The final research plan illustrates the iterative nature taken to develop the PROSCeSS intervention (see Fig. 2). It highlights the interconnected relationship between studies rather than each taking a linear and silo approach, especially when considering the inputs from the scientific literature and stakeholders’ needs and perspectives.
Step 1: Conduct a needs assessment
Beyond identifying gaps in the application of the settings-based approach to sports clubs, the mapping review identified 14 evidence-driven strategies previously used to promote health in sports club settings. The identified strategies were categorised using previous guidelines for HP in sports clubs (Kokko, 2014a) which were applied during the development of the HPSC approach. The original strategies were labeled as: communication, dynamic, education, experience, feasibility, goals, mobilization, monitoring, motivation, participative approach, partners, planning, policies and resources.
Forty-five French sports and public health stakeholders participated in the concept mapping study (Stacey Johnson et al., 2020) that generated 78 statements about the support they need to promote health in sports club settings. Following multidimensional scaling and hierarchical cluster analysis, statements were categorised into 9 thematic clusters: Tools for HP, Communication tools, Stakeholder training courses, Diagnostic & Financing, Awareness & Mobilization, Advocacy, Policies & Methods and Sharing & Networking. Participants rated 35 of the statements as highly important and feasible for sports clubs to implement to increase their HP actions.
Comparing current literature (Susanna Geidne et al., 2019) to the stakeholder-identified needs, similarities were seen between the two studies within several strategies (communication, education, mobilization, evaluation or monitoring and policies), although results were not completely aligned. Therefore, a process was required to merge the literature-informed evidence-base and the context-informed stakeholder perspective to generate a robust, evidence-based theory that also reflected stakeholders’ perspectives.
Step 2: Create a matrix of change
Reviewing the literature to identify theoretical models highlighting the application of the settings-based approach to sports clubs, article content on the HPSC concept (Kokko, 2014b) was analysed. This provided a basis for the theory of change, but lacked a clear definition of concepts used, such as the health determinants (economic, environmental, organizational [previously cultural] and social).
To be able to use the HPSC concept as basis for our intervention, the authors needed to clarify the concept and validate a model. Therefore, an initial model was developed, including definitions of the sports club levels and health determinants within each level. This was followed by a Delphi study to validate the theorical model and develop a measurement tool for sports clubs to self-evaluate HP perceptions at the three levels presented in the HPSC conceptual model (participants, coaches and managers) and to develop the PROSCeSS intervention. Based on three previous Delphi studies (Kelly et al., 2014; Kokko, Kannas, & Villberg, 2006; Robertson, Eime, & Westerbeek, 2018), the HPSC concept was refined into a model, with clear definitions of the 4 health determinants (economic, environmental, organizational [previously cultural] and social) at the 3 sports club levels: the club as an organization (macro), managers (meso) and coaches (micro). Creating the measurement tool through an international Delphi study—a 3-scale, 62-item questionnaire (e-PROSCeSS)—allowed the evaluation of the four health determinants at each level (macro, meso, micro). Only stakeholders from 13 countries at the international level (international sports organizations and academics) took part in this Delphi study, which limited local club and stakeholder input, but ensured that the tool was usable internationally.
Armed with a clear theoretical model, a qualitative iterative process was undertaken to classify the intervention strategies into the model to align the theory, intervention and measurement tool. The 14 evidence-driven strategies from the mapping review were transformed into 69 intervention components by the authors. These were then classified into the theoretical model by three groups of stakeholders: sports students, French sport and health stakeholders, and Swedish sport and health stakeholders. During three half-day workshops, each group classified the 69 intervention components into one or more sport club levels and health determinants in the HPSC model. Undertaking this exercise with the evidence-driven components further modified the theoretical model, adding levels (e.g., individual, second line actors and sports federations), and highlighted the importance of a system (the club and lower levels) in the system (the external stakeholders of the club).
At this stage, the authors realized that a bottom-up approach considering sport stakeholders’ needs was necessary to ensure contextual relevance and stakeholder buy-in for implementation. The 35 most important and feasible ideas from the concept mapping study were also integrated in the HPSC model using a similar process with the French stakeholder group. This led to further clarification of the external levels, redefining them once again into governmental actors, sports federations and public health actors and defining the health determinants specific to the levels (see Table 1 and Fig. 3).
Step 3: Select theory-based intervention methods
To better inform the PROSCeSS intervention content and understand how HP has previously been developed in sports clubs, the authors conducted a capitalization study to evaluate 8 French sports clubs with promising HP projects (Aurélie Van Hoye et al., 2021). Results highlighted that 13 of the 14 evidence-driven strategies identified by the mapping review were implemented in sports clubs (min = 9; max = 13). The policy strategy was not targeted by any of the interventions. Key competencies needed by HP project managers identified in this study were: (1) a deep understanding of the context (needs of the targeted population, resources and sport discipline), (2) the ability to mobilize internal and external human resources, (3) communication skills and (4) an ability to write grant applications (Aurélie Van Hoye et al., 2021).
As stakeholders had requested the addition of a national sports federation level in the HPSC model, the authors wanted to investigate how federations promoted health. National sports federations operated similarly to sports clubs, including promoting health topics in silos (doping, citizenship, etc.), not embedding HP in policy documents and having short term HP programs and events without a clear agenda or whole-of-organization project.
This step provided valuable experiential knowledge of the current state of HP in French sports clubs. For example, there was no consistent approach or pattern in strategy implementation (i.e., across the 8 sports clubs, strategies were used in a different order, refraining the identification of a systematic sequence for HPSC), which reinforced the need for a tailored and flexible approach, as reflected in the open and dynamic nature of the settings-based approach (Dooris, 2006; Mittelmark, 2014). In addition, the current status of HP in sports federations brought attention to the work needed at this level.
Step 4: Integrate methods in an organized program
To build intervention content, based on the refined HPSC model and intervention framework, 29 stakeholders (coaches, managers and local level stakeholders) were invited to create program content and tools. A six-month process, including 4 collective workshops and individual sports club meetings supported the creation of the PROSCeSS intervention. These stakeholders and the authors defined two intervention designs, aided in creating a massive open online course (MOOC) with four modules and a single season sports club intervention. An analysis of ongoing programs (Gaelic Athletic Association (Lane, Murphy, Donohoe, & Regan, 2017) and Good Sport Program (Kingsland et al., 2015)) informed the pace of the intervention and its steps. Involving stakeholders led to the identification of practical tools preference and their creation, adaptation of the vocabulary, as well as modifications in expectations of sports club’s commitment and involvement. Stakeholders also identified implementation gaps, designed solutions, and contributed to the creation of tools. For example, a partnership map with roles of external agencies was created to help sports clubs find resources within their environment. Finally, the program was designed and included 7 different steps to fully achieve implementation (see Fig. 4).
Step 5: Plan for adoption, implementation and sustainability
During a pilot feasibility trial, only four of the 14 selected sports clubs had executed at least 5 of the 7 steps of the intervention, during a sporting season. Reasons for not committing to more than 5 steps of the intervention were: lack of interest (2 clubs), activities already in place (3 clubs) and lack of human resources (5 clubs). The 4 clubs that completed at least 5 steps of the intervention, implemented between 9 to 13 different HPSC strategies and 15 to 23 or the coordinated intervention components. The strategies most commonly implemented were experience, resources and communication; the least implemented were partners, education and feasibility. Moreover, no club committed to the intervention evaluation as planned, none completed the e-PROSCeSS questionnaires on HP perceptions within their club. Lessons learned from stakeholders’ voices after the pilot trial were the need to offer more time and flexibility in achieving each step, the need for formal engagement in the project, the identification of a single individual for intervention implementation rather than establishing a dedicated HP committee, which was too challenging time and resource wise to recruit, a shorter training session and a more flexible and open evaluation.
Step 6: Generate an evaluation plan
In order to evaluate the HPSC approach, the measurement tool created during step 2 had to be psychometrically validated. Face validity was undertaken with 20 stakeholders (managers, coaches and sports participants) in French and English, followed by full psychometric validation in French with 473 respondents. While the concept of HP could not be directly measured, latent variables on dimensions of HP such as organizational, social and economic determinants were validated, providing a premier version of the e-PROSCeSS tool, allowing comparisons of HP perceptions between managers, coaches and participants. Relationships with sport drop-out intentions, self-rated performance and quality of life were also found, identifying them as potential outcomes of the PROSCeSS intervention. The final version of the questionnaire includes 26 items on the macro scale, 15 items on the meso scale and 15 items on the micro scale (see Table 2).
Finally, to evaluate both the implementation process and preliminary evidence of intervention effect, a hybrid type-3 design was planned with 30 sports clubs in France (B. Tezier et al., 2022). Data would be gathered via clubs recording their HP activities and productions during the 8 intervention steps over 18-months (see Fig. 4). Additionally, focus groups with participants and interviews with project managers was planned, rather than completing the e-PROSCeSS questionnaires, which was not doable during the pilot. This design allows for an understanding of how strategies were implemented at different levels, as well as investigates effects on the outcomes of the intervention.