committeeyoucanletgo

RESEARCHOpenAccess"Tomeansomethingtosomeone":sport-for-developmentasaleverforsocialinclusionKarenVanderVeken1*,EmelienLauwerier1,2andSaraWillems1AbstractBackground:Sociallyexcludedgroupsareathigherriskoflowwell-beingandpoorhealth.
Thelinkbetweensocialexclusionandhealthinequitiesiscomplex,andnotbeinginvolvedinsocietymakesitdifficulttobereachedbystandardpreventionprograms.
Sport-for-development(SFD)programsarelow-thresholdandmaybepromisingsettingsforinclusiveactions.
WeexploretheunderlyingmechanismsthroughwhichSFDmighthaveanimpactonsocialinclusionandexaminethenecessaryconditionsthatworkasacatalystfortheseunderlyingmechanisms.
Methods:Arealistevaluationapproachwasadopted.
Anon-profitSFDorganizationinamiddle-largecityinFlanders,Belgium,formedthesettingforasinglecasestudy.
Documentanalysis,participatoryobservations,interviews,andafocusgroup,weresourcesforidentifyingnecessarycontextelementsandessentialmechanismsthroughwhichSFDcouldpromoteitsparticipants'healthandwellbeing.
Results:AmongthemostefficientmechanismstriggeredbytheFoundation'sactivitiesarelearningbyfun,connectingwithpeers(ofwhomsomeserveasrolemodel)andengagingasavolunteerwithsomeresponsibilities.
Buildingtrustinoneselfandinothersisanecessaryprocessthroughoutallthesemechanisms.
Facilitatingcontextfactorsincludetheactivities'accessibilityandunconditionalapproach(creatingasenseofsafety),thepopularityofthefirstdivisionfootballteamtheFoundationisassociatedwith(leadingtoasenseofbelonging),asteadynetworkofsocialpartnersandastronglypositiverelationshipwiththeSFDcoach(es).
Conclusions:OurfindingsdemonstratethataSFDsettingmaybeavehicleforengaginghard-to-reachpopulationgroups.
Itenhancessociallyvulnerablepersons'senseofcompetenceandconnectedness,leadingtoopportunitiestoimprovelifeandworkskillstransferrableoutsideSFDsettings.
Basedonthesefindings,suggestionsareprovidedthatmayenhancethefieldandhelptodevelopfeasible(policy-led)interventionsdesignedtopromotesocialinclusion.
Keywords:Sport-for-development,Socialinclusion,Self-efficacy,RealistevaluationBackgroundSocialexclusioncanbedefinedasthe"lackordenialofre-sources,rights,goodsandservices,andtheinabilitytopar-ticipateinthenormalrelationshipsandactivities,availabletothemajorityofpeopleinasociety"[1].
Itisinherentlymulti-causalandrelationalinnature,andleadsamongotherstolossofstatus,autonomy,self-esteem,andexpecta-tions[2].
Sociallyexcludedoftenfindthemselvesinadownwardspiral:inadequateaccesstofood,housingandotherbasicresources,leadtoadversityandpoorhealth[3–5],furthercomplicatingtheaccesstoservicesthatenhancetheabilityofthesociallyexcludedtocopewiththeirsitu-ation(e.
g.
education,sportandpreventivehealthservices,healthylifeandworkconditions…)[6].
Sociallyexcludedyouth,forexample,isathigherriskof(chronic)healthcomplaints,mentalhealthproblemsandadultmorbidityandmortality[5,7–9].
Sporthasthepotentialtoincreaseindividuals'resilience,heredefinedas"theabilitytoadapttoadversityortocope"oras"areducedvulnerabilityfortheadverseoutcomesofstressordysfunction"[10,11].
ATheAuthor(s).
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*Correspondence:Karen.
VanderVeken@Ugent.
be1DepartmentofPublicHealth&PrimaryCare,ResearchgroupEquityinHealthCare,GhentUniversity,Ghent,BelgiumFulllistofauthorinformationisavailableattheendofthearticleVanderVekenetal.
InternationalJournalforEquityinHealth(2020)19:11https://doi.
org/10.
1186/s12939-019-1119-7systematicreviewreported40differentpsychologicalandsocialbenefitsofparticipationinsport,withasmostcom-monpositiveoutcomesfewerdepressivesymptoms,higherself-esteem,bettersocialskills,higherconfidenceandhighercompetenceamongstsportparticipantsthannon-sportparticipants[12].
Moreover,ahealthylifestyleinclud-ingphysicalexerciseiseffectiveinpreventingchronicdis-easesatalaterage,especiallywhenstartinginchildhood[13–16].
However,theabundantpositiveoutcomesofsportparticipationneedtobeputincontext.
Regularsportclubsarenotaccessibletoall.
Especiallyforthoseatriskofsocialexclusion,participationinsportandleisureactivitiesislim-ited,duetofinancial,geographicalandsocio-culturalbar-riers[17–19].
Yet,preciselyat-riskpersonscouldbenefitmostfromboththehealthimprovingandresilience-enhancingeffectofsport),fortheyencountermorehealthrelatedproblems[5,8,9].
Sport-for-Development(SFD)isapotentialanswertothecatch-22ofthoseneedingitmostnotbeingabletoaccesssportandbenefitfromit.
SFDcanbedefinedas"theuseofsporttoexertapositiveinfluenceonpublichealth,thesocializationofchildren,youthsandadults,thesocialinclusionofthedisadvantaged,theeco-nomicdevelopmentofregionsandstates,andonfosteringofinterculturalexchangeandconflictresolution"[20].
So-ciallyvulnerablegroupscanbereachedmoreeasilybysuchlocallyorganized,accessibleinitiativesincomparisontostandardsportclubs,because(geographic,financial,cul-turalandsocial)barriersareliftedandbecauseparticipantsareactivelyrecruited[21,22].
SFDhasincreasinglybeenlinkedtopositiveoutcomessuchaspersonaldevelopmentandenhancedresilience[22–33].
Thesemaybeimportantintermediateoutcomes,andmayfurtherenhancechancesonemploymentandotheropportunitiesforsocialinclu-sion.
EvidencehasnotonlytobegatheredregardingtheoutcomesofSFDwiththeaimofsocialinclusion,butalsounderwhichcircumstancesandhowSFDmayleadtoitssuccesses.
Insightintotothesepractices,and,morespecif-ically,whatworksforwhominwhichcircumstancesmayprovidevaluableinformationforthedesignof(policy-led)interventionsdesignedtocombatsocialexclusion.
Thecurrentstudyispartofafour-year(2016–2019)transdisci-plinaryresearchproject–CATCH(CommunitySportsforAT-riskyouth:innovativestrategiesforpromotingpersonaldevelopment,healthandsocialCoHesion)-aimedattheexplorationofhowandwhenlow-thresholdsportpracticeshavetheireffectinpromotingsocialinclusion.
InthefirstphaseoftheCATCHresearchproject,aprogramtheory(PT)wasdevelopedonhowandunderwhichconditionslowthresholdsportpracticesmaybeavehicleforsocialin-clusionofsociallyvulnerablepopulations.
Thistheory(cf.
Table1)wasdevelopedbasedonamultiplecasestudyandinsightsfromliteraturereview.
Inthecurrentstudy,weaimtotestandrefinethistheory,throughanevaluationofamiddle-largeSFDorganizationinFlanders,Belgium.
StudiedcaseWeevaluatedactivitiesoftheKAAGentFoundation(fur-therreferredtoas'theFoundation'),theproductofapublic-privatepartnershipbetweenthecityofGhentanditsfirstdivisionfootballclubKAAGentwhichislocatedinGhent,amiddle-sizedcityinthenorthernpartofBelgiumTable1.
CATCHtheoryonSFDasleverforhealthandsocialinclusionVanderVekenetal.
InternationalJournalforEquityinHealth(2020)19:11Page2of13(Flanders),attheedgeofoneofFlandersmostdeprivedneighborhoods[34].
TheFoundationembodiesthefootballclub'ssocialreturntosocietyintheformofactivitiesgener-atingsocialcohesion,healthandinclusion,especiallyforvulnerablepopulationsinGhentanditssurroundings[35].
In2018,566personsparticipatedinoneofthe743socialemancipatoryandsportiveactivities(25,409contacthourswithtargetpopulation).
ThefootballteamsGBandGPcountedonaverage15participantsineverytraining.
AllcommunityworkoftheFoundationisorganizedalongsidetheirpolicymodel,referredtoas#COBW(ComeonBlueWhite,referringtothecolorsoftheclub)andexplainedinTable2.
TheKAAGentFoundationcasestudyaimsatexamin-ing1)whichconditionsareputforwardbytheSFDorganizationinpromotingsocialinclusionandappeartobenecessaryelementstohaveitseffects;and2)whatmechanismsarefoundtoexistandareperceivedofasessentialworkingelementstohaveanimpactwithinthecontextofthisparticularSFDorganization.
MethodsDesignoftheevaluationstudyArealistevaluation(RE)wasimplemented[34],whichaimsatidentifyingthehiddencausalforcesbehindempiricallyobservablepatternsorchangesinthosepat-terns[37].
Thisisdonethrough'retroduction':goingbackfromobservedpatternsandlookingbelowthesur-faceforwhatmighthaveproducedthem[38,39].
Realistthinkingthusstartsfromtheempiricaloutcome,tracingprocessesbackwardstostudythequestion'Whatworksforwhom,why,andunderwhichcircumstances'[36]throughidentificationofthekeymechanisms(M),influ-entialcontextfactors(C)andexpectedoutcomes(O).
Context-Mechanism-Outcome(CMO)configurationsthenserveasaheuristicfortheorydevelopment,clarify-ingwhatprecededthevisibleoutcome.
Theoutputofarealistevaluationisaprogramtheory(PT)or,asisthecaseinthisstudy,arefinedPT(thatbuildsfurther/testsanalreadyexistingPT).
Datacollection&analysisThecasestudyoftheKAAGentFoundationtookplacebetweenJanuaryandDecember2018.
Duringthattime,anumberofqualitativedatawerecollectedthrough,re-spectively,documentanalysis,observationsofgroupac-tivities,in-depthinterviewsandafocusgroupdiscussion(FGD).
AnoverviewofthedatasourcescanbefoundinAdditionalfile1.
Table2.
#COBWPolicymodelKAAGentFoundationVanderVekenetal.
InternationalJournalforEquityinHealth(2020)19:11Page3of13First,themainpolicydocumentsandreportsofthefoundationhavebeenstudied,ofwhichthemostim-portantappearedtobetheFoundation'sStrategicPolicyPlan2017–2020,inwhichtheFoundation'spolicymodelisexplained(cf.
Table2).
DocumentanalysistakingplacebeforetheinterviewsandFGDallowedthere-searcherstoidentifyanimplicitprogramtheory(cf.
Re-sults-Fig.
1)underlyingtheFoundation'spolicymodel,andtoconsequentlystructuretheinterviewsandFGDassuchthatthesupposedmechanismsdescribedintheunderlyingPTcouldbetested(i.
e.
confirmed,deniedoradaptedbyinterviewees).
Otherdocumentsanalyzedwere:theFoundation'stwolatestyearreports(2017,2018),itssubventionpolicyshowinghowsocialreturnisrequiredforsubventionsgiventolocalfootballclubs,somechatsofclosedFacebookgroups,thecurriculumoftheTeamBuffalosocio-educativetrainingsandup-datesontheFoundation'swebsite.
DocumentanalysismainlyincreasedtheunderstandingofhowtheFounda-tiondefines'socialinclusion'intoacoupleofproxyindi-catorsandprovidedinsightinhowtheFoundationcommunicateswithparticipantsandstakeholders.
FromMaytoJuly2018,onetotworesearchersobservedtrainingactivities(inaparticipatorywaywheneverpossible),teameventsandtournaments,ofwhichtheytookfieldnotesinasemi-structuredobservationreport,focusingontheidentificationofkeymechanisms(M)andcontext(C)fac-tors.
Inthedataanalysis,theseelementswerecounter-checkedwithcontext,mechanismsandoutcomesidentifiedthroughinterviewsandFGD.
Thefollowingsubprojectswereobserved:BuffaloDanceAcademy:adanceschoolforchildrenaged12–15yearsinadeprivedneighborhoodnearthestadium;BuffaloLeague:aseriesofcommunity-basedactivitieswithchildren(2–12years)fromschoolsinthesamedeprivedneighborhood;GeestigeBuffalo's(FunnyBuf-falos,furtherreferredtoasGB):amixed(male+female)footballteamforadults(18+years)withpsychosocialand/orpsychiatricdifficulties;GantoisePlantrekkers('AstutesfromGhent',furtherreferredtoasGP):aseparatemale/fe-malefootballteamforsociallydeprivedadults(18+years),e.
g.
homelessorpeoplestrugglingwithaddiction.
Duringtheparticipatoryobservations,relationsoftrusthavebeenestablishedwithparticipants,enablingin-depthinterviews(October–November2018)withFig.
1ProgramtheoryunderpinningKAAGentFoundation'spolicymodelVanderVekenetal.
InternationalJournalforEquityinHealth(2020)19:11Page4of13elevenofthem.
Intervieweeswereselectedbasedontheirinterestintellingtheirstory,takingintoaccountafairdistributionbetweentheGB(N=6)andtheGP(N=5),betweenhabituésandnewcomers,andarepre-sentationofthedifferentvulnerabilities(poverty,home-lessness,addiction,psychosocialdifficulties…)facedbytheparticipants.
Recruitmentofparticipantsforkeyin-formantinterviewstookplaceduringtheparticipatoryobservation.
SincewomenareunderrepresentedbothintheGBandGP,thisshowsinthegenderdistributionofinterviewees.
Forthissemi-structuredin-depthinter-view,withanaveragelengthof50min,aninterviewguidewasusedthatallowedexplorationofkeymecha-nismsandcontextfactorsasidentifiedintheFounda-tion'sPT(cf.
Figure1).
Interviewswereaudio-recordeduponpermissionoftheinterviewee(9outof11)-whennotaudio-recorded,notesweremadebytheinterviewer.
Lastly,aFGD(N=8)tookplace(November2018).
Participants(twocoordinators,3socialpartners,twoparticipantsoftheFoundation'sactivitiesandoneSFDpolicyexpert)werepurposivelyselected.
Havingob-servedrespectfulandstraightforwardcommunicationbetweenthesestakeholdersforalmostayear,wewereconfidentthismixedconstellationwouldnotendangeranyoftheparticipantsandmightbeanopportunityforopendiscussionandin-depthinsightsinthefunctioningofSFDingeneral,andtheFoundationanditsnetworkinspecific.
TheFGDwasmoderatedbytwoexperiencedresearchersinqualitativeresearchanddiscussedthefindingsofthe(anonymized)interviews,andparallelsbetweentheFoundation'spolicyplanandabythere-searchersdevelopedPT(cf.
Table1)onhowSFDmayimpacttheparticipant'shealthandwellbeing.
TheFGDwasaudio-recordedandtranscribed.
Alldocuments,observationreports,interviewandFGDtranscriptswereenteredinNVivo11software.
Threeresearcherswereinvolvedinthedataanalysis.
Firstaprocessofopen,axialandselectivecodingwascarriedoutseparatelybytworesearchers,withregulardiscussionstofindcommongroundontheirrespectiveanalysisofthedata.
Wheneverconflictinganalysesoc-curred,feedbackwasrequestedfromkeystakeholdersorathirdCATCHresearcher.
Thentheresearchteamde-velopedhypothesesastohowandinwhichcircum-stancestheFoundation'sworkmightlead,ornot,toimprovedwellbeing.
Thesehypotheseswereprofoundlystudied,searchingdataactivelyforkeymechanisms(M)generatingintendedandunintendedoutcomes(O)con-cerningtheSFDparticipants'wellbeingandforcontextfactors(C)triggeringorhinderingthesekeymechanism.
ThehypotheseswerealsodiscussedintheFGD.
Writteninformedconsentwastakenfromallpartici-pants.
ThestudywasapprovedbytheethicalcommitteeofGhentUniversity(numberB670201836103).
ResultsThissectionconsistsofthreeparts.
Inthefirstpart,wetranslatetheFoundation'spolicymodel#COBW(cf.
Table2)intoarealistprogramtheory(Fig.
1).
Thisana-lyticstepprecededandinspiredfurtherdatacollection(interviewsandfocusgroups).
Inasecondpart,wescanthroughalldatausingrealistspectacles,identifyingkeymechanismsandcontextfactorsthathaveseemedtobecrucialingeneratingbeneficialoutcomesfortheFoun-dation'sparticipants.
Inthelastpart,wepresentevi-dencederivedfromobservationsandperceptionsofparticipantsandkeystakeholders,insupportofthethe-oreticalassumptionsmadeintheFoundation'sPT.
Programtheoryunderpinning#COBWFromthe#COBWpolicymodel,wederivedthefollowingcontext(C),mechanism(M)andoutcome(O)asbuildingblocksoftheFoundation'sPT:Throughunconstrainedandinclusiveactivitiesinwhichpeopleparticipatevolun-tary(C1),likemindedorsimilarlybackgroundedpeershavetheopportunitytomeet,tosharefunanduncondi-tionedtime(M1),makingitpossibleforparticipantstogainself-confidenceandtrustinothers(O1).
Suchcontext,whereinparticipantsfeelsafeandexperienceasenseofbelonging(C2),andinwhichsocialpartnerscollaborateinalargernetwork(C2),allowstheparticipantstotakeupsomeengagementandresponsibilitywithintheteam,andlateron,withintheFoundationandthecommunity(M2).
Assuch,alearningcontextisshapedfortheparticipantstobuildlifeskillssuchassocialskillsandbasicworkskills,andtogainasenseofusefulness(O2).
Thisprogramthe-oryisillustratedinFig.
1.
KeycontextfactorsInwhatfollows,wedescribesomeofthenecessarycon-textfactorsthatmakeSFDasuccessfultooltopromotehealth.
Someoftheseelementsareatthesametime(ini-tialorintermediate)outcomesoftheprogram'skeymech-anismsandfacilitatingcontextfactorsforkeymechanismsthatmaybetriggeredlateronintheprogram,whenne-cessaryconditionsaremet-theseelementsareidentifiedas(O&C).
Unconstrained&inclusiveactivities(C)ParticipantsoftheFoundation'sactivitiesspeakofaspontaneous,funandrespectfulatmosphere.
Theycon-sidertheactivitiesanidealplacetoventilate,tolosefrustrations,tomakecontact,orevenfriends,andtogrowself-confidence.
Itdoesnotmatterwhetheryoucanplayfootballornot.
Thewaythatweplayfootball,makeseveryonehavefun,andrelax.
(…)Thenitisfuntojustemptytheheadabitthroughfootball,andthesocialhappeningmattersaswell.
(J).
VanderVekenetal.
InternationalJournalforEquityinHealth(2020)19:11Page5of13Voluntaryparticipation(C)FortheFoundationitmattersthatparticipantscomebe-causetheywanttocome,notbecausetheyareobliged.
Participantsarerecruitedbydifferentsocialpartners(e.
g.
socialwelfarecouncil,thepsychiatrichospitalsorout-reachteams…),proposingtheFoundation'sactivitiesonavoluntarybasis.
DatasupporttheideathattheFoundationsucceedsinmotivatingitsparticipantsinthelongrun.
E.
g.
whenparticipantKcametoplayforthefirsttimeintheteam,oneofthepsychiatricnursesfromthesocialnetworksaid:"Thisisjustatry,mostlikelytherewillbenonexttime.
"Yet,participantKkeptoncomingback.
Somethingsimilarwaswordedinaninterviewwithan-otherparticipant:ItwasnewtomeandIwantedtotry.
ButIneverthoughtIwouldstaythislong.
(I).
KAAgenttrademark(C)ManyoftheparticipantsarebigfansoftheKAAGentfirstdivisionfootballteam.
KAAGentisknownasafootballclubproudofitssupporters,withattentionforthecommonman,womanorchildinthestreet.
ThismakestheirsupportersandthecitizensofGhent,foot-ballfanornot,asproudoftheirclubastheclubisofitsfans.
WeobservedtheclublogoonthesportsoutfitoftheFoundation'sstaffworkinglikeamagnet:childreninthestreetshouttheclub'snameandplaywiththeFoun-dation'svolunteers,curiousparentsandneighborscometoseewhat'shappening.
CommunityactivitiesorganizedbytheFoundationareverypopularevents.
Allwanttobepartoftheclubthatpresentsitselfasonebigfamily.
Senseofsafety:nopressuretosucceed(O&C)ObservationandinterviewdataprovidedevidencefortheaccessibleandsafeenvironmentcreatedbytheFoundation.
SenseofsafetyisatthesametimeaninitialoutcomeoftheFoundation'sactivities(asexperiencedbyitsparticipants)andanecessarycontextfactorforfurtheroutcome.
Thereislesspressuretoperform.
(I).
Everyonehashisownstory.
Andhisownexperience.
Andthemomentoftraining(…)isamomentoflettingallthatgo.
Andnotreallybeingoccupiedwithallthat.
(H).
Positiverelationwithcoach(O&C)Aconstructiverelationwiththecoachbeinganinitialout-putofcrucialimportancetofurtherrealizationoftheFoun-dation'sgoals,itisessentialtofindproofofsuchrelationintheinterviewswithparticipants.
Althoughnotalwaysmen-tionedexplicitlyininterviews,evidencewasfoundatmanyoccasions,includingobservationsoftheactivities.
Yes,itisthebestthathappenedtome.
ThatImet[thecoach].
(…)Inthebeginningwedidnotmatch.
Iwasnotalwaysgoodorsafe…Butafteracoupleofmonthswestartedreallytalking.
AndatonepointIsaidIcouldnotgoonlikethat.
Andsincethatmomentwehavecontin-uedgrowing.
Andwebecamefriends.
(B).
Itisimportanttoknowthatthecoachacceptsyou,knowshowyouarewithyourlimitations.
Alsoimportantisthefactthatthecoachstrivesforequalparticipationingames,anddoesnotletyousitatthesidelineallthetime.
(I).
Self-awareness&self-confidence(O&C)Inthevoiceandtheattitudeofmostrespondents,youcanhearrealization,consciousnessofthelengthofthepaththeyhavewalked.
Self-awarenessisnotonlyaninitialoutcomeoftheFoundation'sactivitiesbutalsoanecessaryconditionforfurtherpersonaldevelopmentandwellbeing.
[Ismoke]1packageaday.
Sometimesthatdoesnotdis-turbyou,andyou'renotreallyoccupiedwithit.
Footballmakesyouloseyourbreath,soyouthinkaboutit.
(E).
TheFoundationstimulatesitsparticipantstosharetheirlifestories,andassuchraiseawarenessaboutis-suesaspovertyandaddiction.
Doingso,participantsthemselvesbecomemoreandmoreawareabouttheirstrengths,theirvulnerabilities,thechancestheymissed,thosetheycanorwanttograb,andsoforth.
Fromthehomelessteam,Istartedtogrowfurther.
Istartedtotrustmyself,togrow,myuncertaintiesstartedtogoaway,thedoubtsaboutmyself.
It[theproject]reallydrewmeup.
ButIhadenormousdellsthatpulledmedownagain.
BecauseImadethesamemistakesagain.
Yet,I'velearnedfromthatand(…)thatiswhatmakesmestrongnow.
Tolearnfromyourownmistakestobeabletofacethefuturepositively.
(A).
AllrespondentscomewithexamplesofhowtheFoun-dation'sactivitiesreinforced,indirectorindirectman-ner,theirself-confidence.
Thecoachtaughtmetofirstbringconfidenceinmygame,andtothenbuildtowardsconfidenceinmyself,andfinallytrustinothers,theworldoutside.
(A).
Socialcohesionandsenseofbelonging(O&C)Regularly,theFoundationorganizesactivitiesotherthanfootball.
E.
g.
theBelgianHomelessCupbringspartici-pantstogetherwithpeersfromalloverthecountryinatwo-daysmeeting:participantsstayinthesameaccom-modationandhaveplentyofopportunitiestodiscuss,watchatheatreshowtogether,govisitavillageetcetera.
TheFoundationorganizessharedlunchesordinners.
Apartfromthenecessity,formanyparticipants,tohaveadecentmeal,thisalsoservessocialcohesion,sinceeat-ingtogetherisasocialeventineveryculture.
Yes,wearequiteattachedtooneanother.
Therearemanyfriends.
Twoweeksago,Iwenttopaint,cleanandorganizethewholehouseofB.
[fellowplayer].
(…)Iinvitealotofpeopletocomefordineratmyplace,forVanderVekenetal.
InternationalJournalforEquityinHealth(2020)19:11Page6of13otherwiseI'mjustalone.
(…)Itismorethanjustsports,that'sright.
(D).
Theconstructivegroupdynamicscreateapowerfulsenseofbelongingamongtheparticipantswhoareusedtovari-ousexperiencesoflonelinessandsocialexclusion.
Anadd-itionalfacilitatingcontextfactoristheexamplegivenbytheFoundationitselfoftreatingallaspartoftheteam,andwel-comingwithopenarmsitsparticipants,nomatterwheretheyareintheirpersonaltrajectory:Itisonewarmgroup,whateverhappens,youstaywelcome.
Andthatisthemostimportantforme.
Ithinkformany,yes.
(C).
Socialpartners(C)Duringthetraining,socialpartnerstaketurningrolestobepresent.
Formostparticipants,theirpresenceisanimportantcontextfactor.
Yes,itdoes[matterthatpartners,suchaspsychiatricnurses,arepresentduringtraining].
Forwhenyouarehav-ingadifficulttime,youcangositwiththemforawhile.
(I).
Therearepeoplewhodon'tdaretogo[talktotheso-cialpartners].
Youhavetopushthemalittle,andsome-timesthecoachaccompaniesthem.
Yes,onceyouhavethat[networkofsocialpartnersandfollow-upofpartici-pants],therestfollowsautomatically.
(B).
EvidenceinsupportoftheFoundation'sPTInthelastpartoftheresultssection,weexaminewhetherinthecaseoftheKAAGentFoundationun-constrained,funandinclusiveactivitiesindeedpromotemeetingbetweenlikemindedpeople,andassuchen-hanceself-confidenceandtrust,shapingacontextidealforlearninglifeskills,includingsocialskills,emotionalskillsandbasicworkskills.
Liftingbarrierstogetparticipantstoplay,andtostayRespondentsconfirmatmanyoccasionsthattheycometotheactivitiesprimarilytohavefunandbeabletoletgoofthings.
Allmentiontheadditionalbenefices(im-provedsocialcontact,emotionalregulation,socialskills,etcetera)though,albeitinasecondarytime.
Thiscon-firmstheexistenceofoneofthemostefficientmecha-nismstakingplaceduringtheFoundation'sactivities:'learningbyfun'.
Justtohaveapleasanttime(…)Justthefeeling,duringthetraining,tobegoneforawhile,twohoursawayfromsociety,fromdailysorrow(…).
Itisdistraction,mostlookverymuchforwardtothattime.
Itisthatmomentoftheweek,andtheretheyare.
(A).
Confirmedbyallrespondentsistheventilatingandrelaxingeffectofsports,especiallywhencoachandfel-lowparticipantsputthefocusonfun,andnotonsportiveresults.
Sportingemptiestheheadalittle.
(…)Youcanletgoofthingsthatyoustrugglewith,andthenthereisroomforotherthings.
(I).
Sportisformanyaneasieraccesstotherapeuticwork.
Especiallyteamsportsisconsideredagreatspringboardtopracticingsocialandemotionalskills.
Althoughfoot-ballmaynotbethemostaccessibleoftheteamsports,asoneoftherespondentsmention:ThepeoplethatItrytoconvincetocomewithmeoftenreactwith'ohfootball,thatisnothingforme'.
Whilethesepeopledoparticipatewhenitisbadminton,forexample.
(I).
However,themannerinwhichthetrainingsessionsareorganized,motivatesalsothosewhohavenevertouchedafootballbefore.
Itisdifferenttoregularfootballclubs,wherefocusisonresultinsteadoffun,andthereis"toolittleplacetohaveagoodlaugh,ortobeallowedtomakeamistake"(G).
Thefactthat"itdoesnotmatterthatmuchwhetheryoucanplayfootballornot"(I),isforsomere-spondentsanimportantfactortostart(andcontinue)tocometothisgroupactivity.
Attheonehand,theFoundationactivelyrecruitspartic-ipantsfromsociallyvulnerablegroups,attheotherhand,ittriestoliftfinancialbarriersinorderforyouthfromallsocialgroupstobeabletoplayinthelocalfootballclub:TheFoundationworkswithchildrenlivinginpoverty.
Therearealmostnofinancialbarriersleftforparents(…):kidsreceivesportsoutfitsandfootballbaskets.
(H).
SeveralrespondentsmentionthefactthattheaccessibleandrespectfulenvironmentinwhichtheFoundation'sac-tivitiestakeplace,makesmeetingandmakingfriendseas-ier.
TheFoundationorganizesitsactivitiesinawaythatparticipantsfeelthatitisasafeenvironment,inwhichtheyarenotobligedtokeepuptocertainexpectations.
Inthis,theFoundation'sactivities,althoughsupposedtoleadtosocialandemotionallearning,arenothinglikemeetingwiththesocialassistant,therapist,oremploymentservice:Youimmediatelyfeellikeinasafezone[attraining].
Thesameaswhenyouenterthepsychiatrichospital.
Theydon'task'wherehaveyoubeen'(H).
Thissenseofsafetyhastodoaswellwithfeelingac-cepted:Usually,whenpeoplerelapse(startagainwithdrugsoralcohol),theyaretoldtoleave.
Or,theywanttocollocateyou.
Theyletyougo.
Yes,Iexperiencedittoo.
ButwhenItoldthetrainerherethatIwouldnotcometothetraining,forIwasrelapsing,hesaid'definitelycome!
'(C).
DopeoplewithsimilarbackgroundmeetmoreeasilyFormostrespondents,participationtotheFoundation'sactivitieshasindeedledtoenhancedsocialcontactoranenlargednetwork.
Itstartedoutwithplaying[football]togetheronce,acoupleofparticipantsbeingquitealright,and…Thenpeoplecomeback,soyoucreateabondwiththem.
AfterVanderVekenetal.
InternationalJournalforEquityinHealth(2020)19:11Page7of13awhileyouaddthemtoFacebook,youdoatournamenttogether,goforadrinkafterwards…(H).
TheFoundationorganizesall-inclusiveactivitiesinthecommunity,butalsoactivitiestargetingspecificgroups,suchaspeoplefacingpsychosocialproblemsandhome-lesspeople.
DoesbringingthemtogetherhelpthemtobemoresociallyincludedTheadvantageoftheFunnyBuffalo's(…)isthatweallhaveapastinpsychiatry.
Insome,youcanseethatclearly;thescarfsontheirarms,theirlegs.
Inothersyoudon'tseeitthatwell,foritisinternalized,butyoudoknowthatalsothosehaveapsychiatrichistory.
Andthenyoumayeasilyfeelaconnection.
(H).
[Ithelpstohaveasimilarstory]Becauseyouknowthattheotherunderstandsyou.
(I).
Asimilarstoryisnotenoughforaconnectionthough.
Oneoftherespondentsmentionsthefactthatgenderplaysaroleaswell.
[Ididnotbuildanetworkthere.
]Perhapsbecausethey'reallmen.
(I)Alsothevarietyinwhereonestandsinthepersonalprocessmayinfluencetheabilitytoconnect:Noteveryoneisasfarinhisorherprogramortherapy.
Thatisnoticeable,whichmakesitsometimesmorediffi-culttogetincontact.
Somepeoplearemoreintrovert,whileothersareabittoosocialorabittoomotivated.
Whichcanalsobeareasonfornotconnecting.
(H).
Onthequestionwhetherfacingthesamevulnerabil-itiesmightalsobeofnegativeinfluenceonthepersonalprocess,arespondentsconfirms:Theothersmightdragyoudownwhentheyhaveadifficulttime.
(…)Thatiswhyitishandytohavedifferentgroupsoffriends.
Whenyourisktobedraggeddown,youcandropthatgroup.
Forme,thereisagroupatthesocialworkplace,agroupinthepsychiatrichospital,andsincerecently,agroupoffriendsfromfootball.
(G).
Justlikesimilaritiesinlifestoriesanddifficultiesmaymakepeoplefeelstronglyconnected,peerexpertsmayserveasapowerfulexampleforothers.
Attheonehand,IdonotwanttobeanexampleforIaswellhavemademistakesinmylife;attheotherhand,IdowanttobeonebecauseIwanttoshowthatitisin-deedpossible,thatyoucanmakeitfinally.
(…)Nomat-terhowmanybooksyouread,itisnotnearlythesameaswhatyouhavedoneorexperiencedyourself.
Youcan-notjustwritethatinabooklet.
Itissomethingthatyoushouldbeabletokeepforyourselfandtosharewiththosepersonsthatneedit.
(A).
TrustinyourselfandothersasnecessaryconditionforgrowthManyparticipantsoftheFoundation'sactivitieshavetrustissues:Themostdifficultthingtochangeistotrust.
Andfinally,whenIhaveatoughtime,sayhowIreallyfeel.
BecauseIhaveatremendousfear…toberejected.
Ialwaysthink:'Iftheywouldknowthewholecontentofmybackpack,theywillnotwanttogetinvolvedwithme'.
IntheFoundation,yougetthefeeling'tobeallowed'–evenwhenIdon'tfullyadmittoit.
(C).
Althoughmanyrespondentsstateittakesawhilebe-foretheyopenupandreallygetintouchwithotherpar-ticipants,mostofthemrecognizethatafterawhilearelationoftrustisbuilt,openingupopportunitiesforrealconnection.
Afterawhilethereisabondoftrustsoforonce[youdaretospeakout].
RecentlyIsentamessagetoX'It'snotgoingwell'.
Totheassistantcoachaswell.
Andthosepeopleareeffectivelythereforyou,youknowAlbeitviaatextoracall'keepyourheadup,buddy'.
Withoutdiggingtoodeeply.
(H).
Respondentsconfirmtheimportanceoftrustinoneselfandtheothersasaconditionforseverallifeskills:Thefirstimportantstepistolearntohavefaithinyourselfandinpeople.
Ifyoudon'thavethat,youcan'tprogress.
(A).
BuildingexperienceandskillsStudydataprovidemanyexamplesofsocial,emotional,attitudinalandwork-relatedskillsbeingstrengthenedthroughparticipationintheFoundation'sactivities.
Iusedtohavealotoffrustration.
IdidnottellanyonebuttheconsequencewasthatIhadmorefightswiththecoach.
Nowthecoachismybestfriend.
Hetaughtmealotofthingstolessenmyfrustration.
That,ifI'mboth-eredwithsomething,Ishouldleaveforamoment.
(…)Thathasmademechangeeverythinginfact.
(…)Iusedtobeaddictedtoalcohol.
Now,itisdifferent.
EvenifIex-periencestress,Inolongerstarttodrink.
(B).
Engagementisimportant.
(…)Alsoforthetrainingsyouengage.
Together,wedoachievesomesortofgoal.
(K).
Whenaloneathomewithoutanyresponsibilityorac-tivitytokeepyoubusy,itiseasytoslipintoisolation,andtoforgethowtotalktopeople,howtostartacon-versation,howtogiveyouropinioninarespectfulman-ner…Thesesocialskillsneedabitofpractice.
Youhavesomethingtodoagain.
OnTuesdayIplayfootballandonThursdayIpreparebreakfast[acommu-nityinitiativeforpeoplewithlittlemeans].
Thosearethingsyoudo,anditdoesyougood.
Otherwiseyou'rejustsittingathome.
(D).
AparticularsocialskillthattheFoundationiskeenonandtriestostimulateatseveraloccasionsiscaringfortheother.
[Welearnhowtocareforoneanother].
Yes,I'vegrowninthat.
[Thatiswhatthecoachsays]Idon'tseeitthatmuchyet.
Butindeed,thegroupfeelingispriorformenow,insteadofthefootball.
Ifwedon'twin,wedon'twin.
ThenIthink:'Ok,wetriedourbest'.
Inthepast,Iwouldneverhaveencouragedmyteammates.
Nowtheencouragementscomeallbythemselves.
(C).
VanderVekenetal.
InternationalJournalforEquityinHealth(2020)19:11Page8of13ThemostbasicattitudinalskillsthattheFoundationseemstobeworkingonthroughSFDare:1)beingen-gaged,e.
g.
comingwhenyouareexpected;2)comingontime;3)gettingthroughoneortwohourswithoutsmokingordrinking;4)communicatinginarespectfulmanner;and5)cooperating,workingtogetherforacommongoal.
ArespondentcomparestheFoundation'sactivitieswithasocialworkplace:Attheonehandthereisalotofstructure,attheotherhandyoufeeluseful.
InthebeginningItoldtherespon-sibleoftheworkplacethatitwasimpossibleformetobemorethan15minwithoutnicotine.
ButsoonIcouldworkoneandahalfhourbetweensmokingbreaks.
(G).
Manyrespondentsillustratehowthisworksforthemonorbesidethesportsfieldaswell:WhenIgoplayfootball,Iwon'tdrink,orverylittle.
IfIwouldnothavetogoplayfootball,Iwoulddrinksome-thing,foryouhavenothingtodo.
AftertrainingImightgoforapint,yes,butitisless(…)yes,thepreviousyear,itwasmore.
Now,youhavetogoplayfootball,soit'sdif-ficulttotakeabottleofvodka.
Youhavetoworkonyourcondition.
Soyougoforarunduringtheweek.
(D).
Thefactthatsportsisbutapleasantpretextforotherthansport-relatedgoalsisbeautifullyillustratedbythefollowingquote:(…)tocollaboratemoreandtolearnfromoneanother.
Becausethatiswhatyoudo.
Notonlyplayingfootball.
Youhearsomeonesayingsomethingthatisapplicabletoyourlife(…).
Soyouconstantlylearnfromoneanother.
(H).
Whereverpossible,thecoachmakesthelinkvisiblebetweenskillspracticedinfootballandtheiruseinreallife.
Thecoachtaughtusthatfootballconsistsofthreethings:youthinkaboutitwithyourhead,youfeelitwithyourheartandyoudoitwithyourfeet.
Hesaysitisexactlythesame'outside':youtakeyourstepswithyourlegs,youmakeyoudecisionsbasedonfeeling,butyoudothinkaboutthem,whetherthey'retherightones.
(A).
TheempoweringeffectofresponsibilityandengagementVolunteeringwithintheFoundation,orelsewhere,isstimulated.
TheFoundationconsidersitanopportunitytobuildbasicsocialandworkskills,whilethepartici-pant'smainmotivationtovolunteeristohaveanoccu-pationandtofeeluseful.
Istartedtodothebreakfastforthesocialwelfarecoun-cilonThursday.
IgotintouchviaX,afellowplayer.
(…)Iusedtotakebreakfastthere,nowIgotheretohelp.
Ihavetobethereat8am,getupat6.
30am.
Itgivesyoustrength.
AfterwardsIeatasandwichthereandwhenIgethome,itisalready12amor1pm.
OnTuesdaysthereisasoupcafé.
Igotacquaintedthroughfootball;yougettoknowpeoplewhodothesethings[volunteering].
(…)PerhapsIcanwork2daysaweeksomewheretostartwith.
ThenIhaveTuesdayfootballandThursdaythebreakfast,sothatmakes4daysfilled.
(…)Youseealotofhomelessatthebreakfast.
Itfulfillsmetohelpthere.
(D).
Iambusy7on7.
(…)Allvoluntarywork.
AslongasI'mbusy,atleastI'mnotinthepub.
(F).
NotallparticipantsoftheFoundation'sactivitiesareinterestedintakingresponsibilitywithintheFoundation,howeverallareaskedtoengageaminimuminthecom-munityactivitiesthattheFoundationinvestsin,e.
g.
sponsorrunsforcharity,organizingacommunitygath-eringindeprivedneighborhoods,animatingchildreninthestreet,etcetera.
Severalrespondentsmentionhowtheseresponsibilities,howlittletheymaybe,bringaboutasenseofpurpose,asenseofbelonging.
Fromthedata,itcouldbeidentifiedasoneofthemostpowerfulSFDoutcomes.
Manysociallyexcludedfeelanobodybecausetheyfeeltheyonlyreceive,andarenolongerabletodosomethingfororhavesomemeaningforothers.
[Aboutwhysportplusissopowerful]Toletonehelptheother.
Thatisimportanttome.
(…)Thatismeaning-ful:togetaroleandtomeansomethingtosomeone.
Bydoinganexercise,forexample.
(I).
IneverthoughtIwouldeveragainbeinsuchpositioninmylife.
ThatIcouldstill,perhapswithoutknowing,havesomemeaningforpeople.
(…)Tofeelusefulinlife,incommunity…Especiallythat.
Becausemanyofusfeellikeafailure.
Asifwewalkaroundheredoingnothing,notbelongingtosociety.
(A)Whydoesn'titworkallthetime,foreveryoneAsmentionedbytheparticipantandsocialpartners,drop-outfromtheFoundation'sactivitiesisratherex-ceptional.
Whenparticipantsdonotreturntotheactiv-ities,thereasonisoftenapositiveone,e.
g.
havingfoundajob,orhavingone'slifebackontrackandforthatrea-sonnolongerhavingthetimetoparticipateintheFoundation'sactivities.
However,notallparticipantssucceedingettingtheirlivesbackontrack.
AskedforpossiblereasonswhytheFoundation'stheoryofchangedoesnotleadtoasuccessfuloutcomeinsomeoftheparticipants,respondentsmainlypointafingeratthein-dividual'sresponsibility.
Perseverance…Continuouslydoubtingwhatyoucan,andwhatyoucan'tdo.
Keeponhangingoutwiththewrongpersons.
Notwantingtolearnfromyourmistake.
Ifyoudon'thavethemotivationorthewilltoachievesomething,itisdifficulttoprogress.
(A).
Somepeopleareperhapsnotreadyforit.
Also,every-oneisdifferent.
Ifyou'resomeonewhoconstantlywantstoperformandyou'renotreallyopenforaccessibilityandforotherpeople;orifyoufeeltoogoodforothers,orlookdownatothersbecausetheyareabitdifferent,thenitispossiblethatitdoesnotworkforyou.
(H).
VanderVekenetal.
InternationalJournalforEquityinHealth(2020)19:11Page9of13Noneoftherespondentsstatesthattheprojecthasnotchangedathingforthem,orhasnotcreatedanim-provement,howsmallitmaybe.
DiscussionInafirststepweexaminedwhethertheintheFounda-tion'spolicyplanasoptimaldescribedcontext(i.
e.
aun-constrainedandinclusiveculture,apositiverelationwiththecoach,acontextinwhichparticipantsfeelsafeandaccepted)waseffectivelyputinplace.
ThenwelookedcloserintotheunderlyingassumptionsoftheFoundation'sPT:couldevidencebefoundinthedatathatsupportsthistheoryTheKAAGentFoundation'sinterventionscanbecharacterizedascomplexseenthenumberanddifficultyofbehaviorsrequiredbythosede-liveringandreceivingtheintervention,seenthedifferentgroupsandorganizationallevelstargetedbytheinter-vention,thenumberandvariabilityofoutcomesandthedegreeoftailoringallowed[40].
Oneofthekeyques-tionsinevaluatingcomplexinterventionsiswhataretheactiveingredientsandhowaretheyexertingtheireffect[40].
Thatiswhyweturnedtoarealistevaluation.
DatasuggestthattheFoundationmakeseffortstoef-fectivelycreatethenecessaryconditionsthroughallofthelevelsofactivities.
Participantsconfirmthattheac-tivitiesareaccessible,thatitallstartslight-footedandinawelcoming,warmatmosphere.
Theymentiontheykeeponreceivingchancesfromthecoachandtheorganizationasawhole–somethingtheyconsidertobedifferentwithotherwelfareactors.
MostalsoconfirmtobeabletoenlargetheirsocialnetworkthroughtheFoundation'sactivities.
Furthermore,theyconsideritanexperientiallearningspace:firsttheylearnmoreaboutthemselves,theirstrengthsandlimitations;thentheylearntohavetrustinthemselvesandinothers,whichal-lowsthemtoopenupandsearchforhelpwhentheyhaveadifficulttime.
SomesuccessfulstrategiestheFoundationusestoen-gageitsparticipantsinSFD,includeactivitiesotherthanplayingfootball,volunteeringandasharedengagementincommunitywork.
ThemostpowerfulcontextfactorsintheFoundation'ssuccessstoryappeartobethecoa-ch(es),thepeerexpertsamongfellowparticipantsoftheactivitiesandthelinkwithsocialpartners.
Theoppor-tunitiesgiventoparticipantstotakecareofoneanother,isastrongemancipatingfactor,allowingparticipantstogrow,topracticesomelifeskills,andtofeelusefulwithbettermentalhealthandwellbeingasadirectconse-quence.
IntheFoundation'spolicymodel,thefinalob-jectiveisemployability.
Itisnotpossibletoaccountforemployabilityasafinaloutcome,becauseofthecom-plexityofboththeinterventionandeachparticipant'spersonalcontext.
TheFoundationisbutasmallradarinacomplexsocietalnetworkandintervenesonlyinalimitedamountofdomains.
Therearemanyotherinflu-entialfactorsthatithasnocontrolover.
Moreover,theexpositiontimeisshort(onaverage2haweek),whichprovidesonlylimitedpossibilitiesforaregularpracticeoftargetedlifeskills.
Nevertheless,anumberofimportantinitialandinter-mediateoutcomescouldbeobserved,potentiallythoughnotobligatoryleadingtothefinaloutcome.
Participationassuch,isanessentialoutcometostartwith.
AsCoalterstates:'Byitsverynaturesportisaboutparticipation.
Itisaboutinclusionandcitizenship.
Sportbringsindivid-ualsandcommunitiestogether,highlightingcommonal-ties…'[41].
ParticipationintheFoundation'ssportactivitiesprovidesimportantopportunitiestocreatere-lationsoftrust–bothwiththecoachandwithpeers–andtoconnectwithothers,somethingisolatedpersonsdonotoftenhavethechanceto.
Accordingtoourdata,initialandcrucialoutcomesfollowingparticipation,arereflectionandincreasedself-awareness–evidencethatisinlinewiththeCATCHprogramtheory.
Alsoatthefirstlevel,basicskills(emotionregulation,communica-tion,beingontime,engagement,respect,remediation…)areputtopractice,assuchenhancingtheparticipant'sgeneralself-efficacy.
Severaltheorieshaveconfirmedtheimportanceofperceivedself-efficacyorperceivedcompetencesinbuildinglasting,intrinsicmotivationtosetgoalsforone-selfandtoself-manage[42–44].
Itdetermines'howlongpeoplewillpersevereinthefaceofobstaclesandfailureexperiences,theirresiliencetoadversity,whethertheirthoughtpatternsareself-hinderingorself-aiding,andhowmuchstressanddepressiontheyexperienceincop-ingwithtaxingenvironmentaldemands'[42],p.
625).
TheFoundationappliesallfourstrategiesdefinedbyBanduraasthepathwaystostrengtheningpeople'ssenseofefficacy:throughreductionofpeople'sstressreactionsandalteringoftheirnegativeemotionalproclivities,throughmasteryexperiences,throughprovisionofsocialmodelsandthroughsocialpersuasion[42],p.
625–626).
AllofthesestrategiesareequallydetectableintheCATCHprogramtheory.
PerhapsthemostpowerfulstrategyoftheFoundation,notonlytoraiseitspartici-pants'senseofefficacybutalsotohavethempracticelifeskills,ismodeling.
Seeingpeoplesimilartooneselfsucceedbysustainedeffort,raisesthebeliefsofnew-comersandparticipantslessfarintheirpersonaltrajec-torythattheytoohavethecompetencestosucceed[42].
WhatBanduracallssocialpersuasion,islabeled'motiv-ationalcoaching'intheCATCHprogramtheory:peoplereceiveencouragement,andtheirattentionisdrawntotheirsuccessratherthantheirfailures.
Thecurrentcasestudyshowsatremendousimpactofthecoach(es)ontheparticipants.
Thecoach'swordsofappreciationcarryalotofweight,participantsturntothecoachforadviceVanderVekenetal.
InternationalJournalforEquityinHealth(2020)19:11Page10of13ofallsorts,thecoachiscalledincaseofpersonalprob-lems,andsoforth.
TheFoundation'scoacheshaveproventobestrongsocialpersuaders,assuchenhancingitsparticipants'senseofefficacyandbeliefinoneself.
InSFDorganizationsperhapsevenmorethaninregularsportclubs,positivecoachingisanefficientandrequiredtechnique.
Ratherthanfocusingonwhatisnotgoingwell,andoneliminationofundesirablebehavior,e.
g.
al-coholconsumption,a'positivecoach'emphasizesthepromotionofvariouscompetencies,includinglifeskillsthatenableparticipantstosucceedintheirlivingenvi-ronments[45,46].
Self-efficacyplaysaninfluentialroleinhealthandwellbeing,becauseitreducespeople'sstress(oftenlinkedtoperceivedinefficacy)anditdeterminespeople'smo-tivationtochangetheirhealthhabits:'whetherpeopleevenconsiderchangingtheirhealthhabits;whethertheyenlistthemotivationandperseveranceneededtosuc-ceed,shouldtheychoosetodoso;howwelltheymain-tainthehabitchangestheyhaveachieved;theirvulnerabilitytorelapse;andtheirsuccessinrestoringcontrolafterasetback'[42],p.
627).
ArelativizingnotecomesfromRyan&Deci,whohavehighlightedtheim-portanceofself-authoredmotivationincontrasttomoreexternallycontrolledmotivation:intrinsicallymotivatedpeoplearemoreenthusiasticandinterestedandhavemoreconfidence,resultinginbetterperformance,resist-ance,creativity,vitality,self-esteemandgeneralwell-being,evenforpeoplewithsimilarlevelsofself-efficacyforacertainactivity[44].
IntheFoundation'sprogramtheory,voluntaryparticipationisindeedconsideredanecessarycontextfactor.
WhilethestudydataprovideevidenceforimprovedwellbeingofparticipantsoftheFoundation'sactivities,healthnorwellbeingareexplicitoutcomesintheFoun-dation'sPT.
Thisgivesoxygentotwoideasthatcouldbedevelopedinalaterphaseoranadditionalstudy.
First,itsupportstheportabilityofthemechanisms(meetingbetween(isolated)peers,becomingself-aware,learningbyfun,groupdynamics,volunteeringandbuild-ingexperience)toothercontexts.
Thisalsomeansthatthesamemechanismsmightleadtodifferentoutcomes.
Secondly,itisinterestingtowitnesshowtheFoundationseemstosucceedinimprovingitsparticipants'wellbeingalthoughhealthandwellbeingarenoarticulatedout-comesintheFoundation'sprogramtheory.
Moreover,theFoundationisrelativelytolerantandunconditionedinitsapproach,somethingwhichisnot(andmostprob-ablycannotbe)thecaseforformalcareinstitutions,suchaspsychiatrichospitals.
Improvedwellbeingseemstobeanimportantintermediateoutcomewhenworkingtowardsamoredistantoutcome,suchasemployability(being'theskillsandabilitiesthatallowyoutobeemployed'[47].
Thisstrengthenstheideathatsuccessfulhealthpromotionrequiresanapproachthatallowsthetargetpopulationtosetitsowngoals,andtodevelophealthagencyinrelationtotheenvironment,forex-amplethroughvaluableinterpersonalrelationships[48].
Atleastinvulnerablepopulations,'empoweringinter-ventions'increasingone'spowertoquestionsocialhealthnorms,haveproventobemoreeffectiveinpro-motinghealththanthemoretraditional'informing'ap-proaches[49–51].
Inthisstudy,healthandwellbeingseemtobepreciousside-effectsofguidingpeopletotheabilitytosetpersonalobjectivesandtolifeskillspro-motingself-efficacy.
TheFoundation'spolicymodelisanidealmodel;thefinalobjective,althoughmentionedatthetopofthepyramid,isnotthatallparticipantsgothroughthewholetrajectoryandfindajobintheend.
Theorganiza-tion'smajorobjectiveistohaveasmanypersonsfromthetargetgroupaspossiblebenefitingfromlevelone,wherebasiclifeskillsarepracticedthatenhanceone'sself-esteemandself-perceivedefficacy,assuchincreas-ingone'sintrinsicandlong-lastingmotivationtopursuepersonalgoals,whethertheyarerelatedtohealth,em-ployabilityorsocialwellbeing.
Animpactonemployabil-ityamongparticipantsoftheFoundation'sactivitiescouldnotbeobserved,orinduecase,notbeattributedtotheFoundationalone.
Strengthsandchallenges.
ParticipatoryobservationsallowedresearcherstobuildrelationshipsoftrustwithSFDparticipantsandstakeholders,facilitatingfurtherdatacollection.
Researcherswereexperiencedinqualita-tiveresearch,hencetheirawarenessofpotentialbiasesassociatedtosuchtrustrelationships,andtheircapacitytomitigatethem.
Regulardiscussionandfeedbackfromkeystakeholders,peerresearchersandSFDactorsexter-naltothecasestudyattheonehand,andaparallelinterventionalstudyinanotherSFDorganizationattheotherhand,challengedtheresearcher'sperspectives,andkeptthemsusceptiblefordifferingviews.
Futurere-searchopportunitiesincludethefollow-uponSFDpar-ticipants(e.
g.
cohortstudy),inordertoobservethelong-termandstructuraleffectsofSFD,suchastheef-fectonemployability,andcasestudiesrejectingtheFoundation'sPT(hencechallengingtheapproximatingCATCHtheory).
ConclusionThisstudyaimedatexaminingwhichconditions,neces-saryforasuccessfuloutcome,areputforwardbythestudiedSFDorganizationinpromotingsocialinclusion,andwhicharethemainmechanismsthroughwhichtheFoundationachievesthisoutcome.
AmongthenecessaryconditionsformakingSFDapowerfulleverforsocialinclusion,arethebackground,experienceandskillsofthecoachesandsocialpartnersVanderVekenetal.
InternationalJournalforEquityinHealth(2020)19:11Page11of13involvedintheFoundation'sactivities–aconclusionsimilartotheoneoftheCATCHprogramtheory.
AmongthemostsuccessfulmechanismsofSFDarethemeetingwithpeers,amongwhichsomeexperiencedoneswhocanbearolemodelforothers,andthepossi-bilitytoengageandtakeresponsibilityintheorganizationorincommunity.
Theopportunitiesgiventoparticipantstotakecareofoneanother,isastrongemancipatingfactor,allowingparticipantstogrow,topracticelifeskills,andtofeeluseful,withbettermentalhealthandwellbeingasadirectconsequence.
ThefinalobjectiveintheFoundation'sprogramtheoryisemploy-ability,butitdoesnotexpect,nordoesitpush,allpar-ticipantstoreachthatgoal.
LifeskillsarepracticedatalllevelsoftheFoundation'sprogramtheory.
Wellbeingshowstobeanunintendedbutnecessaryintermediateoutcomeontheroadtoemployability.
Thisisausefulinsightforpractitionersandpolicymakers.
Sociallyvul-nerableandsociallyexcludedpersonsarenoteasytoreach.
Sportactivitiesorganizedinaveryaccessibleand(culturally)acceptablemanner,areasafeandfunstart-ingpointforpeoplefromthetargetgrouptoreturnto–asshownaswellintheCATCHprogramtheory,builtoninsightsfrominternationalliteratureandvariousna-tionalSFDprojects.
Fromthatsafestartingpoint,SFDteamsthatarepositivelycoached,cangrowintoasociallearninglabinwhichmanyofthedeterminantsofsocialexclusioncanbeaddressed.
Policymakersandprojectfundersneedtobeawarethattheprocessthroughwhichsociallyvulnerablepersonsbondwithpeersandwithcoaches,isatime-consuming,however,quintessentialprocessiftheaimistoengagethetargetgroupinasus-tainableself-caringdynamicsleadingtopersonalhealthgoal-setting.
SupplementaryinformationSupplementaryinformationaccompaniesthispaperathttps://doi.
org/10.
1186/s12939-019-1119-7.
Additionalfile1.
OverviewofdatacollectedinthecasestudyKAAGentFoundationAcknowledgementsTwotrainees,SofieDeGussemandCharlotteHeyninck,bothstudentsinthemaster'Managementandpolicyofhealthcare'attheUniversityofGhent,wrotetheirmaster'sthesisonthecasestudyKAAGentFoundation.
Theyhelpedinthecollectionandanalysisofthedata.
Inherroleaspromotorofthetwotrainees,Dr.
KaatjeVanRoy,postdoctoralresearcherintheresearchunitEquityinHealthofGhent,hadavaluablecontributionaswellintheanalysisofthedata.
Authors'contributionsKVandELcollectedandanalyzedthedata.
KVwrotethemanuscript,withsubstantivecontributionsbyEL,amongothersimprovingthemanuscript'sdiscussion.
SWsupervisedthestudy,providedtechnicalguidanceandguardedoverallstudyquality.
Allauthorsreadandapprovedthefinalmanuscript.
Authors'informationKarenVanderVekenholdsaMScinpoliticalsciences,oneinhealthpolicyandmanagement,andaprofessionaldegreeinmidwifery.
Sheisexperiencedinprimarycareasapractitionerandprojectmanagerinthefieldsofhealth,educationandsocialinclusion,mostlyinlow-andmiddle-incomecountries.
AsPhDstudentattheDepartmentofPublicHealthandPrimaryCare(GhentUniversity),shecurrentlyfocusesonsocialmechanismsrelatedtoSFDthatmaypromotehealthandwell-beinginsociallyvulnerablepopulations.
EmelienLauwerierhasabackgroundinclinicalpsychologywithaPhDinhealthpsychology.
SheworksattheDepartmentofPublicHealthandPrimaryCareandtheDepartmentofPsychologyandEducationalSciencesatGhentUniversity.
Herexpertiseisontopicsrelatedtotheareasofhealthpromotionandcommunication,evidence-basedinterventiondesign,plan-ningandimplementationofhealthbehaviorchangeinterventions,andchronicdiseasecareandprevention.
SaraWillemshasabackgroundinHealthPromotionwithaPhDinMedicalSciences.
SheisheadoftheDepartmentofPublicHealthandPrimaryCareandleadstheresearchgroupEquityinHealthCare.
Herresearchfocusesonequityinaccessto(primary)healthcareandsocialdifferencesinthedeliveryandoutcomesofcare.
FundingThisstudyispartoftheCATCHresearchproject,fundedbyFlandersInnovation&EntrepreneurshipunderGrantnumberIWT150060.
AvailabilityofdataandmaterialsThedatasetsgeneratedand/oranalyzedduringthecurrentstudyarenotpubliclyavailableduetotheunavailabilityofEnglishtranslationsforallofthetranscripts,butareavailablefromthecorrespondingauthoronreasonablerequest.
EthicsapprovalandconsenttoparticipateThecasestudywasapprovedbytheethicalcommitteeofGhentUniversity(numberB670201836103).
ConsentforpublicationNotapplicable.
CompetinginterestsTheauthorsdeclarethattheyhavenocompetinginterests.
Authordetails1DepartmentofPublicHealth&PrimaryCare,ResearchgroupEquityinHealthCare,GhentUniversity,Ghent,Belgium.
2DepartmentofExperimental-Clinical&HealthPsychology,GhentUniversity,Ghent,Belgium.
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