), three publications for enjoyment (Jallinoja,
Pajari, & Abseth, 2010; Jepson et al., 2012; van Uden-Kraan, Drossaert,
Taal, Seydel, & van de Laar, 2008), and one publication for fostering
group processes (Casey, De Civita, & Dasgupta, 2010). Search in the
grey literature resulted in two reports on CoM (Beijer, 2009; Hiemstra,
2005).
For each group-based principle for action, assessment instruments
found in scientific and grey literature are described in Table 2, pre-
senting data collection procedures, typology of indicators relating to the
principles, strengths, weaknesses, and information on reliability and
validity, if available. Identified group-based instruments for active
participation were: assessing participation levels within groups, based
on Pretty’s participation ladder (Pretty, 1995; Wagemakers et al.,
2008), and Rifkin’s spider method to assess community participation
levels (Laverack, 2006b; Rifkin et al., 1988). The group-based instru-
ment identified for enjoyment and fostering group processes was group
interviews (Casey et al., 2010; Jallinoja et al., 2010; Jepson et al., 2012;
van Uden-Kraan et al., 2008). CoM documents added evaluation ap-
proaches combining group interviews and group activities – making a
collage or ranking Images – providing concrete examples of experiential
learning and creating immediate feedback loops (Hiemstra, 2005).
3.3. Operationalisation of group-based principles for action into statements
None of the instruments identified addressed the defined indicators
for group-based CoM principles for action in a comprehensive way.
Therefore, we developed a new tool based on the insights gained from
literature and practice, and in consultation with fellow researchers. The
format of the tool, probing dialogue by statements (Jallinoja et al.,
2010), use of cards to engage participants (Wagemakers et al., 2008),
and reporting in the form of spider diagrams (Laverack 2006a; Rifkin
et al., 1988), was inspired by some of the identified instruments. The
group-based principles for action were operationalised as follows:
• Active participation: 1) participation in group formation, 2) partici-
pation in physical activity programme content decision making, and
3) participation in community initiatives.
• Enjoyment in physical activity: 1) expressions of enjoyment (physi-
cally, verbally, and non-verbally) and 2) safe and supportive en-
vironments.
• Fostering group processes: 1) social support, looking at group compo-
sition (size, (cultural) diversity, boundaries, phase) and group struc-
ture (roles, norms, social support, and cohesion), 2) role of the ex-
ercise trainer, and 3) learning achievements.
The indicators were translated into eight statements. Together with
in-depth questions, the statements formed a semi-structured interview
protocol, the APEF tool (Table 3), generating quantitative and quali-
tative data. The statements were used in focus groups toprobe theme-
driven dialogue between researcher and respondents, as well as dia-
logue among respondents.
The APEF tool was crosschecked with experts from a culturally
sensitive research agency and tested in a pilot project in 2013 (Herens,
Wagemakers, den Besten & Bernaards, 2015). Based on pilot experi-
ences, adaptations were made. Initially, participants voted on the
statements successively and then joined in a plenary group discussion.

57
 Table 2
Overview of measurement instruments for group-based principles for action.
Instrument Data collection procedure
Active participation
Focus group to assess Group interview Use of cards
participation levels describing Pretty’s level of
[1] participation [2]. Participants
select most appropriate card.
Assessing participation Use of cards describing level of
levels [3,4] participation. Participants
select most appropriate card.
Rifkin’s spider method to Visualises six themes relating
measure participation to participation levels
[5]
Enjoyment
Focus group [6] Group interview Probing
dialogue by showing
conflicting statements
Focus group [7] Group interview
Focus group [8] Group interview
58
Physical activity collage Group activity Creating group
[5] collage Participants choose
favourite image or text and
explain their choice
Physical activity mapping Group activity Participants
[5] prioritise PA activities using
stickers, followed by dialogue
on sticker patterns
Evaluation physical Participants choose object/
activity 1 [5] picture fitting their feelings
during exercise class, followed
by discussion
Evaluation physical Group draws cartoons
activity 2 [5] symbolising their feeling
during exercise class
Evaluation physical Participants choose a smiley
activity 3 [5] each time they participate in
an activity
Variables
Role, task, responsibility, commitment,
ownership, task motivation, decision
making, Pretty’s participation levels
Pretty’s participation levels
Power relations, decision making,
mission, goals, action plan, expectations,
commitment, ownership, participation
levels
None made explicit
Valuing activities Role of safety
Participants’ preferences in PA activities
None made explicit
Emotions regarding physical activity
challenges and skills Value attribution to
activities Degree of enjoyment
Participants’ preferences in physical
activity activities
Emotions regarding physical activity
challenges and skills Degree of
enjoyment Value attribution to activities
Emotions regarding physical activity
challenges and skills Value attribution to
activities
Emotions regarding physical activity
challenges and skills Value attribution to
activities
Emotions regarding physical activity
challenges and skills Value attribution to
activities Degree of enjoyment
Reliability and validity Strengths
Unknown Used in Dutch low SES
migrant groups in Amsterdam
Unknown Used in CoM physical activity
groups.
Unknown Assesses a broad variety of
variables in an easily
interpretable way
Unknown Used for men and women
Used in small groups (n = 5)
Topic list formulated by Used in migrant groups Used
group of researchers from in low, socially disadvantaged,
various ethnic backgrounds and high SES groups Used for
men and women
Unknown Used in small groups (4–10
participants)
Unknown Suitable for all kinds of target
groups to a max of 20
participants Suitable for
illiterate target groups
Unknown Suitable for all kinds of target
groups to a max of 20
participants Suitable for
illiterate target groups
Duration ca. 30–40 min
Unknown Suitable for low-literate target
groups Non-verbal; makes
feelings explicit Visualisation
Unknown Suitable for low-literate target
groups Non-verbal; makes
feelings explicit Visualisation
Unknown Suitable for illiterate target
groups Non-verbal; makes
feelings explicit Visualisation
Weaknesses
Used in women’s groups only
(aged 25–45 years)
M. Herens, A. Wagemakers
Not suitable as group method, as
cards were used selectively and
difficult to understand
Focus on programme
participation in steering group
or project team, not clear
whether or not method is used in
group settings
Physical activity enjoyment not
leading theme
Used in target group 50–65 years
Duration 70–120 min
Questions only address
enjoyment in potential sport or
physical activity activities
Enjoyment not directly
addressed
Used for cancer patients
Focus on yoga
Time consuming
Choice of pictures is target-
group sensitive
Shows individual results
Method applicable for one
session only
Choice of objects/pictures is
target group sensitive
Method applicable for one
session only
Requires some artistic skills
Shows individual results
Method only applicable at
activity level
Evaluation and Program Planning 65 (2017) 54–68
(continued on next page)
M. Herens, A. Wagemakers Evaluation and Program Planning 65 (2017) 54–68

In the pilot project, discussions started as soon as a statement was read

collaboration in steering group

Group processes not addressed
out loud. Therefore, we changed procedures and asked participants to

No immediate feedback of
vote first and then discuss a statement, before proceeding to the next

participants’ language

Focus on programme
statement.
Observer must speak

Hard to objectify

or project team
4. Implementation of the APEF tool
Weaknesses

Unknown
results
The APEF tool has been used in 10 different CBHEPA groups. In this
paper, we provide the scores on the statements on the group-based
principles for action across groups and refer to another paper for de-
tailed narratives on the group-based principles for actions based on
discussing the statements (Herens, Wagemakers, Vaandrager et al.,

1 Wagemakers et al., 2008; 2 Pretty, 1995; 3 Beijer, 2009; 4 Rifkin et al., 1988; 5 Hiemstra, 2005; 6 Jallinoja et al., 2010; 7 Jepson et al., 2012; 8 van Uden-Kraan et al., 2008. 9 Casey et al., 2010.
Suitable for small groups (4–5
Immediate feedback of results
Signals both verbal and non-
Can be used during exercise

2015). We also present both participants’ and researchers’ reflections

on the implementation of the APEF tool.
class by exercise trainer
Used in groups of 6–10

verbal behaviour

4.1. Implementation in CBHEPA groups

participants

From May 2013 to May 2014, the APEF tool was used in 10 CBHEPA
Strengths

persons)

groups participating in the CoM evaluation study (Herens et al., 2013)

in five municipalities (convenience sampling). The CBHEPA pro-
grammes were diverse in duration and nature of activities, e.g. walking
or running, endurance training, aerobics. Two programmes had a fixed
duration (10–13 weeks). Respondents in these programmes met for the
focus group during adult education activities. The other eight CBHEPA
Reliability and validity

programmes offered continuing activities (Table 4). Information on

respondents’ personal and socio-economic conditions was derived from
data collected in the overall CoM evaluation.
A total of 76 respondents participated, 84% women, 16% men,on
Unknown

Unknown

Unknown

Unknown

average 61.6 (sd 13.2) years of age. Nearly 50% of the respondents were
of non-Dutch origin, representing 15 different countries of origin.
Household incomes were relatively low, 48.5% less than €1350 a
month. Educational levels were also relatively low, 42.2% had no or
only primary education. Over 90% were not employed. The majority,
65.2%, participated longer than six months in the physical activity
Role exercise trainer Role group leader
Task performance and impact of group

group and were physically active on average 210.1 (sd 147.2) min/day.
Physical activity groups were rather homogenous in terms of sex: six
size Balance cooperation and

groups were only women and one group were only men. The other
competition Commitment

three groups were mixed.

In all CBHEPA programmes, group members volunteered to parti-
None made explicit

None made explicit

cipate in a focus group. At the start of the focus group, respondents

Power relations

were asked to give oral consent for participation and for the proceed-
ings to be audio recorded. Next, the aim and procedure of the APEF tool
Variables

were explained by the researcher (first author), who acted as a facil-

itator to generate a free flow of information among respondents.
Assistance was provided by one or two junior researchers. Dutch was
the language of conversation in all groups, in line with common prac-
tice in the physical activity groups. Ethnic diversity within groups was
by taking a number of steps,
own and group performance

high, turning Dutch into the mutual language of communication. But

Group interviews Mapping
Participants estimate their
Data collection procedure

Observation in the group

Dutch not being the mother tongue of several group members, the fa-
followed by explanatory

actors Completion actor

cilitator had to make additional efforts to explain concepts when

needed. At the start, the facilitator made clear that participants were
Group interview

there because we wanted to learn from them − that they are the ex-
perts. Furthermore, she promoted interaction among participants and
overview
dialogue

encouraged those who kept silent to participate in the discussion.

To provide for immediate feedback, the statements, written on
flipcharts, were presented in the groups. Each statement was read out
aloud. With coloured voting cards carrying text and symbols, re-
spondents scored for each statement whether they ‘agreed’ (green card
with ), ‘did not agree or disagree’ (yellow card with ) or ‘disagreed’
Fostering group processes

Group observation [5]

(red card with ). Group scores were reported on flipcharts during the
Actor mapping [5]
Table 2 (continued)

focus group and further discussed in-depth. The duration of each focus
Focus group [9]

3 D graph [5]

group ranged from 50 to 70 min. At the end of each session, re-

Instrument

spondents were asked to reflect on their experiences during the focus

group. Field notes were taken during each focus group and used for
reflection by the researchers.
The focus groups were conducted in rather open settings, using the

59
M. Herens, A. Wagemakers Evaluation and Program Planning 65 (2017) 54–68

Table 3
Components of the APEF tool.

Variables Statement Examples of in-depth questions

Active participation
Group formation
Content activity class
Community initiative
1. We, as an exercise group, choose who participates in the exercise group
2. We, as an exercise group, choose the activities for the exercise class
3. Some participants within the exercise group take the initiative to exercise
together
How long have you been exercising together?
How are participants recruited?
Do you ever bring a friend or a neighbour?
What does your physical activity programme look like?
Were you involved in the choice of activities, and, if so, how did
that work?
How important is that for you?
Can you give an example of somebody taking the initiative?

Enjoyment
Enjoyment of physical activity
Feelings of safety
4. Exercising together in the exercise group ensures that I like being
physically active
5. The exercise group offers me safety to be physically active
What physical activity do you like most?
Is the programme consistent with your preferences?
How do you ensure that everybody can enjoy the physical activity
class?
What comes to your mind if we talk about safety?
How does the group support safety?

Fostering group processes

Social support
Role exercise trainer
Learning achievements
6. Exercising in the exercise group offers me support to be physically active
7. Within the exercise group, the exercise trainer is an example for me to be
physically active.
8. By exercising in the exercise group, I learn how to be more physically
active in my daily life
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?
In what way is the exercise trainer an example?
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?

sports venue (a sports club canteen or classroom) as meeting place. In
six focus groups, exercise trainers who remained present were asked not
to take part in the dialogue. Sometimes, other people were present or
had access. In four focus groups, listeners were present who were also
told not to contribute to the discussions, as they were not participating
in the CBHEPA programme.
4.2. Results of the APEF tool
For each focus group, mean scores per statement were calculated
(1 = disagree; 2 = do not agree or disagree; 3 = agree) and visualised
in spider diagrams (Fig. 2). As can be seen from the diagrams, the 10
groups differed mostly in scores on the statements on active partici-
pation, less on the statements on enjoyment, and even less on the
statements on fostering group processes.
Group mean scores on participation in group formation ranged from
1.0 (disagree) to 3.0 (agree). Various reasons for disagreement on the
statement that group members themselves choose who participates in
the group, were given: in FGs 1 and 2 (women’s groups of non-Dutch
origin), the exercise trainer was responsible for recruitment, whereas in
FGs 3, 4, 9, and 10 (mixed or women’s groups of Dutch origin) the
dominant view was that people act on their own responsibility. Group
mean scores on participation in the content of the physical activity pro-
gramme ranged from 1.0 to 2.7. The main reason given by respondents
for disagreement on the statement that the exercise group chooses the
activities for the exercise class, was their trust in the exercise trainer:
‘he/she knows what is good for us’. Reasons for neither agreeing nor
disagreeing related mostly to respondents acknowledging that they did
have an influence on content. Therefore, they did not feel any need to
agree or disagree. Group mean scores for participation in community
initiative ranged from 1.6 to 2.8, meaning that in some groups more
than in others participants take the initiative to exercise together.
Group mean scores for enjoyment, liking physical exercise together
in group, ranged from 2.2 to 3.0. FG 1 scored lowest, probably because
respondents were no longer exercising together and had experienced
multiple changes in exercise trainer. Group mean scores for feelings of
safety, meaning that the exercise group offers safety for being physically
active, ranged from 2.1 to 3.0. FGs 3, 4, 9, and 10 (Dutch respondents)
scored lower, compared to the other FGs. Reasons for neither agreeing
nor disagreeing related to a large variety of views on safety, such as
concepts related to environmental safety, e.g. security of materials and
protection against loss or theft, and concepts related to emotional
safety, e.g. mutual care and respect.
Group mean scores for social support, support offered by the exercise
group for physical activity, ranged from 2.3 to 3.0. FGs 3 and 4 (Dutch
respondents) scored slightly lower, compared to other FGs. This might
be related to the physical activity environment (outdoors). Social sup-
port evoked considerable debate as for many participants the concept
was not clear and encompassed for example complimenting and helping
one other, reaching out to non-attending group members, and group
norms such as ‘physical activity is healthy’. Group mean scores for the
role of the exercise trainer, as an example to be physical active, ranged
from 2.6 to 3.0, reaching the highest level of consensus in all FGs.
Apparently, the exercise trainer has a key role in the physical activity
group. Group mean scores for learning achievements, to learn to be more
physical active in daily life, ranged from 1.9 to 3.0. FGs 3 and 9 (Dutch
respondents) scored lower, compared to other FGs. The main reason for
disagreement related to respondents’ awareness of the difference be-
tween intentions (knowing what is good for you) and practice (doing in
daily life what is good for you), probably more easily expressed by
Dutch respondents.
Respondents’ reflections on their experiences with the APEF tool,
collected at the end of each focus group, indicated that the APEF was
perceived as very clear. Some indicated that discussing the statements
helped them to understand better the purpose of the CBHEPA pro-
gramme and made them more aware of the overall programme aims. It
was ‘nice’ to share personal experiences in the physical activity group
through dialogue. Respondents learned something new about their

60
 M. Herens, A. Wagemakers

Table 4
Characteristics of CBHEPA programmes.

Municipality FG Respondents CBHEPA programme characteristics

N = 76 Programme Duration Sports venue Frequency Main activities Target group

A 1. women (n = 6) Be Interactive Fixed (10 weeks) Community centre Weekly (1.5 h) Walking/running Socially vulnerable migrant
women
Embedded in language class
E 2. women (n = 6) Scoring with Health Fixed (13 weeks) Sports club canteen 2x week (3 h) Sport introduction of various activities Socially vulnerable groups
Embedded in education trajectory (18 months follow-up
meetings once every 6 weeks)
H 3. women (n = 8) Outdoor fitness, group 1 Continuous Playground outdoor Weekly (1 h) Group fitness class Socially vulnerable groups in
fitness community
men (n = 1)
4. women (n = 6) Outdoor fitness, group 2 Continuous Playground outdoor Weekly (1 h) Group fitness class Socially vulnerable groups in

61
fitness community
men (n = 2)
R 5. women (n = 6) Exercise to music Continuous Community centre Weekly (1 h) Group exercise to music Socially vulnerable migrant
women
6. women (n = 10) Exercise for elderly women Continuous Community centre Weekly (1 h) Adapted group exercise to music, Socially vulnerable (migrant)
including fall prevention women
7. women (n = 11) Turkish folk dance for women Continuous Community centre Weekly (1 h) Group exercise to music Socially vulnerable migrant
women
8. men (n = 7) Exercise for men Continuous Residential care home Weekly (1 h) Group fitness class Socially vulnerable migrant
men
T 9. women (n = 4) Special Gym Continuous Community centre Weekly (1 h) Adapted group exercise class Women/men 55+, with
chronic illness
men (n = 3)
10. women (n = 6) Keep Fit Continuous Community centre Weekly (1 h) Adapted group exercise class Elderly women 55+

*FG 6 was conducted during language class in a community centre, in the presence of four migrant women not participating in the physical activity group. *; **In FG 9, five group members participated in the FG without participating in the CoM
evaluation study; no background details were made available, except sex and ethnic origin.
Evaluation and Program Planning 65 (2017) 54–68
M. Herens, A. Wagemakers
fellow participants, it was fun to participate, and it was interesting to
hear other people’s views. In some focus groups, respondents were
surprised about the level of consensus they reached. They also ex-
pressed the hope that the results from the focus group would help im-
prove physical activity opportunities at community level.
Some respondents indicated that participating in a group discussion
62
Evaluation and Program Planning 65 (2017) 54–68
Fig. 2. Mean group scores per APEF statement.
was new for them and therefore a bit exciting. Some also indicated that
they experienced some discomfort when they did not immediately
grasp the meaning of a statement. It was not always well understood
that the yellow card could be used in the event of doubt.
In addition, the scoring procedure (‘agree–disagree’) reminded some
respondents of other occasions when they had to give their opinion (e.g.
M. Herens, A. Wagemakers
hospitals), and they were questioning more generally the need to con-
tinuously evaluate everything.
4.3. Researchers’ reflections
On the basis of the researchers’ experiences with the APEF tool in 10
groups, they observed that respondents were actively involved in group
dialogue and made efforts to communicate clearly. Non-CBHEPA par-
ticipants and exercise trainers, when present, may, however, have in-
fluenced the dialogue. The focus groups require a thorough preparation
in order to facilitate the whole process, including the voting procedure
and the group dialogue.
Respondents remained actively involved throughout the group in-
terview. Working with statements and the voting procedure generated
immediate interest and interaction. Respondents started reading the
statements or the cards out loud and stimulated others to join in. The
downside was that they may also have influenced one another, e.g. by
shouting out ‘green’ before everyone had made their choice. On several
occasions, respondents started to confer immediately with one another,
in particular in the event of doubt about the meaning of a statement,
forgot to use their vote cards, or gave their votes only after discussion.
In some focus groups, respondents, more often those of non-Dutch
origin, endeavoured to give the ‘right’ answers, for example by cor-
recting one another’s answers. Sometimes, when there was disagree-
ment, respondents even got annoyed. Several times, the facilitator had
to intervene by indicating that differences in views were welcomed.
In groups of non-Dutch origin, participants all made an effort to
express themselves clearly to one another and to the facilitator, even
though Dutch was not the mother tongue. Several times, the facilitator
had to provide extra explanations on concepts or repeat the explanation
in other words. Occasionally, group leaders or group members, profi-
cient in Dutch, translated. Ethnic diversity within the physical activity
groups, however, was so substantial that arranging for formal inter-
pretation was not practicable.
In four groups, listeners were present; and in six groups exercise
trainers remained present. Although they were asked not to take part in
the dialogue, all exercise trainers at some point started to intervene.
Various roles could be identified. In the role of interpreter, exercise
trainers regularly reformulated a statement or question, or slowed
down the speed of conversation. Occasionally, they took over the dia-
logue and started to speak for, or on behalf of, the respondents. In the
role of mediator, exercise trainers encouraged respondents to answer,
by giving examples or by complimenting them. In the role of gate-
keeper, exercise trainers got involved in the organisation of the focus
group, taking care of group members leaving, or time keeping. In the
role of guarding over the group’s collective consciousness, exercise
trainers encouraged participants to reflect on past or current group is-
sues. Sometimes, the exercise trainers were a source of distraction, as
they got respondents engaged in day-to-day matters.
From the researchers’ perspective, it is clear that the APEF tool re-
quires good organisational and material skills prior to, and during, the
focus group, e.g. flip charts need to be prepared in advance, need to be
attractive and presented clearly. The use of an example statement at the
start helped to explain the purpose and procedure of the focus group.
Additionally, giving instructions on practicalities, such as individual
reflection on each statement before showing the voting cards, is helpful.
Organisational assistance facilitated the smooth conduct of the focus
groups, e.g. in handing out voting cards, and keeping track of the
scores, reading them out loud. It also enabled the facilitator to reach out
to those respondents who kept silent.
5. Discussion of the development, use, and results of the APEF tool
This paper describes the development, use, and results of the APEF
tool to assess group-based principles for CBHEPA programmes targeting
socially vulnerable groups. The APEF tool contributes to the
63
Evaluation and Program Planning 65 (2017) 54–68
understanding of group level aspects in CBHEPA programmes by
monitoring the group-based principles for action on the one hand, and
simultaneously facilitating group processes on the other. Development
of the tool was guided by a constructionist (Patton, 2002) and (parti-
cipatory) action-oriented evaluation approach. In the APEF tool, dia-
logue, reflection, and discussion with and among participants is centre
core, and conditional for engaging stakeholders and respecting multiple
perspectives. The APEF tool is innovative, because, as far as we know,
no other tools address the group-level principles for action using a
constructionist and participatory approach. Known instruments iden-
tified in our literature search, address group level factors and influences
using mainly individual level techniques, such as questionnaires or
interviews. The APEF tool combines individual scoring with probing a
discussion in the group around statements and overall scores, thus
grasping individual and group-level perceptions and interactions. This,
we believe, is helpful in building a deeper understanding of the mul-
tidimensionality of today’s modern health promotion. In doing so, the
APEF tool can be placed on the ‘modern’ end of the continuum of health
promotion principles (Gregg & O’Hara, 2007).
We highlight the tool’s value in visualising results both within and
across groups, and the issues of interest regarding the evaluation of
group-based principles for action. This research generated evidence
emphasising the need for a better understanding of the processes of
value co-creation at different levels in CBHEPA programmes, and ways
to facilitate, manage, and supervise them from a social constructivist
paradigm. The need for actor involvement in evaluation is highlighted
to deepen our understanding of the social construction of reality and
processes of value attribution in community-based programmes.
Finally, we reflect on strengths and limitations of our methodology to
develop and use the APEF tool.
5.1. Engagement of stakeholders
Our results and experiences show that, during the different phases
of development of the tool, some stakeholders were more successfully
engaged than others. CBHEPA programme developers and practitioners
were successfully involved during the development phase of the APEF
tool, whereas target group representatives were not, mainly because of
practical constraints (time, resources). Nevertheless, thetool was suc-
cessful in reaching out to socially vulnerable groups, mostly of non-
Dutch origin, in CBHEPA programmes – possibly indicating that
CBHEPA professionals have the good understanding of the target
group’s needs. In addition, a culturally sensitive evaluation method was
realised by developing the APEF tool in consultation withexperts from a
culturally sensitive research agency.
With respect to target group engagement, in each of the selected
CBHEPA programmes, group members representing different ethnicities
were all invited to participate, stimulated by the facilitator’s direct
personal approach. It might be, that also (some outward) characteristics
of the researcher, being female and of similar age to most participants,
have been helpful in facilitating the discussion (Smithson, 2000), as
well as the fact that focus groups were held in groups existing prior to
the study: people who already know each other can create an en-
vironment of trust, allowing the participants to discuss their views very
openly (Dahlin Ivanoff & Hultberg, 2006). During each focus group,
themes were probed, dialogue among the target group was initiated,
and all respondents were encouraged to participate. Some concepts
used in the statements, especially safety and social support, appeared to
have different meanings for different respondents, and this actually
stimulated the discussion on those concepts. Therefore, there was room
for a culturally sensitive interpretation of concepts; this was appre-
ciated by respondents, as it contributed to their learning from other
cultures and getting a better understanding of one another.
Dialogue, including feedback, cross-checking, and discussing results
with participants, not only contributes to the validity of the results
(Butterfoss, 2006; Koelen, Vaandrager, & Colomer, 2001), but also
M. Herens, A. Wagemakers
increases satisfaction with evaluation and consequently increases par-
ticipation (Naylor, Wharf-Higgins, Blair, Green, & O’Connor, 2002;
Wagemakers, Vaandrager et al., 2010).
5.2. Visibility of results
Visibility of the APEF tool was achieved in the groups by the voting
procedure and in the programmes by spider web diagrams for re-
porting. Working with vote cards in different colours and smiley illus-
trations, checking by counting aloud, and writing down the scores for
each statement on flipcharts provided immediate feedback, made re-
spondents alert, and was therefore successful in engaging respondents
in a group dialogue. Moreover, visibility is an important incentive for
involvement and action (Koelen, Vaandrager, & Wagemakers, 2012;
Lorenz & Kolb, 2009; Wagemakers, Vaandrager et al., 2010). Reporting
through spider web diagrams makes it possible to draw lessons on each
of the principles for action at group level and to compare groups in
CPHEPA programmes. For example, in general, statements on active
participation scored lower than the other group-based principles.
5.3. Assessing group-based principles for action
Our assessment of group-based principles for action was part of a
broader evaluation to study the effectiveness of CBHEPA programmes,
in which an ecological perspective was used in order to grasp outcomes
at multiple levels and the interaction between levels (Herens et al.,
2013; Herens, Wagemakers, Vaandrager, van Ophem, & Koelen, 2016).
This is different from most other studies on the effectiveness of physical
activity, which usually only tune in on indicators for individual physical
activity behaviour and health improvement. Consequently, addressing
group-based principles has added value in evaluation, but also entails
new challenges, such as principles being intertwined and the sig-
nificance of group level results in relation to the effectiveness of
CBHEPA programmes.
The APEF tool is complementary to methods and tools that collect
individual level data and to measurement instruments for community
participation or capacity building, in which the domains assessed, e.g.
‘learning opportunities and skills development’, ‘resource mobilization’,
‘leadership’ and ‘communication’ (Liberato, Brimblecombe, Ritchie,
Ferguson, & Coveney, 2011) focus on communities rather than on
groups. Only the domain ‘participatory decision-making’ is more or less
similar to the first variable, active participation, in the APEF tool. An-
other commonality with some other tools is for example that both the
APEF tool and Rifkin’s participation measurement instrument (Rifkin
et al., 1988), which assesses the functioning of a collaboration, sum-
marize individual scores following by reflection and discussion by the
group or stakeholders.
The group-based principles for action were operationalised by
identifying indicators in the literature. However, the indicators could
not be sharply defined, probably because principles for action are
multifaceted and complex constructs, as they are both intangible and
omnipresent. For example, our findings show that fostering group
processes, together with leadership, become apparent as generic prin-
ciples, contributing to active participation and providing the conditions
for experiencing enjoyment. To disentangle the effects of the different
principles for action in evaluation is, if even possible, a harsh en-
deavour.
The reciprocal relationship between individual behavioural out-
comes − such as increased physical activity behaviour and processes at
group level, including group-based experiential learning (who learns
what, when, and from whom), development of group norms, cohesion,
skills, and collective efficacy – needs to be explored further (Brawley,
Rejeski, & Lutes, 2000; Estabrooks, Harden, & Burke, 2012). This calls
for a more systematic approach, such as the use of mixed modelling to
determine underlying causal mechanisms of these approaches (Herens,
Bakker et al., 2016). For example by using a realist synthesis protocol to
64
Evaluation and Program Planning 65 (2017) 54–68
identify key combinations of contextual factors and mechanisms that
trigger outcomes on different levels (Herens, Wagemakers et al., 2016).
Another approach might be the further explorations of how to con-
sistently measure important variables, such as group environment,
process, and structure, or to compare and contrast across studies
(Estabrooks et al., 2012). The concept of group dynamics offers valu-
able insights to start with. Although there is no single conceptual model
or theory serving as a basis for analysis of group dynamics in physical
activity promotion in relation to behavioural outcomes (Estabrooks
et al., 2012), research shows the importance of social cohesion, social
order and control, and social support (Burke, Carron, Eys,
Ntoumanis, & Estabrooks, 2006; Carron, Hausenblas, & Eys, 2005;
Carron, Spink, & Prapavessis, 1997; Christensen, Schmidt, Budtz-
Jørgensen, & Avlund, 2006; Estabrooks & Carron, 2000 Estabrooks
et al., 2012). Some studies indicate that group dynamics strategies
applied in group-based physical activity interventions contribute sub-
stantially to effective physical activity behaviour change and main-
tenance (Burke et al., 2006; Estabrooks et al., 2012; Harden, Burke,
Haile, & Estabrooks, 2013).
Future research on physical activity behaviour and maintenance
should not only focus on how individuals act, but also on how in-
dividuals, groups, and environments interact.The need to incorporate
more systematically a perspective on group dynamic theories under-
lying the success or failure of community-based physical activity in-
terventions in different social and cultural contexts is proposed, in order
to understand better the mechanisms of social support and social capital
development (Estabrooks et al., 2012). In line with these further ex-
plorations, it is also recommended to study the utility of the tool in
groups in other settings within the field of health promotion, for ex-
ample groups focusing on promotion of healthy nutrition. In terms of
evaluation demands, this calls for explicit strategies in community-
based health promotion programmes to involve actors from all levels,
and aligning accountability with learning through evaluation, of which
the APEF tool is an example.”
5.4. Strengths and limitations
The APEF tool was developed using an iterative, explorative pro-
cess. A focus on evaluating real-world interventions was maintained
through systematically collected practice-based evidence by using the
APEF tool in 10 different groups, including 76 respondents.
The major strength of the APEF tool is that it combines theoretical
and practice-based knowledge in a practicable format, suitable for
formal evaluation. It contributes to a better understanding of the group
dynamics and contexts in place, and generates knowledge that is ac-
ceptable to the stakeholders (Patton, 2012). The iterative process,
highlighted in this paper, was based on a constructionist and (partici-
patory) action-oriented approach. Theoretical and practice-based in-
dicators for group-based principles for action were explored, and group
measurement instruments suitable for socially vulnerable groups were
inventoried. In this process, we organised the involvement of different
stakeholders in developing the different aspects of our evaluation
strategy. On the other hand, the APEF tool in itself does not, without
additional effort, feed a dialogue between target group and programme
developers. Apart from the evaluator, who reported back to, e.g., pro-
gramme developers, no insights were gathered on how learning ex-
periences were shared within groups, within programmes, or within
communities. Although, ideally, participation is fostered throughout
the whole evaluation process, whether it is desirable to strive for par-
ticipation at all levels by all stakeholders is disputable, as this might not
be reasonable or could even constrain the evaluation process (Nitsch
et al., 2013).
The APEF tool was used in existing groups, which can be considered
as homogeneous to some extent, meaning that members share values,
norms, roles and specific goals they want to achieve (e.g. being physical
active). This stimulates interaction between participants in the group,
M. Herens, A. Wagemakers Evaluation and Program Planning 65 (2017) 54–68

resulting in emergent views that might not be reducible to individuals
(Hydèn & Bülow, 2003). This distinguishes focus groups from other
(qualitative) methods, and should be reflected in the analysis of the
data. The group as a unit of analysis means that constructed knowledge
needs to be contextually interpreted (Dahlin Ivanoff & Hultber, 2006;
Smithson, 2000).
Voting procedures, group discussions, and results may have been
influenced by peer pressure from other respondents, people who
dropped in (some focus groups were in open settings), listeners, or
exercise trainers. This lack of a contained environment may have had
an impact on individual responses and may have influenced our results.
On the other hand, our account of the use of the APEF tool is illustrative
of the day-to-day practicalities with which one has to deal in mon-
itoring real-life interventions.
6. Lessons learned
The APEF tool generated insight into participants’ perceptions of the
group-based principles for action. In addition, it helped to improve our
understanding of group dynamics and contexts in place, and it gener-
ated knowledge acceptable to the stakeholders. Therefore, we believe
that the APEF tool is a valuable contribution to the ongoing discourse
on monitoring and evaluating physical activity promotion programmes
and the methods currently in use. The APEF tool is not, however, meant
to replace other methods for collecting hard data, such as quantitative
measurements at the individual level. Also, as recommended by the
WHO (2013), demographic data on the target population need to be
monitored.
We believe that the selected indicators are suitable for future use,
grasping the essence of group-based principles for action in CBHEPA
programmes. Rephrasing the abstract wording in some statements
should, however, be considered for socially vulnerable groups of non-
Dutch origin. Two statements in particular, those addressing social
support and group safety, generated considerable debate. Additional
explanations, rephrasing support as ‘help’ or ‘assistance’, and safety as
‘no need to be afraid’ or ‘feeling secure’, enabled respondents to un-
derstand the statement better. It is recommended for future purposes to
divide the statement on safety into two statements: one addressing
environmental safety and the other addressing emotional safety. As we
did not monitor whether outcomes of the APEF tool are translated to
other participants or programme developers, anotherrecommendation
is to further explore ways to communicate learning experiences gen-
erated by the APEF tool in a systematic way among the different sta-
keholders in CBHEPA programmes.
Using the APEF tool requires careful management of group dy-
namics in order to facilitate the voting procedure, to guide and focus
the discussion, and to reach out to participants who keep silent.
Moreover, the role of the facilitator in focus groups is to stimulate group
discussion between participants rather than discussion between herself
and participants, which is the case in group interviews (Parker & Tritter,
2006). Thus, the facilitator encourages and empowers participants to
talk to one another, to share experiences in a non-judgemental way and
to express their opinions (Dahlin Ivanoff & Hultberg, 2006). Therefore,
group facilitation encompasses a broad range of skills, including pro-
cess structuring, communication, conflict handling, and listening
(Hovmand, 2014; Vendix, 1999). Important skills highlighted in the
literature are to be a good listener and to learn from the groups (Dahlin
Ivanoff & Hultberg, 2006). The facilitator in our case (first author) is,
besides a researcher, a skilled trainer who facilitated many interactive
planning processes over the years. As not all facilitators are also re-
searcher and because it is challenging to manage the group dynamics
when one is using the APEF tool, the splitting of the facilitator role and
the researcher role should be considered. This could support observa-
tional reporting on group interactions during the focus groups, adding
to a better understanding of group roles and power relations, thereby
taking the group as a unit of analysis (Dahlin Ivanoff & Hultberg, 2006;
Smithson, 2000).
We also recommend the use of the APEF tool over time, as a long-
itudinal monitoring tool, to explore changes over time. It should be
noted, however, that this calls for a critical reflection on the pros and
cons of multiple measurements in the same groups, because changes in
outcomes can result from changes in opinions as well as from re-
spondents being more able to answer the questions.
7. Conclusion
The APEF tool provides clear guidance for collecting data on in-
dicators of group-based principles for action. In line with a con-
structivist and action-oriented approach, experiences with the APEF
tool demonstrate that information on participants’ perceptions of
group-based principles for action – active participation, enjoyment, and
fostering group processes – can be collected systematically. The tool
leaves room for collecting practice-based evidence for each unique case,
for an evaluation approach in which different strategies can be followed
to involve stakeholders (depending on the context or what is considered
most appropriate), for reaching the target group, and for respecting
multiple perspectives. Dialogue, discussion, and reflection are central
and conditional for each of the different group-based principles for
action. Therefore, fostering group processes and managing group dy-
namics is crucial when the APEF tool is being used.
Competing interests
The authors declare that there are no competing interests.

Appendix A

• Search strategy for APEF indicators in scientific literature

This overview presents the initial and subsequent search queries for indicators of the APEF principles for action in the Scopus database. Basic
terms in the literature search were sport* OR physical activit* AND variabl* OR indicator*. Inclusion criteria were discipline (medicine/health
professional/psychology/social science/nursing science/multidisciplinary) and language (English). Then, CoM guiding principles and theoretical
concepts were included as search terms: participation, enjoyment OR pleasure, group dynamic*, social cognitive theory OR social learning OR role
model OR social capital, in combination with the inclusion criteria physical activity, sport, full text availability, and focus on team or group level.

Initial search Inclusion based on Hits# APEF specified Search Hits Inclusion Additional query Hits
query query # based on #

sport OR physical Discipline: Medicine/Health 4279 AND participation 497 • PA AND social cognitive 2
act* variabl* professions/Psychology/Social behaviour/ theory OR social learning
OR indicator* Sciences/Nursing Sciences/ sport OR role model OR social
group AND Multidisciplinary Language: • group- capital

65
M. Herens, A. Wagemakers Evaluation and Program Planning 65 (2017) 54–68

NOT school English based

settings
• full text
available
AND participation level 1
OR participation ladder
OR active participation OR
community participation
AND enjoyment OR 46 • PA 7
pleasure behaviour/
sport
• full text
available
AND group dynamic* 137 • PA AND review AND Group 3
social cognitive theory behaviour/ level OR team
OR social learning OR sport
role model OR social • group-
capital based
settings
• full text
available

Appendix B

• Search strategy for APEF measurement instruments

This overview presents the initial and subsequent search queries for the measurement instrument of the APEF principles for action in the Scopus
database. Basic terms of the literature search were sport* OR physical activit* AND tool* OR instrument* or method group AND NOT school.
Inclusion criteria were discipline (medicine/health professional/psychology/social science/nursing science/multidisciplinary) and language
(English). Then, CoM guiding principles and theoretical concepts were included as search terms: participation (excluding questionnaires and sur-
veys), enjoyment OR pleasure, group dynamic* OR group evaluation* OR group interacti* OR group motivation. Publications on questionnaires and
surveys were excluded. Inclusion criteria were: full text of articles is available; methods focus on physical activity settings and behaviour, are
applicable to CoM target groups, are engaging, provide immediate feedback in the PA groups, and provide insight into elements of each CoM guiding
principle at group level. In this stage, methods based on individual interviews or questionnaires were also excluded. Finally, the search term ‘focus
group’ was added

Initial search query Inclusion based on Hits # APEF specified Search Hits Inclusion based on Additional query Hits
query # #

sport OR physical Discipline: Medicine/Health 20824 AND participation 821 • PA behaviour/ AND focus group 1
act* tool* OR professions/Psychology/Social sport participation OR
instrument* OR Sciences/Nursing Sciences/ • group-based participation ladder
method group Multidisciplinary Language: settings OR participation
AND NOT English • full text level
school available
• no (individual)
questionnaires
or survey
AND enjoyment OR 109 • PA behaviour/ 3
pleasure sport
• full text
available
• no (individual)
questionnaires
or survey
AND group dynamic* OR 442 • PA behaviour/ AND focus group 1
group evaluation* OR sport group context team
group monitor OR group • group-based
interacti* OR group settings
motivation • full text
available
• no (individual)
questionnaires
or survey

66
M. Herens, A. Wagemakers
References
Aldridge, J. (2014). Working with vulnerable groups in social research, dilemmas by
default and design. Qualitative Research, 14(1), 112–130.
Bandura, A., & McClelland, D. C. (1977). Social learning theory. General Learning
Company.
Bandura, A. (2004). Health promotion by social cognitive means. Health
Education & Behavior, 31(2), 143–164.
Beijer, C. (2009). Verspreiding van de interventie Communities in Beweging onder allochtone
vrouwen. [Dissemination of the program Communities on the Move among migrant women]
MSc Thesis Health and Society. The Netherlands: Wageningen University.
Brawley, L. R., Rejeski, W. J., & Lutes, L. (2000). A group mediated cognitive behavioral
intervention for increasing adherence to physical activity in older adults. Journal of
Applied Biobehavioral Research, 5(1), 47–65.
Burke, S. M., Carron, A. V., Eys, M. A., Ntoumanis, N., & Estabrooks, P. A. (2006). Group
versus individual approach? A meta-analysis of the effectiveness of interventions to
promote physical activity. Sport and Exercise Psychology Review, 2(1), 19–35.
Butterfoss, F. D. (2006). Process evaluation for community participation. Annual Review of
Public Health, 27.
Carron, A. V., Spink, K. S., & Prapavessis, H. (1997). Team building and cohesiveness in
the sport and exercise setting, use of indirect interventions. Journal of Applied Sport
Psychology, 9(1), 61–72.
Carron, A., Hausenblas, H., & Eys, M. (2005). Group dynamics in sport. Morgantown: WV,
Fitness Information Technology, Inc.
Casey, D., De Civita, M., & Dasgupta, K. (2010). Understanding physical activity facil-
itators and barriers during and following a supervised exercise programme in type 2
diabetes, a qualitative study. Diabetic Medicine, 27(1), 79–84.
Christensen, U., Schmidt, L., Budtz-Jørgensen, E., & Avlund, K. (2006). Group cohesion
and social support in exercise classes, Results from a Danish intervention study.
Health Education & Behavior, 33(5), 677–689.
Cooperrider, D. L., Whitney, D., & Stavros, J. M. (2005). Appreciative inquiry handbook.
The first in a series of AI books for leaders of change. US: Crown Custom Publishing, Inc.
Dahlin Ivanoff, S., & Hultberg, J. (2006). Understanding the multiple realities of everyday
life: Basic assumptions in focus-group methodology. Scandinavian Journal of
Occupational Therapy, 13(2), 125–132. http://dx.doi.org/10.1080/
11038120600691082.
De Leon, C. F. M., Glass, T. A., & Berkman, L. F. (2003). Social engagement and disability
in a community population of older adults, the New Haven EPESE. American Journal
of Epidemiology, 157(7), 633–642.
Estabrooks, P. A., & Carron, A. V. (2000). The physical activity group environment
questionnaire, an instrument for the assessment of cohesion in exercise classes. Group
Dynamics, Theory, Research, and Practice, 4(3), 230.
Estabrooks, P. A., Harden, S. M., & Burke, S. M. (2012). Group dynamics in physical
activity promotion, what works? Social and Personality Psychology Compass, 6(1),
18–40.
Glanz, K., Rimer, B. K., & Viswanath, K. (2008). Health behavior and health education,
theory, research, and practice. California: John Wiley & Sons.
Green, L. W., Glasgow, R. E., Atkins, D., & Stange, K. (2009). Making evidence from
research more relevant, useful, and actionable in policy, program planning, and
practice. Slips twixt cup and lip. American Journal of Preventive Medicine, 37(6 (Suppl.
1)), S187–S191.
Gregg, J., & O’Hara, L. (2007). Values and principles evident in current health promotion
practice. Health Promotion Journal of Australia, 18(1), 7.
Hagberg, L. A., Lindahl, B., Nyberg, L., & Hellénius, M. L. (2009). Importance of enjoy-
ment when promoting physical exercise. Scandinavian Journal of Medicine & Science in
Sports, 19(5), 740–747.
Harden, S. M., Burke, S. M., Haile, A. M., & Estabrooks, P. A. (2013). Generalizing the
findings from group dynamics–based physical activity research to practice settings,
what do we know? Evaluation & The Health Professions, 38(1), 3–14.
Herens, M., Wagemakers, A., Vaandrager, L., van Ophem, J., & Koelen, M. A. (2013).
Evaluation design for community-based physical activity programs for socially dis-
advantaged groups—The case of communities on the move. JMIR Research Protocols,
2(1), e20. http://dx.doi.org/10.2196/resprot.2327.
Herens, M., Bakker, E. J., van Ophem, J., Wagemakers, A., & Koelen, M. (2016). Health-
related quality of life, self-efficacy and enjoyment keep the socially vulnerable phy-
sically active in community-based physical activity programs, a sequential cohort
study. PLoS One, 11(2), e0150025. http://dx.doi.org/10.1371/journal.pone.
0150025.
Herens, M., Wagemakers, A., Vaandrager, L., van Ophem, J., & Koelen, M. A. (2016).
Contexts, mechanisms and outcomes that matter in Dutch community-based physical
activity programs targeting socially vulnerable groups. Evaluation & The Health
Professions, 1–38. http://dx.doi.org/10.1177/0163278716652940.
Herens, M., Wagemakers, A., Vaandrager, L., & Koelen, M. A. (2015). Exploring partici-
pant appreciation of group-based principles for action in community-based physical
activity programs for socially vulnerable groups in the Netherlands. BMC Public
Health, 15, 1173. http://dx.doi.org/10.1186/s12889-015-2515-6.
Herens, M., Wagemakers, A., den Besten, H., & Bernaards, C. (2015). Welke factoren zijn
van invloed op duurzaam beweeggedrag bij vrouwen van niet-westerse herkomst?
[Which factors influence physical activity maintenance in women of non-Western
origin?]. Tijdschrift voor Gezondheidswetenschappen, 93(3), 93–101.
Hiemstra, A. (2005). Meedoen en meebewegen, hoe doe je dat? Werkvormen en instrumenten
uit projecten met een community aanpak gericht op een gezonde en actieve leefstijl.
Manual. Nieuwegein, NL: Netherlands Institute for Sport and Physical Activity
(NISB).
67
Evaluation and Program Planning 65 (2017) 54–68
Hildebrandt, V., Bernaards, C., & Stubbe, J. (2013). Trend report physical activity and health
2010/2011Leiden: TNO Innovation for Life.
Hovmand, P. S. (2014). Community based system dynamics. New York: Springer.
Hydèn, L.-C., & Bülow, P. H. (2003). Who’s talking: Drawing conclusions from focus
groups-some methodological considerations. International Journal of Social Research
Methodology, 6, 305–321. http://dx.doi.org/10.1080/13645570210124865.
Hyyppä, M. T., & Mäki, J. (2003). Social participation and health in a community rich in
stock of social capital. Health Education Research, 18(6), 770–779.
Jallinoja, P., Pajari, P., & Absetz, P. (2010). Negotiated pleasures in health-seeking life-
styles of participants of a health promoting intervention. Health, 14(2), 115–130.
Jepson, R., Harris, F. M., Bowes, A., Robertson, R., Avan, G., & Sheikh, A. (2012). Physical
activity in South Asians, an in-depth qualitative study to explore motivations and
facilitators. PloS One, 7(10), e45333.
Koelen, M. A., & Linström, B. (2005). Making healthy choices the easy choices: The role of
empowerment. European Journal of Clinical Nutrition, 59(1), S10–S16.
Koelen, M. A., Vaandrager, L., & Colomer, C. (2001). Health promotion, dilemmas and
challenges. Journal of Epidemiology and Community Health, 55(4), 257–262.
Koelen, M. A., Vaandrager, L., & Wagemakers, A. (2012). The healthy alliances (HALL)
framework; prereqisites for success. Family Practice, 9(S1), i32–138.
Kok, M. O., Vaandrager, L., Bal, R., & Schuit, J. (2012). Practitioner opinions on health
promotion interventions that work, Opening the ‘black box’ of a linear evidence-
based approach. Social Science and Medicine, 74(5), 715–723.
Kuroda, Y., Sato, Y., Ishizaka, Y., Yamakado, M., & Yamaguchi, N. (2012). Exercise mo-
tivation, self-efficacy, and enjoyment as indicators of adult exercise behavior among
the transtheoretical model stages. Global Health Promotion, 19(1), 14–22.
Løvoll, H. S., & Vittersø, J. (2014). Can balance be boring? A critique of the challenges
should match skills hypotheses in flow theory. Social Indicators Research, 115(1),
117–136.
Laverack, G. (2006a). Improving health outcomes through community empowerment, a
review of the literature. Journal of Health, Population and Nutrition, 113–120.
Laverack, G. (2006b). Evaluating community capacity, Visual representation and inter-
pretation. Community Development Journal, 41(3), 266–276.
Legrand, F. D., Bertucci, W. M., & Thatcher, J. (2009). Telic dominance influences af-
fective response to a heavy-intensity 10-min treadmill running session. Journal of
Sports Sciences, 27(10), 1059–1067.
Liberato, S. C., Brimblecombe, J., Ritchie, J., Ferguson, M., & Coveney, J. (2011).
Measuring capacity building in communities: A review of the literature. BMC Public
Health, 11, 850 [http://www.biomedcentral.com/1471-2458/11/850].
Lindström, M., Hanson, B. S., & Östergren, P.-O. (2001). Socioeconomic differences in
leisure-time physical activity, the role of social participation and social capital in
shaping health related behaviour. Social Science & Medicine, 52(3), 441–451.
Lomax, C. L., Brown, R. G., & Howard, R. J. (2004). Measuring disability in patients with
neurodegenerative disease using the ‘yesterday interview’. International Journal of
Geriatric Psychiatry, 19(11), 1058–1064.
Lorenz, L. S., & Kolb, B. (2009). Involving the public through participatory visual research
methods. Health Expectations, 12(3), http://dx.doi.org/10.1111/j.1369-7625.2009.
00560.x.
Ministry of Health Welfare and Sports (2011). Landelijke nota gezondheidsbeleid,
Gezondheid dichtbij [Policy note, Health close to People]. The Hague: Ministry of Health,
Welfare & Sports.
Morrens, B. (2008). Sociaal kapitaal en gezondheid, een overzicht van de recente on-
derzoeksliteratuur. Tijdschrift voor Sociologie, 29(2–3), 138–157.
Mullen, S. P., Olson, E. A., Phillips, S. M., Szabo, A. N., Wójcicki, T. R., Mailey, E. L., et al.
(2011). Measuring enjoyment of physical activity in older adults, invariance of the
physical activity enjoyment scale (paces) across groups and time. International Journal
of Behavioral Nutrition and Physical Activity, 8(1), 103.
Naylor, P. J., Wharf-Higgins, J., Blair, L., Green, L., & O'Connor, B. (2002). Evaluating the
participatory process in a community-based heart health project. Social Science and
Medicine, 55(7), 1173–1187.
Nitsch, M., Waldherr, K., Denk, E., Griebler, U., Marent, B., & Forster, R. (2013).
Participation of different stakeholders in participatory evaluation of health promo-
tion. A literature review. Evaluation and Program Planning, 40, 42–54.
Parastatidou, I. S., Doganis, G., Theodorakis, Y., & Vlachopoulos, S. P. (2012). Exercising
with passion, initial validation of the passion scale in exercise. Measurement in
Physical Education and Exercise Science, 16(2), 119–134.
Parker, A., & Tritter, J. (2006). Focus group method and methodology: Current practice
and recent debate. International Journal of Research & Method in Education, 29(1),
23–37. http://dx.doi.org/10.1080/01406720500537304.
Patton, M. Q. (2002). Two decades of developments in qualitative inquiry, A, personal,
experiential perspective. Qualitative Social Work, 1(3), 261–283.
Patton, M. Q. (2012). Essentials of utilization-focused evaluation. Thousand Oaks, CA: Sage
Publications Inc.
Pescosolido, A. T., & Saavedra, R. (2012). Cohesion and sports teams: A review. Small
Group Research, 43(6), 744–758.
Pretty, J. N. (1995). Regenerating agriculture policies and practice for sustainability and self-
reliance. Washington, D.C: Joseph Henry Press.
Putnam, R. (2001). Social capital, Measurement and consequences. Canadian Journal of
Policy Research, 2(1), 41–51.
Raedeke, T. D. (2007). The relationship between enjoyment and affective responses to
exercise. Journal of Applied Sport Psychology, 19(1), 105–115.
Rice, M., & Franceschini, M. C. (2007). Lessons learned from the application of a parti-
cipatory evaluation methodology to healthy municipalities, cities and communities
initiatives in selected countries of the Americas. Promotion & Education, 14(2), 68–73.
Rifkin, S. B., Muller, F., & Bichmann, W. (1988). Primary health care, on measuring
participation. Social Science & Medicine, 26(9), 931–940.
M. Herens, A. Wagemakers
Rinne, M., & Toropainen, E. (1998). How to lead a group—Practical principles and ex-
periences of conducting a promotional group in health-related physical activity.
Patient Education and Counseling, 33.
Saan, H., & de Haes, W. (2008). Kennismanagement voor gezondheidsbevordering. TSG,
86(4), 159–163.
Sallis, J. F., Cervero, R. B., Ascher, W., Henderson, K. A., Kraft, M. K., & Kerr, J. (2006).
An ecological approach to creating active living communities. Annual Review of Public
Health, 27(1), 297–322.
Sim, J., Bartlam, B., & Bernard, M. (2011). The CASP-19 as a measure of quality of life in
old age, evaluation of its use in a retirement community. Quality of Life Research,
20(7), 997–1004.
Smithson, J. (2000). Using and analysing focus groups: Limitations and possibilities.
International Journal of Social Research Methodology, 6, 305–321. http://dx.doi.org/
10.1080/136455700405172.
Snyder, M., & Stukas, A. A., Jr. (1999). Interpersonal processes, The interplay of cogni-
tive, motivational, and behavioral activities in social interaction. Annual Review of
Psychology, 50(1), 273–303.
Spink, K. S., Wilson, K. S., & Priebe, C. S. (2010). Groupness and adherence in structured
exercise settings. Group Dynamics, Theory, Research, and Practice, 14(2), 163.
van Uden-Kraan, C. F., Drossaert, C. H., Taal, E., Seydel, E. R., & van de Laar, M. A.
(2008). Self-reported differences in empowerment between lurkers and posters in
online patient support groups. Journal of Medical Internet Research, 10(2).
van der Deijl, M., Etman, A., Kamphuis, C., & van Lenthe, F. (2014). Participation levels of
physical activity programs for community-dwelling older adults, a systematic review.
BMC Public Health, 14(1), 1301.
Vendix, J. A. M. (1999). Group model-buildig: Tackling messy problems. System Dynamics
Review, 15(4), 379–401.
Vernon, S., & Ross, F. (2008). Participation in community exercise classes, barriers to
access. British Journal of Community Nursing, 13(2), 89–92.
Wagemakers, A., Corstjens, R., Koelen, M., Vaandrager, L., van’t Riet, H., & Dijkshoorn, H.
(2008). Participatory approaches to promote healthy lifestyles among Turkish and
Moroccan women in Amsterdam. Promotion & Education, 15(4), 17–23.
Wagemakers, A., Vaandrager, L., Koelen, M. A., & Leeuwis, C. (2010). Coordinated action
checklist, a tool for partnerships to facilitate and evaluate community health pro-
motion. Global Health Promotion, 17(3), 17–28.
Wagemakers, A., Vaandrager, L., Koelen, M. A., Saan, H., & Leeuwis, C. (2010).
Community health promotion, A framework to facilitate and evaluate supportive
68
Evaluation and Program Planning 65 (2017) 54–68
social environments for health. Evaluation and Program Planning, 33(4), 428–435.
Wallerstein, N., Oetzel, J., Duran, B., Tafoya, G., Belone, L., & Rae, R. (2011). What
predicts outcomes in CBPR? In M. Minkler, & N. Wallerstein (Eds.), Community-based
participatory research for health, From process to outcomes (pp. 371–397). San
Francisco: Jossey-Bass.
Wendel-Vos, G., Dutman, A. E., Verschuren, W., Ronckers, E. T., Ament, A., van Assema,
P., et al. (2009). Lifestyle factors of a five-year community-intervention program, the
Hartslag Limburg intervention. American Journal of Preventive Medicine, 37(1), 50–56.
Withall, J., Jago, R., & Fox, K. (2011). Why some do but most don't. Barriers and enablers
to engaging low-income groups in physical activity programmes, a mixed methods
study. BMC Public Health, 11(1), 507.
World Health Organization (1986). The ottawa charter for health promotion. Copenhagen:
WHO.
World Health Organization (2013). Physical activity promotion in socially disadvantaged
groups, principles for action. Copenhagen: WHO.
Zucchermaglio, C. (2005). Who wins and who loses, The rhetorical manipulation of social
identities in a soccer team. Group Dynamics, Theory, Research, and Practice, 9(4), 219.
Dr Ir Marion Herens recently finalised her PhD research in which she evaluated the
impact of Dutch community-based physical activity programmes targeting socially vul-
nerable groups. In the domain of health and physical activity promotion, she has held
multiple job positions, relating predominantly to the formulation, implementation, and
evaluation of lifestyle interventions and health policy at national and municipal level. She
has facilitated many interactive planning processes and is a skilled trainer. Presently, she
holds the position of food and nutrition security expert at Wageningen
University & Research - Centre for Development Innovation (CDI).
Dr Ir Annemarie Wagemakers, Associate Professor, has wide experience with complex
public health-promotion projects. Her research focuses on the combined influence of
lifestyle and the social and physical environment of health and well-being in real-life
settings. The research is usually based on the use of mixed methods including action
research methods, strong stakeholder participation including low SES groups, integral
health policy, and interdisciplinary approaches. Currently, Annemarie is amongst other
things project leader and co-promotor in the projects ‘Connecting Care, Sport and
Physical Activity’ and ‘Care-Physical Activity Initiatives’, and she is co-promotor of the
project ‘Citizen Science for Public Health’.