Karlijn Leenaars

To stimulate physical activity (PA), the Dutch Ministry of Health, Welfare and Sports introduced Care Sport Connectors (CSCs) in 2012. This function is 40% funded by the state, with the remaining 60% funded by the municipality or other local organisations. CSCs are employed specifically to connect the primary care sector and the PA sector in order to guide primary care patients towards local sport facilities. The defined outcome of CSCs is an increased number of residents participating in local PA facilities and being physically active in their neighbourhood. This new CSC function is challenging because previous studies have shown that differences between the primary care and the PA sector can hinder their mutual collaboration.

A broker, like the CSC, seems promising for improving intersectoral collaboration. However, to our knowledge the work, significance and challenges of brokers has not been studied often. Most studies focus on a brokers’ position and its impact on a network performance measured with quantitative outcome measures. The case of the CSC enables us to explore the broker role in connecting the primary care and the PA sector in order to stimulate PA. This insight is necessary firstly because the CSC function is new and unique and therefore the latest Dutch policy and its accountability need to be evaluated. Secondly, because intersectoral collaboration between the primary care and the PA sector is challenging, insight in CSCs’ role and impact seem to be relevant to further improve this connection. Thirdly, because the role and impact of a broker in establishing intersectoral collaboration is not studied often and therefore an insight helped us to advance health promotion theory and practice.

The case of the CSC enables us to explore the role and impact of a broker on stimulating intersectoral collaboration. To explore CSCs’ role and impact in connecting the primary care and the PA sector four research questions were studied in different chapters:
1. What are the processes that contribute to the connection between primary care, and PA sector?
2. What are the conditions at national and local level that facilitate or hinder CSCs in connecting the primary care and the PA sector
3. Which impacts are mediated by CSCs and what are the perceived societal benefits for the municipality, neighbourhood, and local residents?
4. What lessons can be learned to advance health promotion theory and practice?

This thesis employed a multiple case study design in which 15 CSCs of nine municipalities spread over the Netherlands were followed in their work from 2014 to the end of 2016. In line with a multiple case-study design, perspectives of different stakeholders (policymakers, professionals, CSCs) in the connection between both sectors on different levels (policy, and community level) were taken into account in which different data collection methods were used (literature review, interview, focus group, document analysis, and questionnaires). Including different perspectives and using a mixed methods approach enabled us to provide a comprehensive insight in the connection between both sectors established by CSCs. In addition, cross-case synthesis helped us to draw general conclusions concerning the connection between the primary care and the PA sector when different cases share some similarities. As CSCs have the task to connect the primary care and the PA sector, and to stimulate PA among the target group, another study – not part of this thesis - is carried out as well, which aims to explore CSCs’ impact on promoting PA among the target group. Chapter 2 provided more detailed information on the design and the methods used in this study.

Chapter 3 describes our systematic literature review which was conducted to gain an insight in collaborative initiatives between the primary care and the sport sector and to identify barriers and facilitators in these initiatives. 28 different initiatives between the both sectors were identified. In these initiatives two approaches to promote PA were distinguished. In the approach to refer primary care patients towards local PA facilities three forms of collaboration were identified: referral scheme, multidisciplinary primary care team with a connection to the sport sector, and a partnership between a community health centre and a sports facility. In the approach to promote PA among the community one form of collaboration was identified: a network among community partners including the primary care and the sport sector. The identified facilitators and barriers differed in the two approaches to promote PA. In the referral of patients, sport professionals’ lack of medical knowledge, and health professionals’ lack of time, were seen as barriers. In networks to organise activities to promote PA among the community, different shared interests and different cultures were seen as barriers.

The role of the CSC in connecting the primary care and the PA sector (in Chapter 3 formulated as sports sector but reflecting the same definition of the PA sector as in the rest of the thesis) was explored in Chapter 4. Three rounds of interview with CSCs in the course of one year were conducted to identify how CSCs perceived their role in connecting the primary care and the PA sector, how they establish a connection between the primary care and the PA sector, and what factors were perceived as barriers and facilitators in this connection. CSCs perceived themselves three roles: 1) broker, 2) referral, and 3) organiser and set up two forms of collaboration structures: 1) project basis, and 2) referral. In their work to connect both sectors, CSCs perceived the following barriers: primary care professionals’ lack of knowledge and time, primary care professionals’ own interests, lack of suitable PA activities for the target group, and a lack of adequate PA instructors. Results of this study showed that the way municipalities implement the CSC funding seems to influence the ease with which the CSC could establish collaboration structures. CSCs working for a care or a welfare organisation had easier access to primary care professionals than CSCs working for a sports organisation or the municipal sport department, and could therefore better fulfil the referral function and guide primary care patients towards local PA facilities. CSCs with a lack of involvement fulfilled mostly the organiser role rather than the referral function.

In chapter 5, we followed up on how CSCs fulfilled their role over time and gained a more in-depth insight into how CSCs fulfilled specifically their role as broker to establish the connection between both sectors. In the course of two years, 13 CSCs were interviewed in multiple interview rounds. During the years, all CSCs mentioned that they performed the broker role. However, differences could be distinguished in how the broker role was fulfilled in order to connect the primary care and the PA sector: 1) fulfilling the broker role by connecting both sectors with their own activities (referral or organisations of activities), and 2) initiating collaboration between both sectors but the CSCs recede themselves of this connection.

The study described in chapter 6 assessed perceptions of primary care, welfare, and PA professionals towards the CSC role and their experiences in the connection between the primary care and the PA sector. In total, 9 focus groups with professionals within CSCs networks were held. Primary care, welfare and PA professionals ascribed three roles to the CSC: 1) broker role, 2) referral, 3) facilitator. No major differences were identified between the different professionals in their perceptions on the CSC role. Professionals found the CSC role and the current established connection promising. However, factors relating to their own sector were currently perceived to hinder this connection, like primary care professionals’ lack of time, money and knowledge, and the lack of suitable PA activities and instructors for the target group.

In chapter 7 we described CSCs’ operational context of nine municipalities. In order to describe CSCs’ operational context a new theoretical framework was developed. The CSC function is a new function, and a framework specific to the context in which CSCs are working was not yet available. On the basis of a literature search, in-depth interviews with experts in the field of public health, and a workshop at the Dutch conference for Public Health, a framework which consisted of five domains: policy, organisation, resources, programs, and partnerships was developed. Based on a document analysis of current policy documents, a questionnaire, and interviews with policymakers of the nine municipalities, information was collected regarding the five domains of the theoretical framework. The results of this study showed the extent to which municipalities had adopted an integral approach seems to be different. An integral approach consists of an integral health and PA policy in combination with an embedding of this policy in partnerships between health and the PA sector at management level. Municipalities with an integral approach structurally embedded CSCs in such a way that CSCs were working from different sectors or within a partnership of primary care, welfare and PA professionals. In these municipalities, other initiatives in the fields of public health, care and PA were also implemented, and programs to promote health and PA were implemented by different organisations. In municipalities that adopted a less integral approach, this was hardly present, and CSCs were structurally embedded only at the PA sector. Given CSCs’ mandate, we argue that the integral approach may be supportive for CSCs’ work, because it is reflected in other operations of the municipality and thus creates conditions for the CSCs’ work. Whether this integral approach is actually supporting CSCs in their work needs to be further studied.

The study in chapter 8 explored CSCs impact on connecting the primary care and PA sector and aimed to explore which structural embedding was the most promising in reaching the desired outcomes. A network survey was used to provide an insight in the CSCs network and professionals’ role in the collaboration between both sectors. During three rounds of interview with 13 CSCs, each with a time span of approximately 6-12 months between them, this network survey was completed. Results of this study showed that all CSCs had organised a similar looking network of primary care, welfare and PA professionals and established a connection between both sectors. However, differences were found between the structural embedding and the way the connection between both sector was established. CSCs working in municipalities who structural embedded CSCs according to an integral approach (e.g. care, welfare and sports organisations, or within a partnership between primary care, welfare and PA professionals) collaborated mostly with the professionals by supporting their activities and implemented a structured form of referral. The other CSCs who were working from the PA sector collaborated mostly with professionals around their own activities as a way to stimulate PA among the residents. Therefore, results of this study showed that a structural embedding according an integral approach seems the most promising in reaching the desired outcomes.

The main findings are summarised and reflected on in Chapter 9. In addition, we reflected on used theory, models and tools used in this study and formulated lessons for both health promotion theory as practice.

This thesis aimed to explore CSCs’ role and impact in connecting the primary care and the PA sector. The results of this thesis contribute to three important insights. First, the structure of the connection between the primary care and the PA sector established by CSCs can be characterised as a chain approach. Secondly, barriers related to the sectors are currently hindering this connection. Thirdly, an integral approach to structurally embed CSCs seems to be an important condition to facilitate the connection between the both sectors.

The results all together showed that the CSC function seemed to be promising in connecting the primary care and the PA sector. However, to make a success of the connection between both sectors changes at both the policy as community level are needed. For example local policy should adopt a more integral approach, and a health-promotion mind set should be promoted among primary care professionals. Further research should focus on CSCs’ impact on stimulate PA among primary care patients, and the development of CSC’ role and the connection between both sectors in course of time.