The BeweegKuur programme: a qualitative study of promoting and impeding factors for successful implementation of a primary health care lifestyle intervention for overweight and obese people.

Abstract

The aim of the study was to identify promoting and impeding factors for successful implementation of a Dutch primary health care-based lifestyle programme called 'BeweegKuur'. BeweegKuur aims to increase the physical activity and change the diet of people at increased health risk due to overweight or obesity.
To determine perceived promoting and impeding factors in the implementation of the BeweegKuur programme for overweight and obese people.
This study consisted of 3 focus group meetings with intervention participants, 15 interviews with health care professionals (HCPs) and 1 focus group session with dieticians. The interviews and focus groups were recorded and transcribed verbatim. The data were analysed with the Nvivo qualitative research software package.
For some intervention participants, the invitation to participate in BeweegKuur came unexpectedly, as they had not been diagnosed with an illness. HCPs were aware of this and took time to explain to participants that the programme was appropriate and safe for them. Participants as well as professionals were generally positive about the feasibility of the programme for overweight and obese people.
HCPs as well as intervention participants were motivated to participate in the programme, and generally indicated that the intervention was in accordance with their needs. The multidisciplinary approach and the combination of physical activity and dietary behaviour change can make the BeweegKuur programme a success if potential impeding factors like those identified in the present study are overcome.

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Family Practice 2012; 29:i68–i74
doi:10.1093/fampra/cmr056
The BeweegKuur programme: a qualitative study of
promoting and impeding factors for successful
implementation of a primary health care lifestyle
intervention for overweight and obese people
J H M Helminka,*, S P J Kremersa, L C Van Boekelb,
F N Van Brussel-Visserc, L Prellercand N K De Vriesd
aDepartment of Health Promotion, School for Nutrition, Toxicology and Metabolism (NUTRIM), Maastricht University,
Maastricht,bDepartment Tranzo, Faculty of Behavioural and Social Science, Tilburg University, Tilburg,cNetherlands Institute
for Sport and Physical Activity, Ede anddDepartment of Health Promotion, School for Public Health and Primary Care (CAPH-
RI) and School for Nutrition, Toxicology and Metabolism (NUTRIM), Maastricht University, Maastricht,
The Netherlands.
*Correspondence to J. H. M. Helmink, Department of Health Promotion, School for Nutrition, Toxicology, and Metabolism
(NUTRIM), Maastricht University, Maastricht, The Netherlands; E-mail: judith.helmink@maastrichtuniversity.nl
Received 18 April 2011; Revised 12 July 2011; Accepted 23 July 2011.
Background. The aim of the study was to identify promoting and impeding factors for successful
implementation of a Dutch primary health care-based lifestyle programme called ‘BeweegKuur’.
BeweegKuur aims to increase the physical activity and change the diet of people at increased
health risk due to overweight or obesity.
Objective. To determine perceived promoting and impeding factors in the implementation of the
BeweegKuur programme for overweight and obese people.
Methods. This study consisted of 3 focus group meetings with intervention participants, 15 inter-
views with health care professionals (HCPs) and 1 focus group session with dieticians. The inter-
views and focus groups were recorded and transcribed verbatim. The data were analysed with
the Nvivo qualitative research software package.
Results. For some intervention participants, the invitation to participate in BeweegKuur came
unexpectedly, as they had not been diagnosed with an illness. HCPs were aware of this and took
time to explain to participants that the programme was appropriate and safe for them. Partici-
pants as well as professionals were generally positive about the feasibility of the programme
for overweight and obese people.
Conclusions. HCPs as well as intervention participants were motivated to participate in the pro-
gramme, and generally indicated that the intervention was in accordance with their needs. The
multidisciplinary approach and the combination of physical activity and dietary behaviour
change can make the BeweegKuur programme a success if potential impeding factors like those
identified in the present study are overcome.
Keywords. HCPs, implementation, lifestyle intervention, overweight and obesity, primary
health care.
Introduction
The number of people who are overweight or obese is
increasing in Western societies.1In the Netherlands,
approximately half of the Dutch adult population was
overweight in 2007, and 12% were obese.2Obesity in-
creases the risk of developing cardiovascular diseases,
some types of cancer and psychosocial problems.3,4
Weight gain is the result of a positive energy balance,
in which energy input through food consumption
exceeds energy output, which is partly determined by
physical activity.5Lifestyle interventions focussing on
both physical activity and healthy diet have proved ef-
fective in preventing weight-related morbidity in rela-
tively controlled research settings.6,7Because of the
gap between theory and practice, the challenge is to
make these interventions suitable for ‘real-world’
settings.8
Primary health care has been suggested as a good
starting point for lifestyle interventions,9but successful
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implementation of lifestyle programmes requires the in-
tervention to be (i) in agreement with patients’ wishes
and expectations and (ii) compatible with the structure
and routines of primary health care. Thus, to make life-
style interventions effective in primary health care, in-
depth insight is needed into impeding and promoting
factors of successful implementation.10A number of
characteristics have been argued to be essential for
good implementation. These include the characteristics
of the innovation itself.11For example, does the innova-
tion fit the organization? What are the impeding and
promoting contents of the innovation? Also, the char-
acteristics of the user are important.11Does the user
have a positive attitude towards the intervention and
is he or she skilled enough10,12The factors which are
crucial on the patient level include knowledge, skills,
attitude and compliance.13Furthermore, the character-
istics of the organization are important. In lifestyle in-
terventions, health care professionals (HCPs) work in
multidisciplinary teams consisting of professionals from
disciplines that have traditionally not been part of the
HCPs work-related network. Finally, the characteristics
of the social–political context are crucial, such as finan-
cial arrangements and policies.11
This article reports on a qualitative study into the
recently developed Dutch primary health care lifestyle
intervention called ‘BeweegKuur’ (Dutch for ‘exercise
therapy’), examining the crucial implementation is-
sues. The objective of this study is to determine per-
ceivedpromoting and impeding
implementation of the BeweegKuur programme for
obese and overweight people.
factors in the
Methods
Background information on BeweegKuur
In 2008, the Netherlands Institute for Sport and Physi-
cal Activity developed BeweegKuur as an evidence-
and practice-based intervention focussing on both
dietary behaviour and physical activity. The aim was
an effective and feasible primary health care-based in-
tervention, which in time could be reimbursed under
the Dutch basic health insurance scheme (for a de-
tailed description of the development process and in-
tervention contents, including the theoretical and
evidence base for the approach, see Helmink et al.14).
Whereas the paper of Helmink et al.10describes the
systematic process of intervention development, the
present study was aimed at a qualitative assessment of
the implementation process. The intervention was ini-
tially developed for diabetic or pre-diabetic patients,
but in 2009, the programme was further developed for
overweight and obese people with a body mass index
>25 in combination with large waist circumference
(>88 cm for women, >102 cm for men), as the main
selection criteria. Inclusion criteria also allow for
people with several types of comorbidity such as
diabetes to be included.
The starting point of the BeweegKuur interven-
tion15is the GP’s practice. The aim of the 12-month
intervention is to guide participants in achieving a sus-
tained healthy lifestyle15(for a detailed description of
the BeweegKuur intervention, see Helmink et al.14).
The GPs refer patients for an introduction by a so-
called lifestyle advisor (LSA), normally a practice
nurse, who was trained prior to the implementation of
the programme to coach and guide patients during the
process of initiating and maintaining lifestyle changes.
Based on the results of an endurance test, the LSA de-
signs an individual exercise programme in close con-
sultation with the patient and a physiotherapist
and the LSA refers the patients to a dietician for
individual assessment (see Fig. 1).
Pilot study
The BeweegKuur programme for obese and over-
weight people was implemented at the end of 2009 at
five pilot locations across the Netherlands. In total, 36
HCPs started to work with the programme, and 87 pa-
tients participated during this period. Qualitative
methods were used to assess the opinions of HCPs
and patients regarding the programme’s feasibility in
primary health care practice. Focus group sessions
with a total of 16 patients were conducted at 3 loca-
tions. Participants were approached by the LSA and
they received a gift voucher for their cooperation. Par-
ticipants filled out an informed consent form and full
anonymity was granted. The data were gathered
between November 2009 and April 2010.
All HCPs in the pilot locations were approached by
the researcher for an interview or focus group. Due to
logistics and time of the HCPs, most of the HCPs were
interviewed individually [n = 15; 4 GPs, 6 physiothera-
pists (2 of whom acted as LSA), 4 practice nurses (3 of
whom acted as LSA), and 1 dietician who acted as an
LSA)]. Three interviews were done by telephone, the
others face to face. In addition, a 1-hour focus group
session with five dieticians was organized. The point
of saturation was reached at the final interview. The
interviews and focus groups were recorded and tran-
scribed verbatim with the consent of the participants
and transcripts were anonymized. Two researchers
(JHMH and LCVB) interviewed the HCPs and led
the focus groups and classified the interviews by
theme, using the Nvivo qualitative research software
package. The content analysis of the transcription was
performed by two researchers (JHMH and LCVB).
A codebook was developed before the interviews
based on the interview scheme and the transcripts
were systematically analysed by the principal investi-
gator (JHMH). A second researcher (LCVB) verified
the coding and made further suggestions. The themes
discussed during the interviews and focus groups are
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systematically presented in Table 1. To facilitate the
interpretation of the data, a thematic framework
method has been used16and the topics were catego-
rized under the following themes: motivation and bar-
riers for participation,
behaviour, combinationof
dietary behaviour and maintaining lifestyle changes.
physical activity, dietary
and physicalactivity
Results
Motivation and barriers for participation
The main reasons for participants to take part in Be-
weegKuur were prevention of diseases and/or compli-
cations, losing weight and changing lifestyle. One
participant stated ‘I want to change my lifestyle, other-
wise I’ll get diabetes’. Some participants were con-
vinced by the LSA or GP to start the intervention,
and for some participants the invitation to participate
in the programme was unexpected because they were
not aware of being at high risk of overweight-related
morbidity as a result of their unhealthy lifestyle.
All HCPs had had 2 years of work experience with
the BeweegKuur programme when it was still aimed
at diabetic or pre-diabetic patients, but they shared
the opinion that the further development of the pro-
gramme for overweight or obese people was an essen-
tial improvement. A practice nurse stated: ‘It’s the
target group that you hope will exercise more. With
this programme, you can offer them something’. An-
other physiotherapist commented: ‘The participants in
this target group feel that they have failed at different
levels, at the level of exercise as well as that of
dietary behaviour. It is a benefit to offer these people
a programme’.
It is a new approach for GPs to identify potential in-
tervention participants based on their overweight sta-
tus, rather than on the diagnosis of a disease. HCPs
noticed some differences between participants with di-
abetes and those with overweight or obesity. In the
perception of HCPs, overweight or obese people were
more embarrassed about their physical appearance
(a practice nurse: ‘Physical appearance plays an
important role’), while diabetes patients were more
FIGURE 1 The pathway of the BeweegKuur intervention
TABLE 1Themes discussed during the focus groups and interviews, per subgroup
Theme
Motivation to participate
Facilitators and barriers of the programme
Content of the programme
Factors determining the success of the
programme
Dietary programme: group education
Dietary programme: individual consultations
Exercise programme
Combination of physical activity and dietary
behaviour advice
Guidance by HCPs
Financial contribution by participants
Differences and/or similarities between diabetes
and obese or overweight participants
Changes in working methods after re-definition of
targetgroupfromDiabetesmellitustooverweight
Skills required to work with the new target group
Inclusion criteria
Refusing to take part in BeweegKuur
Collaboration by HCPs
Maintaining lifestyle changes
Focus group with patients
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Interviews with HCPs
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Focus group with dieticians
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aware of the fact that a healthy lifestyle could improve
their health (LSA: ‘Diabetic patients are more aware
that they can do something about their health’). These
professionals thus indicated that the main reason for
overweight and obese people to participate was to lose
weight, while the diabetic patients generally appeared
to participate to improve their health. The professio-
nals reported they needed more time to convince non-
diabetic participants that it is good and safe to
participate in BeweegKuur, since diabetic patients
were already more used to seeing their GP or practice
nurse regularly to discuss their lifestyle. A GP stated:
‘A diabetic patient is already a patient with a chronic
disease and comes four times a year to the GP for
a check-up. You talk about lifestyle with these pa-
tients more often. An overweight or obese patient is
only too heavy and not sick yet. It is not always easy
to start and talk about lifestyle and weight with these
people’. All HCPs thought it was important that the
participants consulted their GP before attending the
programme, although in practice this did not always
occur due to GPs’ lack of time. One HCP said: ‘I think
it’s important. It can also be important for the
participant to have the GP’s support’.
Most HCPs had attended the course on motiva-
tional interviewing17provided to all professionals in-
volved in the intervention; only some GPs did not
attend. The HCPs thought that motivational inter-
viewing was an important skill to motivate patients to
participate in BeweegKuur. However, a barrier in this
respect was lack of time for optimal use of motiva-
tional interviewing techniques. A practice nurse stated
‘I do not have enough time to apply Motivational
Interviewing in the right way’.
HCPs stated that one important reason for patients
to refuse participation was having to pay for the exer-
cise programmes offered by the physiotherapists,
which some were unwilling or unable to do. A physio-
therapist said: ‘Paying for the exercise programme is
a problem in this area. At first, we let them pay to ex-
ercise here, but a lot of patients refused to come. Now
it is free and more people came’. Finally, time invest-
ment by participants or inability to come to meetings
during working hours was also reasons to refuse.
A LSA stated: ‘The people in the overweight and
obese group are younger and have to work during the
day when the meetings are planned’.
Physical activity
The focus group participants who had been allocated
to the independent exercise setting had started various
physical activities, such as walking, cycling, Nordic
walking, swimming, and dancing. Participants allo-
cated to the start-up and supervised exercise settings
were positive about the physiotherapy programme.
A respondent stated: ‘The physiotherapist sees every-
thing, even when it doesn’t go well’. Supervision by
the physiotherapist was perceived as valuable and
some participants wanted to stay with the physiothera-
pist after the three months of training. This option was
indeed offered at two locations, at a price which was
almost equal to going to a gym. Some participants pre-
ferred to exercise alone, while others preferred group
exercising. A patient stated: ‘I rather exercise in
a group, we have a nice group’. Another patient pre-
ferred to exercise alone: ‘If you go for a walk you can
do it whenever you want, whereas in a group you have
to be there on time’.
HCPs perceived the three exercise settings to be
appropriate for this target group, though they also
reported that some participants were disappointed
about being allocated to the independent exercise
setting. Some participants had expected that the
programme would consist of 3 months of training
with a physiotherapist, rather than having to exer-
cise on their own. One LSA stated: ‘Some patients
are enthusiastic because they think they can go to
the supervised exercise setting. If we refer them
to the independent exercise setting, they’re really
disappointed’.
Dietary behaviour
Respondents were satisfied with the dietary pro-
gramme offered to them. They indicated that it was
important that the content and goals of the dietary
programme were made clear from the start. Atten-
dance at individual consultations with dieticians var-
ied, partly because of costs, the expectation that it
would not add much to the group meetings or negative
experiences with past visits to a dietician. As one re-
spondent expressed it: ‘In the past I went to a dietician
and she told me what I was allowed to eat and what
not. If you have a consultation with the dietician she
focuses on you. Now I am in a group, so the attention
is not only focused on me, and for me that works bet-
ter’. Other respondents thought they would benefit
more from individual consultations: ‘I think that you
can make better arrangements with the dietician dur-
ing an individual consultation than during the group
meetings’. The majority of the respondents were will-
ing to participate in the group education meetings.
A reason not to attend the meetings was a fear of
showing dietary behaviour and emotions in the group.
For some respondents, the information in the meet-
ings was not new; nevertheless, they felt that the
meetings were useful as a back-up to prevent an un-
healthy lifestyle. A respondent stated: ‘The informa-
tion in the meetings is not new, but now I have a back
up so I will improve my behaviour sooner’. Another
perceived advantage of the group meetings was that
participants could compare themselves with others.
Some respondents had wanted more information
about the combination of their diet and their increased
exercise behaviour.
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Some LSAs were of the opinion that they ought to
be present at a patient’s first dietary education meet-
ing, to lower the threshold. Since participants already
knew the LSA, this could increase their willingness to
go. An LSA stated: ‘Patients think it is nice if we are
there’. It was perceived as important by HCPs that
LSAs explained to participants that BeweegKuur con-
sisted of both an exercise and a dietary programme
and that they should try and convince participants to
attend the first session to see ‘that it’s not so bad’.
Some dieticians saw that participants were very nega-
tive at the start, but became more positive during the
meetings. A dietician: ‘One participant was very skep-
tical and didn’t know what to do before the meeting.
During the meeting, she was talking the most’. A dis-
advantage of the individual consultations is that Dutch
health insurance does not cover the full costs. People
consulting a dietician have to pay part of the cost
themselves, which made some participants decide not
to attend individual consultations. A dietician stated:
‘The payment really plays a role. One participant can-
celled the BeweegKuur when he heard he had to pay’.
Combination of physical activity and dietary behaviour
The respondents thought the exercise programme was
the most attractive part of BeweegKuur, although they
all regarded the combination of exercise and dietary
behaviour as necessary. One respondent said: ‘It isn’t
possible to do the one without the other’. The combi-
nation of the exercise and dietary programme was per-
ceived as a considerable burden, especially for those in
the supervised exercise setting, and particularly in the
beginning.
HCPs were also convinced of the necessity of com-
bining the dietary and exercise programmes. However,
most of the dieticians aimed their educational efforts
solely at improving dietary behaviour. A dietician
stated: ‘I only aim at an improved diet and not at more
physical activity’. Only one dietician took the partici-
pants’ increased physical activity behaviour into
account in their dietary advice.
Maintaining lifestyle changes
The focus groups revealed that participation in Be-
weegKuur was perceived as a success by the partici-
pants when they lost weight, and that continuation of
a healthy lifestyle was also an important aim for the
participants. Some respondents doubted whether they
would be able to maintain their healthy lifestyle after
the programme: ‘I think it’ll be hard to keep up the
healthy lifestyle’.
HCPs commented that it was important that the list
of available local exercise facilities was complete and
up to date, to sustain lifestyle changes. An important
prerequisite for sustained engagement in physical ac-
tivity is a smooth transition of the participants to local
facilities. The five pilot locations had worked with the
BeweegKuur programme for almost 2 years, and their
lists were now sufficiently complete. During the first
year of the programme, however, the list had been in-
complete, which had hindered the transition. All pro-
fessionalsintendedto discuss
programme with participants when these patients re-
turned to their practice after completing the pro-
gramme, in order to follow-up on the process of
lifestyle change. Practice nurse: ‘I always talk about
their lifestyle with the patient when they return at
a check up’. A GP stated: ‘I only see the participants
once a year and there is not always time to talk about
the programme. But I always try to talk about
lifestyle’.
theBeweegKuur
Discussion
A new aspect of lifestyle interventions such as Be-
weegKuur, at least for primary health care in the
Netherlands, is that the selection of potential partici-
pants is based on risk factors for diseases, rather than
on actual diagnosis of a disease. This approach im-
plies a shift towards a more preventive attitude for
all professionals concerned. For some participants,
the invitation to participate in the programme was
unexpected, as they were not diagnosed with a disease.
HCPs were aware of this and indicated they needed
more time to explain to patients that the programme
was appropriate and safe for them. In this study, par-
ticipants as well as HCPs were generally positive
about the feasibility of the programme for overweight
and obese people. Referral by a GP was perceived
as important by both participants and professionals.
A study by Schmidt et al.18showed that being moti-
vated by a GP can be important for patients and pro-
vides a strong incentive to exercise. Attractive features
of our intervention are the multidisciplinary approach
and the combination of physical activity and improved
dietary behaviour. However, our study also identified
some potentially impeding factors for the implementa-
tion of BeweegKuur, as outlined below.
An important skill to motivate participants is moti-
vational interviewing, and all HCPs had been trained
to use this. Previous studies showed that motiva-
tional interviewing is effective in coaching lifestyle
changes.19–22However, these techniques are not easily
applied in routine practice and require intensive train-
ing and practice support by specific feedback.19The
fact that motivational interviewing takes more time
than traditional counselling techniques could be a bar-
rier for HCPs to implement it in the BeweegKuur pro-
gramme. In our study, they did indicate lack of time,
as was also reported in other studies.12,23–25
The BeweegKuur programme was perceived as
a success by the participants when they lost weight
or reached their target weight. However, weight
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reduction results from a consistently negative energy
balance over a prolonged period, and exercise will
lead to an increase in muscle tissue, resulting in better
physical condition but not necessarily in weight reduc-
tion for all participants. HCPs in particular should ex-
plain this to the participants, and discuss realistic
objectives.
The majority of the participants were referred to
a dietician. Some respondents had found that dieti-
cians’ advice had not helped them in the past, and
therefore no longer wanted to consult a dietician. It is
crucial that the dieticians’ counselling adds to previous
experiences and fits in with the BeweegKuur lifestyle
approach. This implies, for example, that dietary ad-
vice should be adapted to the increased physical
activity in the patients’ daily routines.
An impeding factor for individual dietary consulta-
tions in BeweegKuur was that health insurance did
not fully cover the costs. A similar financial impeding
factor was identified for the start-up and supervised
exercise sessions. Some people were unable or unwill-
ing to pay their share of the cost (a relatively small
amount of money; 15 Euros a month) of exercising
with a physiotherapist, and in some cases refused to
participate in the programme.
Some participants were disappointed when they
were referred to the independent exercise setting.
These respondents had expected that the BeweegKuur
involved three months of exercising with a physiothera-
pist, while in fact they had to exercise on their own,
without supervision. The different exercise settings
thus need to be explained in more detail to partici-
pants before they start. Some participants were not
convinced they would be able to maintain their
healthy lifestyle after the programme. A complete list
of available local exercise facilities was perceived as
crucial by the HCPs, as well as giving attention to life-
style during follow-up meetings after completion of
the programme.
Strength of this study is the qualitative study meth-
odology that incorporated both HCPs and patients.
The results of this study have been directly used to in-
form practice; the gathered information has been used
to improve the nation-wide implementation of the Be-
weegKuur in the Netherlands. Some limitations of the
present study need to be acknowledged. The same
two researchers interviewed and structured the data,
which could have introduced bias in the interpretation
of the data. Furthermore, the HCPs in this study were
selected on the motivation to work with the interven-
tion. Therefore, this selective sample could be more
positive about the intervention than their colleagues.
To conclude, both HCPs and participants were mo-
tivated to participate in the programme, and they
generally indicated the intervention to be in accor-
dance with their wishes and needs. If the various po-
tential impeding factors identified in the present
study are taken into account, the multidisciplinary
approach and the combination of physical activity
and dietary behaviour advice can make the BeweegKuur
programme a success.
Acknowledgements
We would like to thank the Dutch Ministry of Health,
Welfare and Sports for its financial support, and ex-
press our gratitude to all health care providers and
patients who participated in interviews or focus
groups.
Declaration
Funding: Dutch Ministry of Health, Welfare and
Sports.
Ethical approval: none.
Conflict of interest: The authors declare that they have
no conflict of interests.
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