Facilitators and barriers in the collaboration between the primary care and the sport sector in order to promote physical activity: A systematic literature review

Abstract

Introduction:
The aim of this review was to identify collaborative initiatives between the primary care and the sport sector in order to promote physical activity (PA), and barriers and facilitators in these initiatives.

Method:
Pubmed, SportDiscus, Web of Science, and SOCindex were systematically searched for publications published between 2000 and June 2014. Publications reporting on collaboration between the primary care and the sport sector to promote PA were included. Publications reporting on non-empirical data were excluded, except for study protocols.

Results:
The search process yielded 1352 publications. After selection, 40 publications were included. Twenty-eight different initiatives were divided into four forms of collaboration, and two approaches to promote PA were distinguished with different kinds of facilitators and barriers. In the referral of patients, sport professionals' lack of medical knowledge, and health professionals' lack of time, were seen as barriers. In networks to organize activities to promote PA among the community, different shared interests and different cultures were seen as barriers.

Conclusion:
This review showed that performance of intersectoral collaboration and the collaboration between both sectors are still unexplored. This review provides a first step towards an insight into collaboration and factors that facilitate or hinder collaboration between these sectors.

Full text

Review
Facilitators and barriers in the collaboration between the primary
care and the sport sector in order to promote physical activity:
A systematic literature review
K.E.F. Leenaars
a,
⁎,E.Smit
b
,A.Wagemakers
a
, G.R.M. Molleman
b
,M.A.Koelen
a
a
Wageningen University & Research Centre, Department of Social Sciences, Health and Society Group, P.O. Box 8130, EW Wageningen, The Netherlands
b
Academic Collaborative Centre AMPHI, Primary Health Care, Radboud university medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
abstractarticle info
Available online 29 October 2015
Keywords:
collaboration
primary care
sport
physical activity promotion
Introduction. The aim of this review was toidentify collaborative initiatives betweenthe primary care and the
sport sector in order to promote physical activity (PA), and barriers and facilitators in these initiatives.
Method. Pubmed, SportDiscus, Web of Science, and SOCindex were systematically searched for publications
published between 2000 and June 2014. Publications reporting on collaboration between the primary care and
the sport sector to promote PA were included. Publications reporting on non-empirical data were excluded,
except for study protocols.
Results.The search process yielded 1352 publications. After selection, 40 publications were included. Twenty-
eight different initiatives were divided intofour forms of collaboration, and two approaches to promote PA were
distinguished with different kinds of facilitators andbarriers. In the referral of patients,sport professionals’lack of
medical knowledge, and health professionals’lack of time, were seen as barriers. In networks to organize activ-
ities to promote PA among the community, differentshared interests and different cultures were seen as barriers.
Conclusion. This review showed that performance of intersectoral collaboration and the collaboration
between both sectors are still unexplored. This review providesa first step towards an insight into collaboration
and factors that facilitate or hinder collaboration between these sectors.
© 2015 Elsevier Inc. All rights reserved.
Contents
Introduction ................................................................ 461
Method .................................................................. 461
Searchstrategy............................................................. 461
Collaboration .......................................................... 461
Primarycare .......................................................... 461
Sportsector........................................................... 461
PromotePA........................................................... 461
Studyselection............................................................. 462
Dataanalysis.............................................................. 462
Assessmentofstudyquality....................................................... 462
Results................................................................... 462
Searchresults ............................................................. 462
Characteristicsofincludedstudies .................................................... 462
Collaborativeinitiativesbetweentheprimarycareandthesportsector ................................... 462
Collaborativeinitiativestoreferprimarycarepatientstosportfacilities................................ 463
CollaborativeinitiativestopromotePAamongthecommunity.................................... 464
Facilitatorsandbarriersinthecollaborationbetweentheprimarycareandthesportsector .......................... 464
Facilitatorsandbarriersincollaborativeinitiativestoreferprimarycarepatientstosportfacilities.................... 464
FacilitatorsandbarriersincollaborativeinitiativestoorganizeactivitiestopromotePAamongthecommunity.............. 465
Barriersto,andfacilitatorsof,intersectoralcollaboration....................................... 465
Discussion ................................................................. 466
Preventive Medicine 81 (2015) 460–478
⁎Corresponding author at: Wageningen University, Health and Society, Postbus 8130, 6700 EW Wageningen.
E-mail address: Karlijn.leenaars@wur.nl (K.E.F. Leenaars).
http://dx.doi.org/10.1016/j.ypmed.2015.10.010
0091-7435/© 2015 Elsevier Inc. All rights reserved.
Contents lists available at ScienceDirect
Preventive Medicine
journal homepage: www.elsevier.com/locate/ypmed

Studylimitations ........................................................... 466
Conclusion................................................................. 466
Conflictofinterest ............................................................. 466
Acknowledgments ............................................................. 466
Appendix A.1. Overview of collaborative initiatives between primary care and sport in order to promote physical activity presented in this review. . .466
AppendixA.2. Overviewofbarriersandfacilitatorsintheinitiativesbetweentheprimarycareandthesportsectorpresentedinthisreview. .... 466
References................................................................. 477
Introduction
To address public health challenges like the increasing number of peo-
ple with chronic diseases, there is a need to join forces both within the
healthcare sector and between the health and other societal sectors, espe-
cially because no organisation has the resources, access, and trust relation-
ships to address the wide range of community determinants of public
health problems (Granner and Sharpe, 2004; Green et al., 2001; Koelen
et al., 2009, 2012). Therefore, intersectoral collaboration –defined as peo-
ple and organisations from multiple sectors working together for a com-
mon purpose –has become an increasingly popular health promotion
strategy (Roussos and Fawcett, 2000). Intersectoral collaboration between
the healthcare and other societal sectors is expected to have the potential
to bring about changes in at least two directions. Firstly, it should lead to
the improvement of health determinants and thereby the health of indi-
viduals and populations. Secondly, it is expected to increase awareness of
the health implications of policy decisions and organisational practice
within and among these different sectors (Green et al., 2001).
Intersectoral collaboration is challenging because it means working
in a new area or setting, with new people with different backgrounds,
interests, and perspectives (Granner and Sharpe, 2004; Koelen et al.,
2012; Lasker et al., 2001). A health broker seems to offer the promise
of improving intersectoral collaboration (Harting et al., 2011). In 2012,
the Dutch Ministry of Health, Welfare, and Sport introduced neigh-
bourhood sport coaches (in Dutch Buurtsportcoach)–to whom a broker
role has been ascribed –to stimulate physical activity (PA) and connect
the sport sector with other sectors. The sport sector covers all PA ser-
vices in the neighbourhood, i.e. sport clubs, fitness centres, PA lessons
at community centres. Some of these coaches, the so-called Care Sport
Connectors (CSCs), are employed specifically to connect the primary
care and the sport sector in order to guide primary care patients to-
wards local sport facilities.Recent years several studies about PA promo-
tion have been conducted in the primary care setting. Reviews provided
an overview of the effect of PA or PA promotion on health outcomes
(Chimen et al., 2012; Pavey et al., 2013; Semlitsch et al., 2013; Vaes
et al., 2013), the effectiveness of PA promotion based in primary care
(Lawlor and Hanratty, 2001; Neidrick et al., 2012; Orrow et al., 2012;
Sanchez etal., 2015; Stevens et al., 2014; Vuori et al., 2013), and the per-
ceptions of primary care providers on PA promotion (Hebert et al.,
2012; Hinrichs and Brach, 2012). In addition, reviews considering
intersectoral collaboration in the field of health promotion provided
an overview of the effectiveness of partnerships for improving commu-
nity health (Roussos and Fawcett, 2000; Zakocs and Edwards, 2006).
However, no review specifically addresses intersectoral collaboration
between the primary care and the sport sector. Research indicates dif-
ferences between both sectors that influence collaboration, such as cul-
ture, target groups, and way of working (Casey et al., 2009a; den Hartog
et al., 2014). However, an overview of barriers to, and facilitators of, this
intersectoral collaboration between the primary care and the sport sec-
tor is –to our knowledge –not available. CSCs may find it useful to have
an overview of initiatives and barriers and facilitators in collaborations
between the primary care and the sport sector so that they can facilitate
collaboration between these sectors and guide primary care patients
towards local sport facilities. Therefore, the aim of this paper is to:
1) document and describe collaborative initiatives between the primary
care and the sport sector to promote PA, and 2) identify barriers and fa-
cilitators in these collaborative initiatives.
Method
Search strategy
To search for literature on collaboration initiatives between the primary care
and the sport sector, a literature searchwasconductedinPubmed,SportDiscus,
Web of Science, and SOCindex. These databases were systematically searched for
original research published in English, Dutch, or German between January 2000
and June 2014. These databases were selected to cover medical and health-
related literature from Pubmed and sport-related literature from SportDiscus.
Web of Science and SOCindex were searched to cover more general literature
about the topic of this review. The time span (2000–2014) was chosen to assess re-
cent evidence on collaboration between the primary care and the sport sector, in
particular because intersectoral collaboration has become popular as a health pro-
motion strategy since the start of the 21th century (Roussos and Fawcett, 2000).
The search strategy combined the concepts: 1) collaboration, 2) primary care,
3) sport sector, and 4) promote PA. Each of these concepts is operationalised in
more detail below. The complete search strategy is shown in Table 1.
Collaboration
Because of the variety in strategies for, and definitions of, collaboration,
Himmelman’s(Himmelman, 2002) categorisation of collaboration and syno-
nyms for (intersectoral) collaboration were used to operationalise the concept
‘collaboration’.‘Broker’was added because of its promising role in facilitating
intersectoral collaboration.
Primary care
Primary care was operationalised by using synonyms for primary care.
Actors representing the primary care sector were added as search terms, as
also health/lifestyle in combination with intervention/programme, because pri-
mary care professionals are often involved in the implementation of these
programmes or interventions.
Sport sector
The sport sector was operationalised with synonyms for sport and com-
bined with actors representing the sport sector.
Promote PA
Promote PA was operationalised with synonyms for the concept ‘promote’
and combined with synonyms for the concept ‘physical activity’.
Table 1
Search strategy for the present review.
Concepts Search
Collaboration (collaborat* OR network* OR coordinat* OR cooperat* OR
intersector* OR inter-sector* OR partnership* OR allianc* OR
multisector* OR multi-sector* OR broker*)
Primary care (“primary care”OR “public health”OR “health sector”OR
“general pract*”OR GP OR physician OR dietician OR
physiotherapist OR “family pract*”OR “health professional*”
OR “health intervention*”OR “health program*”OR “lifestyle
program*”OR “lifestyle intervention*”)
Sport sector ((sport OR sports OR physical activity or exercise) AND
(sector OR club* OR organi?ation* OR professional* OR facility
OR facilities OR provider* OR organized OR non-organized OR
counsellor* OR service*))
Promote physical
activity
((promot* OR improv* OR stimulat* OR increas*) AND
(“physical activity" OR sport OR sports OR exercise OR “active
lifestyle”))
Other AND Language = (English OR Dutch OR German) AND
Document Type = NOT(review OR editorial OR conference
abstracts OR book OR theoretical arguments) AND
NOT(developing countries)
461K.E.F. Leenaars et al. / Preventive Medicine 81 (2015) 460–478

The Boolean operators ‘OR’and ‘AND’were used to separate synonyms and
link the concept and the different search term groups.
Study selection
In the first selection phase, titles and abstracts of the identified publications
were reviewed by the first author (KL). A random selection of 11% of all titles
and abstracts was reviewed by a second reviewer (AW), resulting in 89.2% agree-
ment between the two reviewers. In the second phase, full texts of potentially rel-
evant publications were independently reviewed by two reviewers (KL and AW
or ES). Any disagreements were resolved by discussion to reach consensus be-
tween the reviewers, or by consulting a third reviewer (AW or ES). For included
publications, backward citations (reference lists) and forward citations (via
Pubmed and Google Scholar) were checked for additional relevant publications.
Publications were included when: they contained empirical data (1) on col-
laboration between primary care and the sport sector in order to promote PA
and (2) were written in English, Dutch, or German and published between
2000 and June 2014.
1. Books, reviews, theoretical arguments, editorials, conference abstracts were
excluded. However, study protocols were included, because they report on
existing plans for collaboration initiatives.
2. Studies originating in developing countries were excluded since there might
be social, cultural, and organisational differences from Western countries
and therefore these studies would not be suitable for this review.
Data analysis
After the study selection, the full texts of the included studies were exam-
ined by two independent researches (KL and AW) to analyse the collaborative
initiative between primary care andsport (type of collaboration, partners, target
group, structure or programme after referral, aim) and to identify barriers and
facilitators in these initiatives.
Assessment of study quality
The quality of included publications reporting on barriers and facilitators in
the collaboration between the primary care and the sport sector were assessed
independently by three researchers (KL, AW, ES) on the basisof Boulton et al.’s
(Boulton et al., 1996) criteria, as shown in Table 2. These criteria focus on as-
pects for good practices in sampling, data collection, and analysis in qualitative
studies andare therefore suitable for the assessment of study quality. Intotal, 18
plusses could be assigned. Studies with fewerthan 7 plusses were considered as
low quality, studies with 7–12 plusses as medium quality, and studies with 13
or more plusses as high quality.
Results
Search results
After the removal of duplicates, the search process yielded 1352 po-
tentially relevant publications. During the first selection phase, 1221
publications were excluded because they did not meet the inclusion
criteria. Full texts of 131 publications were assessed, leading to the in-
clusion of 25 publications. Fifteen additional publications were included
via forward and backward citation tracking. The final sample consists of
40 original publications describing a collaborative initiative between
the primary care and the sport sector in order to promote PA. Fig. 1 is
aflow chart representation of the literature selection process.
Characteristics of included studies
Of the 40 studies included in this review, 9 were conducted in
Canada and 8 in the USA. Nineteen studies were performed in Europe,
of which 12 in the UK, 5 in the Netherlands, 1 in Sweden, and 1 in
Germany. Three studies were conducted in Australia and one in
Colombia. Four studies in this review are study protocols, 14 used quan-
titative methods, 14 qualitative methods, and eight, mixed methods to
study the collaborative initiative. Ten studies aimed to study the effect
of the collaborative initiative on participants’PA behaviour, eight
aimed to study the experiences of professionals involved in the initia-
tive, seven aimed to study network structures and functions, four eval-
uated both process andeffects of the initiative, four studied participants’
experiences, and three did not mention their aim.
Collaborative initiatives between the primary care and the sport sector
Of the 40 studies included in this review, 20 publicationsreported on
20 different initiatives between the primary care and the sport sector.
The other 20 publications reported on eight different initiatives: the
BeweegKuur programme(n = 4), PAC (n = 4), VicHealth (n = 2), col-
laboration between a Community Health Centre and a YWCA (n = 2),
SESPAN (n = 2), CN-Diabetes (n = 2), PARS (n = 2), and NERS (n =
Table 2
Quality assessment of qualitative studies.
Introduction
1. Is the aim of the study clear?
(i.e. clearly formulated at the beginning and consistent with the way data were
collected and analysed)
2. Is a qualitative approach appropriate to the aim?
(i.e. aim conceived in terms of investigating 'what' or 'how')
Sample and generalisability
3. Are the criteria for selecting the sample clearly described?
(i.e. exclusion and inclusion criteria specified)
4. Is the method of recruitment clear?
(i.e. an account of from where, by whom, and how those potentially included
in the sample were contacted)
5. Are the characteristics of the sample adequately described?
(i.e. age, gender, ethnicity, social class, and other relevant demographic
characteristics)
6. Is the final sample adequate and appropriate?
(I. e. large and diverse enough for the aims of the study to be fulfilled)
Methods of data collection
7. Is the fieldwork adequately described?
(i.e. an account of where data were collected, by whom, in what context)
8. Are methods of data collection adequately described?
(i.e. an account of the ways the data were elicited, and the type and range of
questions)
9. Are the data collected systematically?
(i.e. evidence of consistent use of interview guide or rationale for ceasing
questioning)
10. Are the data collected sensitively?
(i. e. evidence of flexible approach, responsiveness to participants' agendas,
follow-up questions, and adequate time given)
11. Are careful records of data kept?
(i.e. audio/video recordings and fieldnotes which can be independently inspected)
Data analysis
12. Are the data analysis processes adequately described?
(i.e. an account of how data were processed and interpreted; of how concepts,
themes, or categories were developed)
13. Is evidence provided in support of the analysis?
(i.e. excerpts from original data, summaries of examples, or numerical data pre-
sented as evidence for interpretation made)
14. Is sufficient original material presented?
(i.e. original material not just a token illustration)
15. Is there evidence that supporting material is representative?
(i. e. excerpts are named or numbered and sources given)
16. Is there evidence of efforts to establish validity?
(i.e. evidence that accounts of the phenomenon reflect it accurately)
17. Is there evidence of efforts to establish reliability?
(i.e. evidence that accounts of the phenomenon are consistent over time or be-
tween researchers)
Discussion
18. Is the study set in a broader context?
(i.e. compared with other studies in terms of methods, findings, or implications;
related to a wider literature and body of knowledge)
Source: based on Boulton etal. (Boulton et al., 1996)
462 K.E.F. Leenaars et al. / Preventive Medicine 81 (2015) 460–478

2). These 28 initiatives can be divided into four different forms of collab-
oration between the two sectors. Thirteen initiatives used a referral
scheme, ten organised a network among different community partners
with representatives of the primary care and the sport sector, four
consisted of a multidisciplinary primary care team with a connection
to the sportsector, and two developed a partnership between a commu-
nity health centre and a sport facility. One initiative, the BeweegKuur
programme, had two different forms of collaboration. Helmink et al.
(Helmink et al., 2010, 2012) and Berendsen et al. (Berendsen et al.,
2011) reported on the multidisciplinary primary care team carrying
out the BeweegKuur programme and were allocated to that group.
Den Hartog et al. (den Hartog et al., 2014) reported on regional and
local BeweegKuur alliances and therefore this publication was allocated
to the network group. Although all these four forms of collaborative ini-
tiativesaim to promote PA, two different settings and approaches can be
distinguished: a primary care setting in which collaboration was set up
to refer and guide specifically primary care patients, and a community
setting in which collaboration was set up to organize PA activities
more in general. In the primary care setting, primary care patients
were referred to sport facilities through referral schemes, a partnership
between a health centre and a sport facility, or a multidisciplinary pri-
mary care team. In the community setting, activities to promote PA
were organized by a community network of primary care and sport pro-
fessionals. Appendix A.1 provides a complete overview of all 28 collab-
orative initiatives.
Collaborative initiatives to refer primary care patients to sport facilities
Referral schemes. Nine of the 13 referral schemes were implemented in
the United Kingdom, two in Canada, one in the Netherlands, and one
in Sweden. In all these initiatives, primary care professionals made the
referral. In four initiatives, a GP made the referral (Foley et al., 2000;
Harrison et al., 2005; Taylor and Fox, 2005; Trinh et al., 2012), and, in
one initiative, a physiotherapist made the referral (Wiles et al., 2008).
Web of
Science
N = 843
PubMed
N = 780
Sport
Discus
N = 217
SOC
index
N = 129
Search results combined N = 1969
Duplicates
N = 617
First selection: reviewing title and abstracts
N = 1352
Excluded N = 1221 (90.3%)
No empirical data: N = 259 (21.2%)
No collaboration between primary care and sport
to promote PA: N = 915 (74.9%)
Language or developing countries: N = 43 (3.5%)
Second selection: reading full text by two independent
reviewers
N = 131
Excluded N = 106 (80.9%)
Duplicates: N = 4 (3.7%)
No full text available: N = 15 (11.5%)
No empirical data: N = 13 (12.3%)
No collaboration between primary care and sport
to promote PA: N = 72 (67.9%)
Language or developing countries: N = 2 (1.9%)
Publications included
N = 25
References screened via forward/backward
citation tracking N = 60
Excluded: N = 45 (75%)
No full text available: N = 1 (2%)
No empirical data: N = 5 (11%)
No collaboration between primary care and sport
to promote PA: N = 39 (87%)
Final inclusion
N = 40
Fig. 1. Flow chart of the literature selection process.
463K.E.F. Leenaars et al. / Preventive Medicine 81 (2015) 460–478

Four initiatives used referral cards to refer patients to a local leisure cen-
tre or sport and recreation organisations (Foley et al., 2000; Taylor and
Fox, 2005;Trinh et al., 2012; Hardcastle and Taylor, 2001). In two initia-
tives, a leisure centre staff member contacted the patient after referral
(Harrison et al., 2005; Annesi et al., 2012), and in three other initiatives
patients were contacted by a member of the initiative (James et al.,
2008; Schmidt et al., 2008; Wormald et al., 2006). Six initiatives did
not explicitly mention the method of referral.
The program after referral differed in the initiatives. In nine initia-
tives, patients were given an exercise program at the sport facility
(Foley et al., 2000; Taylor and Fox, 2005; Hardcastle and Taylor, 2001;
Annesi et al., 2012; James et al., 2008; Crone et al., 2008; Lee et al.,
2009; Moore et al., 2011; Murphy et al., 2010). One of these initiatives
used a standardised exercise support protocol (Annesi et al., 2012). In
four initiatives, prescribed PA could be either self-monitored, organised
activities, or a consultation with a sport advisor for referral to exercise
groups or information (Trinh et al., 2012; Schmidt et al., 2008;
Wormald et al., 2006; Kallings et al., 2008), andin one initiative patients
received a subsidised leisure pass (Harrison et al., 2005). One initiative
did not mention the programme after referral (Wiles et al., 2008).
The focus in all 13 referral schemes was on promoting PA among sed-
entary patients or patients who could benefit from PA. Four initiatives had
amorespecific focus: to effect a change in lifestyle, or to achieve 30 mi-
nutes of moderate PA at least five days per week, (Foley et al., 2000;
Schmidt et al., 2008; Wormald et al., 2006; Murphy et al., 2010). All 13 re-
ferral schemes referred primary care patients, but five initiatives had a
more specific target group: patients from deprived neighbourhoods or
patients with risk factors for certain diseases, like cardiovascular disease,
diabetes, anxiety, or depression (Wiles et al., 2008; Annesi et al., 2012;
Schmidt et al., 2008; Moore et al., 2011; Murphy et al., 2010).
Multidisciplinary primary care team with a connection to the sport sector.
Four initiatives consisted of a multidisciplinary primary care team
with a connection to the sport sector. Two multidisciplinary primary
care teams were organised in Canada, one in the Netherlands, and one
in Germany. Three initiatives consisted of a multidisciplinary care
team carrying out the programme, establishing links withlocal sport fa-
cilities or referring patients to these local sport facilities (Helmink et al.,
2010, 2012; Berendsen et al., 2011; De Civita and Dasgupta, 2007;
Hofreuter-Gatgens et al., 2011; Nasmith et al., 2004). These multidisci-
plinary care teams consisted always of a GP, a physiotherapist, and a di-
etician. These three initiatives targeted specific groups: patients with
diabetes (De Civita and Dasgupta, 2007; Nasmith et al., 2004), primary
care patients (Helmink et al., 2010, 2012; Berendsen et al., 2011), and
residents aged 60 years or older who were not in need of care and
were living independently (Hofreuter-Gatgens et al., 2011). The other
initiative integrated a PA counsellor in the primary care team (Fortier
et al., 2007, 2011a, 2011b; O'Sullivan et al., 2010). Patients received in-
tensive autonomy-supportive counsellingover a three-monthperiod by
the PA counsellor.
Partnership between a community health centre and a sport facility. Two
initiatives, both in the USA, organised a formal partnership between
a community health centre and a local sport facility, with the aim of
improving access to an exercise programme for low-income patients
(Boyd et al., 2006; Candib et al., 2008; Cashman et al., 2012). In these
initiatives, patients received free membership of the YMCA after re-
ferral by community health centre professionals.
Collaborative initiatives to promote PA among the community
Network among community partners including the primary care and the
sport sector. Ten initiatives organised a network for the organisation of
activities to promotePA among the community. Four of these networks
were organised in the USA. The other networks were organised in
Canada (n = 1), Australia (n = 2), United Kingdom (n = 1), the
Netherlands (n = 1), and Colombia (n = 1). All these 10 networks
consisted of different community-based, non-profit, and public organi-
sations (Casey et al., 2009a, 2009b; den Hartog et al., 2014; Baker
et al., 2012; Balcazar et al., 2012; Barnes et al., 2010; Cheadle et al.,
2010a, 2010b; de Groot et al., 2010; Evans and Sleap, 2013; Litt et al.,
2013; Meisel et al., 2014). The 10 initiatives aimed to promote PA
among different target groups. Three had a more specificaim:twoini-
tiativesaimed to make it easier for people to be active in their daily rou-
tines and to make healthy choices more available (Baker et al., 2012;
Barnes et al., 2010), and one initiative aimed to reduce cardio-vascular
disease (CVD) risk factors among Hispanics (Balcazar et al., 2012).
Nine networks targeted the whole community, and four of these net-
works had a more specific target group in the community: Hispanics
(Balcazar et al., 2012), low-income groups (Casey et al., 2009a,
2009b), children (de Groot et al., 2010), primary care patients (den
Hartog et al., 2014), and older adults (Cheadle et al., 2010a, 2010b).
Facilitators and barriers in the collaboration between the primary care and
the sport sector
Of the 40 publications included in this review, 13 reported facilita-
tors and/or barriers in 12 different collaborative initiatives. Seven stud-
ies in these publications were assessed as high quality and six studies as
medium quality (Appendix A.2).
Seven publications reported on barriers and/or facilitators specificto
the collaboration between the primary care and the sport sector: four
reported on facilitators/barriers in the referral of primary care patients
to local sport facilities (Foley et al., 2000; Trinh et al., 2012; Wiles
et al., 2008; Cashman et al., 2012), and three reported on facilitators/
barriers in the promotion of PA through a community network (Casey
et al., 2009a, 2009b; den Hartog et al., 2014). The other six publications
reported on barriers and/or facilitators not specific to the collaboration
between the primary care and the sport sector but to intersectoral col-
laboration in general (De Civita and Dasgupta, 2007; Baker et al.,
2012; Cheadle et al., 2010a; de Groot et al., 2010; Evans and Sleap,
2013; Meisel et al., 2014). Table 3 gives an overview of facilitators and
barriers in the different forms of collaboration and approaches, and
Appendix A.2 provides a complete overview of facilitators and barriers
in the collaborative initiatives.
Facilitators and barriers in collaborative initiatives to refer primary care pa-
tients to sport facilities
Facilitators for the referral of primary care patients to local sport facil-
ities were reported in two publications on a referral scheme (Foley et al.,
2000; Trinh et al., 2012) and in one publication on a partnership between
a health centre and a sport facility (Cashman et al., 2012). Trinh et al.
(Trinh et al., 2012) and Cashman et al.(Cashman et al., 2012) reported
that collaboration provided physicians with a better understanding and
awareness of the services and support available to their patients. The re-
ferral scheme also laid the groundwork for a relationship between physi-
cians and sport organisations. Foley et al. (Foley et al., 2000)a
ndCashman
et al.(Cashman et al., 2012) reported that the referral process provided a
welfarist and commercial benefit for leisure. Both publications reported
funding (Foley et al., 2000)orremuneration(Trinh et al., 2012)asapri-
ority or a key influence on ongoing implementation.
Barriers to the referral of primarycare patients to local sport facilities
were reported in three publications on a referral scheme (Foley et al.,
2000; Trinh et al., 2012; Wiles et al., 2008) and in one publication on a
partnership between a health centre and sport facility (Cashman et al.,
2012). Three publications identified lack of communication as a barrier
in the collaboration (Foley et al., 2000; Trinh et al., 2012; Cashman et al.,
2012). Physicians mentioned the lack of feedback from the sport or lei-
sure professionals on their patients’progress. Another barrier was lei-
sure or sport professionals’limited medical knowledge (Foley et al.,
2000; Wiles et al., 2008). Therefore, physicians and physiotherapists
were ‘unsure’and ‘apprehensive’of the PA programme for the patients
464 K.E.F. Leenaars et al. / Preventive Medicine 81 (2015) 460–478

and ‘uncomfortable’with the leisure or fitness professionals. Also, phy-
sicians’and physiotherapists’lack of time was identified as a barrier that
caused problems for physicians to implement the interventions. Bar-
riers to the partnership between the health centre and sport facility re-
sulted mostly from the success of the partnership. The high number of
patient referrals led to overcrowding, which resulted in reducing the
number of referred patients who could use the facility.
Facilitators and barriers in collaborative initiatives to organize activities to
promote PA among the community
Three publications reported on facilitators/barriers in the promotion
of PA through a community network with representatives of the prima-
ry care and the sport sector (Casey et al., 2009a, 2009b; den Hartog et al.,
2014). Trust and shared interests among members (Casey et al., 2009b),
having enough time to develop trust among members (den Hartog et al.,
2014), funding (Casey et al., 2009b), formalisation of the partnership
agreement (Casey et al., 2009a), and the engagement of key stake-
holders (Casey et al., 2009a) were seen as facilitatingfactors for partner-
ship formation. Short communication lines and communicating roles
and responsibilities (den Hartog et al., 2014; Casey et al., 2009b), the or-
ganisation’s capacity to participate and develop programmes, the orga-
nisation’s commitment, engagement of more than one person from a
sport organisation (key leaders that influence the strategic direction of
the sports club), professional organisation (reduce the impact of staff
turnover), and visibility of results for the partners (den Hartog et al.,
2014; Casey et al., 2009b) were seen as facilitating factors for the part-
nership function.
The barriers identified in publications on networks among different
community partners topromote PA were mainly the inverseof the facil-
itators mentioned above. So, a lack of communication, unclearroles and
responsibilities, staff turnover in professional organisations (Casey et al.,
2009b), lack of agency capacity (Casey et al., 2009b), lack of leadership
(Casey et al., 2009b), and uncertainty about funding (den Hartog et al.,
2014) were mentioned asbarriers in the collaboration between the pri-
mary care and the sport sector.
Some of the barriers were caused by differences in shared interests
and culture in both sectors (Casey et al., 2009a, 2009b; den Hartog
et al., 2014). Differences between the shared interest of professional orga-
nisations (interest in the programme) and that of volunteer groups (in-
creased club memberships) (Casey et al., 2009b), and different cultures
in the primary care and the sport sector (preferred meeting time and tar-
get groups) (den Hartog et al., 2014)ledtodifficulties in engaging sport
organisations in the partnership (Casey et al., 2009a, 2009b; den Hartog
et al., 2014). Sport organisations did not always recognise the benefits
of the partnership (Casey et al., 2009a, 2009b)orwerenotfamiliar
with the types of participant in the intervention programme (obese
people, often in combination with low socio-economic status) (den
Hartog et al., 2014). In addition, health professionals’lack of time
to establish partnerships (Casey et al., 2009a) or to refer patients
(den Hartog et al., 2014)hinderedthecollaboration.
Barriers to, and facilitators of, intersectoral collaboration
Six publications reported on barriers and/or facilitators without spe-
cifically addressing these in relation to the collaboration between the
primary care and the sport sector. However, the facilitators and barriers
identified in these publications largely resembled facilitators and bar-
riers found for the collaboration between the primary care and the
sport sector. In addition, factors identified as barriers or facilitators
were often the inverse of the facilitators or barriers. So, recruiting di-
verse partners and engaging key stakeholders (Baker et al., 2012; de
Groot et al., 2010; Meisel et al., 2014), time to build relationships, shared
interest among partners, consistent meeting attendance, leadership
skills (Baker et al., 2012), the involvement of more than one person
from the organisations in the partnership (Baker et al., 2012), commu-
nication (De Civita and Dasgupta, 2007; Baker et al., 2012; Meisel
et al., 2014), funding (Baker et al., 2012; de Groot et al., 2010), clarity
about roles and responsibilities (Baker et al., 2012; de Groot et al.,
2010), and building upon an existing structure (De Civita and
Dasgupta, 2007)wereidentified as factors that facilitated the devel-
opment of these collaborative initiatives, or whose absence hindered
it.
Table 3
Overview of facilitators and barriers specified for the four forms of collaboration between the primary care and the sport sector.
Form of collaboration Approach and setting Facilitators Barries
Referral schemes (Foley et al., 2000;
Trinh et al., 2012; Wiles et al., 2008)
Setting: primary care
Approach: referral of primary
care patients
- Better understanding and
awareness of service
- Groundwork for relationship
- Commercial benefit
- Funding
- Lack of communication
- Lack of feedback from sport
professionals on patients’progression
- Sport professionals’limited medical
knowledge
- Health professionals’lack of time
Network of community partners
(Casey et al., 2009a, 2009b;
den Hartog et al., 2014;
Baker et al., 2012; Cheadle et al.,
2010a,2010b; Evans and
Sleap, 2013; Litt et al., 2013)
Setting: communityApproach:
organisation of activities to
promote physical activity
among the community
- Short communication lines
- Clear roles and responsibilities
- Funding
- Time
- Capacity of organisation
- Shared interests
- Trust
- Engagement of key stakeholders
- Partnership agreement
- Commitment
- Visibility of results for partners
- Consistent meeting attendance
- Diverse partners
- Engagement of more than one person
from a sport organisation (key leaders)
and professional organisation
(reduce impact of staff turnover)
- Lack of communication
- Unclear roles and responsibilities
- Uncertainty about funding
- Health professionals’lack of time
- Lack of agency capacity
- Differences in shared interests of
the primary care (interest in the
programme) and the sport sector
(increased club membership)
- Staff turnover
- Lack of leadership skills
- Fixed protocol
- Different cultures (preferred
meeting time and target groups)
Multidisciplinary primary care team
(De Civita and Dasgupta, 2007)
Setting: primary careApproach:
referral of primary care patients
- Communication
- Funding
- Recognised need and importance
- Positive effects on patients
Partnership (Cashman et al., 2012) Setting: primary careApproach:
referral of primary care patients
- Mutual and complementary
missions of both organisations
- Cultural shift in how physical activity is viewed
- Burnishing of the sport facility’s public image
- Overcrowding
- Inadequate feedback about patients
465K.E.F. Leenaars et al. / Preventive Medicine 81 (2015) 460–478

Discussion
This review has shown that collaboration between the primary care
and the sport sector, and the performance of these collaborative initia-
tives, are still unexplored. Most publications reported on the effects of
PA promotion on patients’health status or PA behaviour. Of the 40 pub-
lications, only 13 mentioned facilitators and barriers, of which nine spe-
cifically aimed to study partnership-related processes. In addition, one
of these publications (den Hartog et al., 2014)madeuseofaframework
for intersectoral collaboration, Koelen et al.’s(Koelen et al., 2012)HALL
framework, to identify factors that hinder or facilitate the success of al-
liances. These findings are consistent with two other reviews consider-
ing intersectoral collaboration, which also noted a lack of empirical
research evaluating the functioning and effectiveness of partnerships
(Roussos and Fawcett, 2000; Zakocs and Edwards, 2006) and the failure
to use theoretical frameworks (Zakocs and Edwards, 2006).
Despite the limited number of studies on partnership-related pro-
cesses in the collaboration between the primary care and the sport sec-
tor, this review has identified facilitators and barriers specific to such
collaboration, alongside facilitators and barriers for intersectoral collab-
oration in general. The facilitators and barriers specific to the collabora-
tion between the primary care and the sport sector differed in the two
approaches to promote PA identified in this review; this can be ex-
plained by differences in the structure of the collaborative initiatives.
The initiatives focusing on the referral of primary care patients can
be characterised as a coordination; this means that organisations or pro-
fessionals modify their activities so that together they can provide bet-
ter services and make these services more user friendly (Himmelman,
2002). In these initiatives, professionals work in their own field in
order to provide a PA programme for primary care patients. This form
of collaboration can also be characterised as multidisciplinary, whereby
different disciplines work independently on different aspects of a pro-
ject (Choi and Pak, 2006). Therefore, in these initiatives, facilitators
and barriers relating to their joint services were identified, such as: a
better understanding and awareness among health professionals
about PA, sport professionals’limited medical knowledge andtheir fail-
ure to provide feedback to health professionals, and health profes-
sionals’lack of time.
The initiatives focusing on the organization of activities to promote
PA through communitynetworks can be characterisedas (intersectoral)
collaboration, in which organisations share resources, alter activities,
and enhance their capacity for mutual benefit and to achieve a common
purpose (Himmelman, 2002). In these networks, professionals work to-
gether in order to develop or implement programmes for PA promotion.
This form of collaboration can also be characterised as interdisciplinary,
whereby different disciplines work together on the same project (Choi
and Pak, 2006). Therefore, professionals in these networks are dealing
with differences in both sectors’shared interest (interest in the pro-
gramme or increased club membership) and cultures (target groups
and meeting time).
The identified general facilitators of intersectoral collaboration, such
as communication, clarity about roles and responsibilities, agency ca-
pacity, leadership skills, and trust, were often the inverse of the barriers
and are mostly similar to other studies on intersectoral collaboration
(Koelen et al., 2012; Roussos and Fawcett, 2000; Zakocs and Edwards,
2006). These factors are inherent in intersectoral collaboration because
this means working in a new area with partners with different interests
and backgrounds (Granner and Sharpe, 2004; Koelen et al., 2012; Lasker
et al., 2001). Therefore, it is not surprising that in collaborative initia-
tives between the primary care and the sport sector these general
factors for intersectoral collaboration were also identified.
This review is a first step towards an insight into collaboration be-
tween the primary care and the sport sector and the factors that facilitate
or hinder collaboration between them. This is valuable information, es-
pecially for professionals deployed to facilitate collaboration between
these two sectors, like the CSC. For example, it is useful to know that
health professionals need to receive adequate feedback on patients’
progress or that more than one person from a sport organisation should
be engaged in the collaboration. However, there is need for more studies
focusing on partnership-related processes between the primary care and
the sport sector. The evaluation of intersectoral collaboration and the use
of frameworks for intersectoral collaboration to assess prerequisites in
partnerships are important because focusing on more intermediate out-
comes enhances the functioning of a partnership by helping to identify
and provide feedback on what is (and is not) working (Roussos and
Fawcett, 2000). Consequently, this can contribute to the success of the
partnership, because many partnerships do not survive their first year
or remain in the development phase of plans or of the implementation
of interventions (Lasker et al., 2001; Kreuter et al., 2000).
To study the effectiveness of the different collaborative initiatives on
stimulating PA was not the aim of this review, but some included stud-
ies reported on the effectiveness. These studies mentioned an improve-
ment on different outcomes. Some studies reported on an increased
number of PA activities organised (Cheadle et al., 2010a, 2010b), other
studies reported on an increased level of PA behaviour (Harrison et al.,
2005; Trinh et al., 2012; Annesi et al., 2012; James et al., 2008;
Wormald et al., 2006; Kallings et al., 2008; Fortier et al., 2011a;
Balcazar et al., 2012), and others on improved health outcomes
(Taylor and Fox, 2005; Annesi et al., 2012; Wormald et al., 2006; Lee
et al., 2009; Boyd et al., 2006; Candib et al., 2008), However, due to
the different measuring methods, target groups, and different outcomes
it is not possible to relate the outcomes to the different forms of collab-
oration. Other studies are necessary to study which of these different
collaborative initiatives are effective for increasing PA.
Study limitations
Although the literature was systematically searched, it is possible that
relevant studies were not found or included. Publications for which no
full text was available were excluded from the search. In addition, only
publications that described very clearly the partners in the collaborative
initiative could be included. Many publications did not mention the pro-
fessions of the partners in the collaborative initiative, thereby making it
hard to ascertain whether professionals from the primary care and the
sport sector were involved. In particular, publications reporting about
networks often do not mention the type of partner. Another limitation
has to do with the study quality of the included publications. Although
all publications were assessed as medium or high quality, some of the
medium quality studies scored low on data collection method (De
Civita and Dasgupta, 2007; Cheadle et al., 2010a). These publications in
comparison with other studies did not describe clearly the processes of
data collection and analysis, and therefore the validity and reliability of
the results of these publications was difficult to determine.
Conclusion
Collaboration between the primary care and the sport sector isunex-
plored. This review provides a first insight into factors that facilitate or
hinder collaboration between these sectors. However, there is need
for more studies focusing on partnership-related outcomes between
the primary care and the sport sector.
Conflict of interest
The authors declare there is no conflict of interest.
Acknowledgments
The study is funded by ZonMw, the Dutch Organisation for health
research and healthcare innovation (project number 525001002).
466 K.E.F. Leenaars et al. / Preventive Medicine 81 (2015) 460–478

Author, year,
country
Study design, method, aim Collaboration initiatives between the primary care and sport sector
Annesi et al.
[2012] Canada
Longitudinal study: questionnaire among 92 obese or overweight adults at
baseline, 12 weeks, and 24 weeks
Aim: report the effects of a six-month application of the Coach Approach
The Coach Approach intervention
- Type of collaboration: referral scheme
- Referral of patients by medical professionals
- Target group: patients with obesity along with cardiovascular
disease, diabetes, or renal disease
- Programme after referral: wellness leader administered the Coach
Approach exercise support protocol, a standardised treatment of
six-monthly one-on-one sessions between a wellness specialist
and participant. Exercise modalities chosen by the participant
- Aim: not mentioned
Baker et al.
[2012] USA
Cross-sectional study, mixed-methods evaluation (key informant interviews,
focus groups, and surveys)
Aim: compare and contrast 25 partnerships with regard to partnership struc-
tures and functions
Active Living by Design (ALbD)
- Type of collaboration: network among community partners
- Partners: several types of partners were represented across the
community partnership initiatives, including health, schools,
urban design, park and recreation, walking/biking clubs, etc.
- Structure: three community partnerships models emerged:
utilitarian, lead agency, and collaboration
- Target group: community
- Aim: make it easier for people to be active in their daily routines
through policy changes, physical projects, and other supporting
efforts
Balcazar et al.
[2012]
USA–Mexico
border
Cross-sectional study: six-week pilot among 37 participants for HEART phase
2. Eighteen participants completed the HEART questionnaire. Ten participants
participated in focus groups
Aim: not mentioned
Health Education Awareness Research Team (HEART)
- Type of collaboration: network among community partners
- Partners: community Health Academy and Leadership Council,
YWCA, the Parks and Recreation Department, council members,
and Mexican American community members
- Structure: YWCA promoters conducted the activities of the Mi
Corazón, Mi Comunidad (MiCMiC [My Heart, My Community])
programme
- Target group: Hispanics
- Aim: reduce CVD risk factors among Hispanics and engage the
community in an environmental restructuring initiative focusing
on nutrition and exercise
Barnes et al.
[2010]
Canada
Cross-sectional study, survey among 34 organisations (response rate 91%)
Aim: whole network analysis to understand the network structure and the
types of linkages among partners
Health Promotion Network (HPN)
- Type of collaboration: network among community partners
- Partners: 34 organisations are included in the HPN. These
organisations are community-based, non-profit (local cycling club,
YMCA), and public organisations (regional health unite, school
boards)
- Structure: two fulltime staff members (one coordinator and one
clerical) were responsible for supporting the network
- Target group: community
- Aim: develop environmental support and policies to make healthy
choices for community members more readily available
Berendsen et al.
[2011] The
Netherlands
Study protocol
Aim: evaluate the effectiveness and cost-effectiveness of the ‘supervised ex-
ercise programme’versus the less intensively supervised ‘start-up exercise
programme’
The BeweegKuur
- Type of collaboration: multidisciplinary team with a connection to
sport
- Structure: multidisciplinary team consists of a general practitioner,
a lifestyle advisor, a physiotherapist, and a dietician. The lifestyle
advisor has the key role in this team and offers wide-ranging
lifestyle counselling. The physiotherapist provides coaching for
physical activity to enable participants to transfer to local exercise
facilities
- Target group: primary care patients
- Aim: improve physical activity and dietary behaviour and thereby
decrease health risk
Boyd et al. [2006]
USA
Longitudinal study: characteristics and clinical variables were taken and
assessed quarterly over a 12-month period among 48 participants
Aim: not mentioned
Triad Exercise Partnership
- Type of collaboration: partnership between Siouxland Community
Health Centre (SCHC) and the YMCA.
- Structure: providers from the SCHC refer patients to the YMCA.
Patients receive a free three-month YMCA membership (after
three months a reduced membership fee)
- Target group: low-income patients
- Aim: improve low-income patients’access to an exercise
programme
Candib et al.
[2008] USA
Cross-sectional study of 1060 adult patients over a 24-month period
Aim: not mentioned
Collaboration between a community health centre and a local YWCA
- Type of collaboration: partnership between a community health
centre and a YWCA
(continued on next page)
Appendix A.1. Overview of collaborative initiatives between primary care and sport in order to promote physical activity presented in this
review.
467K.E.F. Leenaars et al. / Preventive Medicine 81 (2015) 460–478

(continued)
Author, year,
country
Study design, method, aim Collaboration initiatives between the primary care and sport sector
- Structure: the community health centre referred patients to a
YWCA. The YWCA delivered an introductory tour, and patients
could immediately attend group exercise classes and use the
swimming pool
- Target group: low-income patients
- Aim: open access for patient exercise
Cashman et al.
[2012]
USA
Multiple case study: interviews with nine staff members of the partnership
(YWCA) and 19 health professionals from the health centre
Aim: describe the partnership, identify challenges, and specify lessons learned
Collaboration between a community health centre and a local YWCA
- Type of collaboration: partnership between a community health centre
and a YWCA
- Structure: the community health centre referred patients to a YWCA.
The YWCA provided access for patient to use the YWCA for physical
activity at no charge to the patient
- Target group: low-income patients
- Aim: promote health among a low-income population by allowing
community health centre patients to use the YWCA for physical activ-
ity at no charge to the patient
Casey et al.,
2009b Australia
Multiple case study: interviews with 22 partnership members of eight
partnerships
Aim: gain a better understanding of the development of partnerships to
establish sport and recreation programmes
The Victorian Health Promotion Foundation (VicHealth)
- Type of collaboration: network among community partners
- Partners: community health, community sport, schools, State Sporting
Association, Primary Care Partnership
- Structure: programme manager and programme officer
- Target group: low-income persons
- Aim: overcome long-term barriers to physical activity participation
Casey et al.,
2009a
Australia
Cross-sectional study: interviews with 22 partnerships members and docu-
ment analysis of eight partnerships
Aim: investigate the partnership-related processes and capacity-building
strategies
The Victorian Health Promotion Foundation (VicHealth)
- Type of collaboration: network among community partners
- Partners: community health, community sport, schools, State Sporting
Association, Primary Care Partnership
- Structure: programme manager and programme officer
- Target group: low-income persons
Aim: increase community-level participation in sports and recreation
by a grant scheme for people who were not currently active and on low
incomes
Cheadle et al.,
2010a USA
Longitudinal study: interviews with community stakeholders, programme
logs, and counts of programme participation at mid-point and at the end of
the projectAim: evaluate SESPAN and formulate lessons learned during
implementation
The Southeast Senior Physical Activity Network (SESPAN)
- Type of collaboration: network among community partners
- Partners: Seattle Department of Parks and recreation, senior centres,
senior housing, community coalitions, healthcare providers
- Structure: a community-organising strategy, involving hiring a
half-time community organiser to develop partnerships and network
among a variety of community-based organisations (CBOs), groups,
and institutions
- Target group: older adults
- Aim: promote physical activity among older adults in SE Seattle
Cheadle et al.,
2010b USA
Longitudinal study, mixed methods: programme logs, key informant
interviews with community partners, participant observation, survey-based
measures
Aim: assess the impact of SEPAN and provide formative information for pro-
gramme improvement
The Southeast Senior Physical Activity Network (SESPAN)
- Type of collaboration: network among community partners
- Partners: Seattle Department of Parks and recreation, senior centres,
senior housing, community coalitions, healthcare providers
- Structure: a community-organising strategy, involving hiring a
half-time community organiser to develop partnerships and network
among a variety of community-based organisations (CBOs), groups,
and institutions
- Target group: older adults
- Aim: promote physical activity among older adults in SE Seattle
Crone et al., 2008
United
Kingdom
Longitudinal study: survey among 2901
referred patients between 2002 and 2003
Aim: compare initial progression, uptake, and completion among patients
referred on the basis of a mental health condition and those referred on the
basis of physical health conditions
Physical Activity Referral Schemes (PARS)
- Type of collaboration: referral scheme
- Referral by health professionals to a leisure provider
- Target group: patients
- Programme after referral: programme of physical activity under the
supervision of qualified exercise professionals. Exercise programmes
were typically gym-based, but could include swimming, circuit
training, or exercise-to-music classes
- Aim: not mentioned
De Civita and
Dasgupta, 2007
Canada
Cross-sectional study: re-examination of the actual reported experiences of a
specific diabetes management pilot
Aim: describe and underscore the utility of Diffusion of Innovations Theory in
identifying and targeting possible challenges to the successful adaption and
sustainability of an innovative diabetes management strategy
Côte-des-Neiges Diabetes Pilot Project (CN-Diabetes)
- Type of collaboration: multidisciplinary team
with a connection to sport
- Structure: the multidisciplinary diabetes management team
consists of a coordinator, a community organiser, two nurses, a
dietician, a foot-care technician, a social worker, and an exercise
consultant. CN-Diabetes established links within the community by
offering group exercise sessions and walking groups
- Target group: patients with diabetes
Appendix A.1 (continued)
468 K.E.F. Leenaars et al. / Preventive Medicine 81 (2015) 460–478

(continued)
Author, year,
country
Study design, method, aim Collaboration initiatives between the primary care and sport sector
- Aim: coordinate diabetes care in conjunction with individual physicians
working at clinics within the CN area of Montreal
De Groot et al.
[2010]
Australia
Cross-sectional study: mixed methods: document analysis, interviews with
16 key informants, a Community Capacity Index
Aim: determine whether the capacity of the community was increased after
Romp & Chomp
Romp & Chomp
- Type of collaboration: network among community partners
- Partners: Barwon Health, CoGG, Geelong Kindergarten Association,
Leisure Networks, Department of Human Services (DHS), Deakin
University, Bellarine Community Health, Dental Health Services
Victoria, and Kids-‘Go for your life’
- Structure: management committee of stakeholders oversaw the im-
plementation of the action plan and assisted the project coordinators
- Target group: children aged 0–5 years
- Aim: increase the capacity of the Geelong community to promote
healthy eating and active play and to achieve healthy weight in under
5s
Den Hartog et al.
[2014] The
Netherlands
Cross-sectional study: eight interviews with regional coordinators, two focus
groups with regional alliances, four interviews with local coordinators, and
two focus groups with local alliances
Aim: explore the successes and challenges associated with collaboration pro-
cesses in local BeweegKuur alliances
The BeweegKuur programme
- Type of collaboration: network among community partners
- Partners: regional alliances between an advisor from each regional
support structure for primary healthcare (ROS), a professional from a
municipal health service (MHS), and a professional from a sports or-
ganisation were initiated. Local alliances between primary care profes-
sionals like GP, practice nurse, physiotherapist and dietician
- Structure: regional alliances establish local alliances, local alliances are
coordinated by a lifestyle advisor
- Target group: primary care patients
- Aim: guide patients towards local sports facilities
Evans and Sleap
[2013] United
Kingdom
Cross sectional study: interviews with 20 programme stakeholders from two
local authority areas
Aim: provide insight into the development processes occurring in Swim for
Health
Swim for Health
- Type of collaboration: network among community partners
- Partners: Amateur Swimming Association, Hull Leisure, East Riding of
Yorkshire Council, Hull and East Riding Public Health Directorates, Hull
University, Humber Sports Partnership, and Sport England
- Structure: strategic planning by a steering group involving representa-
tives of all programme stakeholders. Day-to-day running by a devel-
opment officer
- Target group: employees, older people, young children and their
families, people with specific health needs
- Aim: improve access to swimming for the whole community with a
focus on four target groups
Foley et al. [2000]
Scotland
Cross-sectional study: 16 interviews with health and leisure personnel
Aim: explore the relationship between health and leisure departments and
the impact of collaborative policy for those who deliver the service
GP Exercise Referral Scheme (GPERS)
- Type of collaboration: referral scheme
- Referral by GPs to a leisure facility. GPs complete a ‘exercise prescrip-
tion’by ticking a series of boxes indicating activities which the GP
believes ‘would be unsuitable’for the patient
- Target group: primary care patients
- Programme after referral: the patient undergoes a consultation with a
member of staff to agree an exercise programme, which is reviewed on
a six-week basis.
- Aim: effect a ‘change in lifestyle’where exercise/activi ty becomes a
form of ‘positive addiction’with the patient being ‘self-motivated’to
continue or increase participation
Fortier et al.
[2007] Canada
Study protocol
Aim: outline the rationale, methods, and interventions for the ongoing
physical activity counselling RCT
The Physical Activity Counselling (PAC) randomised control trial (RCT)
- Type of collaboration: multidisciplinary team with a connection to
sport
- Structure: integration of a PA counsellor in the primary healthcare
team to provide intensive PA counselling
○Phase I: PA counselling provided by the healthcare provider during a
regular primary care visit
○Phase II: intensive autonomy-supportive PA counselling over a
three-month period by the PA counsellor
- The PA counsellor has an university degree in exercise sciences with
knowledge of exercise psychology, behaviour change counselling, and
clinical exercise physiology, as well as certification from the Canadian
Society for Exercise Physiology
- Target group: primary care patients
- Aim: not mentioned
Fortier et al.,
2011a, 2011b
Canada
RTC: 98 (82%) patients completed the trail, questionnaire, fitness test
Aim: assess the incremental effects of intensive physical activity counselling
from an integrated physical activity counsellor, above and beyond brief
counselling from a primary care provider
The Physical Activity Counselling (PAC) randomised control trial
- Type of collaboration: multidisciplinary team with a connection to
sport
- Structure: integration of a PA counsellor in the primary healthcare
team to provide intensive PA counselling
(continued on next page)
Appendix A.1 (continued)
469K.E.F. Leenaars et al. / Preventive Medicine 81 (2015) 460–478

(continued)
Author, year,
country
Study design, method, aim Collaboration initiatives between the primary care and sport sector
○Phase I: PA counselling provided by the healthcare provider during a
regular primary care visit
○Phase II: intensive autonomy-supportive PA counselling over a
three-month period by the PA counsellor
- The physical activity counsellor has a BSc in Human Kinetics, is also a
Certified Fitness Consultant, and was integrated into the practice one
month before the intervention began
- Target group: primary care patients
- Aim: not mentioned
Fortier et al.,
2011a, 2011b
Canada
RCT: questionnaire among 120 participants of the PAC trial
Aim: examine whether self-determined motivation moderated the media-
tional influence of quantity of motivation on the relationship between the
intervention and physical activity in the PAC trial
The Physical Activity Counselling (PAC) randomised control trial
- Type of collaboration: multidisciplinary team with a connection to
sport
- Structure: integration of a PA counsellor in the primary healthcare
team to provide intensive PA counselling
○Phase I: PA counselling provided by the healthcare provider during a
regular primary care visit
○Phase II: intensive autonomy-supportive PA counselling over a
three-month period by the PA counsellor
- Target group: primary care patients
- Aim: not mentioned
Hardcastle and
Taylor, 2001
United
Kingdom
Cross-sectional study: interviews with 15 newly referred older women
(50–80 years of age)
Aim: provide insight into the cultural and social processes experienced by
older women in a GP exercise-referral programme
Exercise-referral program: Hailsham, East Sussex UK
- Type of collaboration: referral scheme
- Referral by a member of the primary care team to a leisure centre with
a referral card indicating various physical or mental indices
- Target group: sedentary patients
- Programme after referral: at the leisure centre an initial appointment is
arranged and further screening is undertaken, including an interview
and the design of a tailored exercise programme. Exercise instructors
are available to offer advice, support, and encouragement during the
programme
- Aim: not mentioned
Harrison et al.
[2005] United
Kingdom
RCT: questionnaire among 545 patients
Aim: examine the effectiveness of the Exercise Referral Scheme and written
information to increase levels of PA at one year, compared with written
information only
Exercise Referral Scheme: local authority borough in the north-west of
England
- Type of collaboration: referral scheme
- Referral by a primary care practitioner ERS
- Target group: sedentary patients
- Programme after referral: exercise officers telephoned clients to ar-
range a one-hour consultation at one of the leisure centres. Patients
received person-specific advice and information. All clients were of-
fered a subsidised 12-week leisure pass, providing reduced entrance
fees to any of the physical activity facilities. At the end of 12 weeks,
patients were invited for an exit interview
- Aim: increase the amount of physical activity clients do each week.
Helmink et al.
[2010] The
Netherlands
Study protocol
Aim: describe the rationale for the development of the BeweegKuur
programme and the development and contents
The BeweegKuur programme
- Type of collaboration: multidisciplinary team with a connection to
sport
- Structure: GP practice staff are responsible for including the patient,
coaching and supervising them, and referring them to allied health
professionals and/or local exercise coaches or a sports physician. The
lifestyle advisor designs an individual exercise programme, which can
be undertaken in the existing local exercise facilities or (temporarily)
under the supervision of a specialised exercise coach or physiothera-
pist
- Target group: primary care patients
- Aim: guide participants in achieving a sustained healthy lifestyle
Helmink et al.
[2012] The
Netherlands
Longitudinal study: two questionnaires among healthcare professionals of 18
pilot practices (round 1: 59 healthcare providers, response rate 59.8%; round
2: 35 healthcare providers, response rate: 60.3%)
Aim: study the motivation of primary care professionals to implement and
continue the BeweegKuur programme
The BeweegKuur programme
- Type of collaboration: multidisciplinary team with a connection to
sport
- Structure: the GP determines whether individuals are eligible for the
intervention. Coaching and supervision are provided by a lifestyle
advisor, usually the practice nurse. The lifestyle advisor designs an
individual exercise programme in consultation with the patient. Pa-
tients can be referred to an independent exercise setting (local exer-
cise facilities), a start-up exercise setting (training with a
physiotherapist for one month) or a supervised exercise setting (train-
ing with a physiotherapist for three months). After training with the
physiotherapist, all patients transfer to exercise at local facilities. In
addition, all patients are referred to a dietician
- Target group: primary care patients
- Aim: guide participants in achieving a sustained healthy lifestyle
Appendix A.1 (continued)
470 K.E.F. Leenaars et al. / Preventive Medicine 81 (2015) 460–478

(continued)
Author, year,
country
Study design, method, aim Collaboration initiatives between the primary care and sport sector
Hofreuter et al.
[2011]
Germany
Cross-sectional study: questionnaire among 315 participants (response rate
68%) and interviews with the intervention team and with participants
Aim: process evaluation of the intervention: reach of the target group, accep-
tance of the intervention, and factors influencing implementation
Active health promotion in old age/Aktive Gesundheitsfördering im
Alter (AGil)
- Type of collaboration: multidisciplinary team with a connection to
sport
- Structure: intervention is carried out by a physiotherapist, physician,
dietician, and a social worker, and consists of existing local network
structures (for example exercise groups). The intervention includes an
information meeting about healthy aging. Participants also have an
individual meeting with the multidisciplinary team. After the meeting,
the participants receive a brief with recommendations. An integral part
in the latter is community services for the implementation of physical
activity
- Target group: older people (N60 year)
- Aim: improve physical activity, healthy nutrition, and the integration
of older people who are not in need of care and are living indepen-
dently without cognitive impairment into network structures
James et al.
[2008] United
Kingdom
Longitudinal study: data collected among 2956 patients between 2000 and
2003
Aim: examine participant and scheme characteristics in relation to access,
uptake, and participation in PARS
Physical activity referral schemes (PARS)
- Type of collaboration: referral scheme
- Referral by a health professional to PARS
- Target group: primary care patients
- Programme after referral: participants were contacted by the PARS
coordinator and offered 8–12 weeks of bi-weekly, supervised exercise
sessions at local leisure facilities
- Aim: not mentioned
Kallings et al.,
2008 Sweden
Longitudinal study: survey among 298 patients (response rate 62%) at
baseline and after six months
Aim: evaluate the feasibility and effects of FaR in a routine clinical setting on
physical activity level and quality of life after six months
Physical activity on prescription (FaR)
- Type of collaboration: referral scheme
- Referral by a health professionals
- Target group: routine care patients with a diagnosis related to insuffi-
cient physical activity or need to be more physical active
- Programme after referral: prescribed physical activity could be either
self-monitored or organised by public physical activity organisations.
Sport or recreation organisations offered activity groups and physical
activity instructors, and a person from this organisation often
contacted the patient
- Aim: not mentioned
Lee et al. [2009]
United
Kingdom
Longitudinal study: audit data collected from 656 Active for Life participants
between 2004 and 2007
Aim: examine the effectiveness of exercise referral schemes in clinical and
psychosocial variables over the 10 weeks of the scheme
Active for Life
- Type of collaboration: referral scheme
- Referral by GPs, practice nurses, or physiotherapists to local leisure
centres
- Target group: individuals aged 13 years
- Programme after referral: referred to four leisure centres where a
10-week tailored exercise programme is delivered by trained staff.
Trained exercise referral staff develop an individually tailored exercise
programme for participants. Each participant is encouraged to attend
sessions twice per week
- Aim: not mentioned
Litt et al. [2013]
USA
Cross-sectional study: telephone interviews with 59 coordinators of active
living collaborative
Aim: examine the characteristics and activities of active living collaborative
groups and the extent to which they have achieved environmental and policy
changes
Active living partnerships
- Type of collaboration: network among community partners
- Partners: most collaborative groups had a diverse membership
representing a range of sectors (public, government, private), disci-
plines (public health, planning, agriculture, sports and fitness), and
perspectives (residents, local leaders, universities, schools, business
leaders, faith-based organisations)
- Structure: most coordinators (76%) reported that their collaborative
had designated a lead agency. These lead agencies were located in
health departments (35%), non-profit organisations (15%), and
healthcare agencies (9%)
- Target group: community
- Aim: partnerships have a focus on active living as a primary or sec-
ondary goal
Meisel et al.
[2014]
Colombia
Cross-sectional study: a questionnaire among 22 organisations (response rate
88%). Information was used to develop a network analysis
Aim: conduct a network analysis
Bogotá’s Ciclovía Recreativa
- Type of collaboration: network among community partners
- Partnerships: City Hall, SoM, SoG, SoH, SoEdu, SRS, IDRD (Sports and
Recreation). Twelve percent of the organisations belonged to Sports
and Recreation and were responsible for the development and
implementation of Ciclovía. Eight percent of the organisations
belonged to Health and were responsible for procedures in case of
emergencies and the promotion of Ciclovía as a strategy to promote PA
- Structure: IDRD leads the Cicolvía programme
- Aim: promote physical activity with a mass programme in which
(continued on next page)
Appendix A.1 (continued)
471K.E.F. Leenaars et al. / Preventive Medicine 81 (2015) 460–478

(continued)
Author, year,
country
Study design, method, aim Collaboration initiatives between the primary care and sport sector
streets are temporarily closed to motorised transport, allowing exclu-
sive access to individuals for leisure activities and physical activity
Moore et al.
[2011] Wales
Cross-sectional study: interviews with 38 exercise professionals involved in
the NERS intervention
Aim: explore exercise professionals’experiences of engaging diverse clinical
populations in an ERS and emerging practices to support uptake and
adherence
National Exercise Referral Scheme (NERS)
- Type of collaboration: referral scheme
- Referral by health professionals to community sports centres
- Target group: sedentary patients with coronary heart disease risk
factors, anxiety or depression, musculoskeletal conditions, and
respiratory/pulmonary conditions
- Programme after referral: motivational interviewing, and patients
were offered a discounted programme for 16 weeks, supervised by
level 3 qualified exercise professionals, employed specifically to deliver
the scheme
- Aim: not mentioned
Murphy et al.
[2010] Wales
Study protocol
Aim: evaluate the overall effectiveness of the intervention
The Welsh National Exercise Referral Scheme (NERS)
- Type of collaboration: referral scheme
- Referral by health professionals working in a range of healthcare set-
tings to community sports centres
- Target group: sedentary patients with coronary heart disease risk
factors, anxiety or depression, musculoskeletal conditions, and
respiratory/pulmonary conditions
- Programme after referral: motivational interviewing and a 16-week
tailored exercise programme run by qualified exercise professionals at
community sports centres
- Aim: participants achieve 30 minutes of moderate physical activity at
least five days per week
Nasmith et al.
[2004] Canada
Cross-sectional study: focus groups and interviews with physicians and pa-
tients
Aim: describe the process followed to develop and implement the model and
the components, and describe the preliminary findings from the evaluation
Côte-des-Neiges Diabetes Pilot Project (CN-Diabetes)
- Type of collaboration: multidisciplinary team with a connection to
sport
- Structure: a coordinator, a community organiser, two nurses, a
dietician, a foot-care technician, a social worker, and an exercise con-
sultant. CN-Diabetes established links within the community, and
physical activity was promoted through group exercise sessions and
walking groups, and links were established with a local sports centre
- Target group: diabetes patients
- Aim: organise healthcare in an integrative framework, promote be-
haviour changes in patients to foster self-care, introduce tools to allow
family physicians to modify their practices, and encourage local com-
munity action to support patients and providers
O’Sullivan et al.
[2010] Canada
Longitudinal study: 15 patients took part in three interviews about their
experiences with this three-month combined-provider PA counselling
intervention
Aim: assess patient experiences and satisfaction with the intervention
The Physical Activity Counselling (PAC) randomised controlled trial
- Type of collaboration: multidisciplinary team with a connection to
sport
- Structure: integration of a physical activity counsellor into an interdis-
ciplinary primary care team. All patients received brief PA counselling
(2–4 min) from their primary care provider during a regular office
visit. The experimental group also received three months of intensive
counselling from a PA counsellor (a total of six sessions)
- Target group: primary care patients
- Aim: not mentioned
Schmidt et al.
[2008] The
Netherlands
Cross-sectional study: questionnaire among 523 female participants and in-
terviews among 38 female participants
Aim: explore female participants’characteristics in ERS located in deprived
neighbourhoods and determine which elements make it appealing for them
to participate in the scheme
Exercise Referral Schemes (ERS)
- Type of collaboration: referral scheme
- Referral by a GP or other health professional to ERS
- Target group: patients aged between 24 and 55 years when GP be-
lieves that the health of the patient would benefit from exercise
- Programme after referral: participants contact ERS for an appointment
with a sport advisor. The sport advisor processes the intake and refers
the patients to one of the exercise groups: swimming, gymnastics,
cardio-fitness, or dancing. The participants follow a 10-week period of
weekly exercise sessions. After this period, participants have the op-
portunity to purchase a second course of 10 lessons
- Aim: encourage GPs’patients living in five deprived neighbourhoods to
pursue a more active lifestyle
Taylor et al.
[2005] United
Kingdom
RCT: questionnaire among 142 participants
Aim: investigate the effect of a widely adopted health service programme to
promote PA, based in a primary-care-leisure-service partnership, on aspects
of mental wellbeing in a middle aged and elderly population
Exercise Referral Intervention
- Type of collaboration: referral scheme
- Referral by a GP to local recreation centres. Patients received a signed
prescription card with information on reason of referral, resting heart
rate and blood pressure, and prohibited activities
- Target group: patients (aged 40–75 years) with one or more of three
coronary heart disease risk factors
Programme after referral: a 10-week programme with two sessions
per week. After 10 weeks, a progress report was returned to the GP.
Participants were encouraged to maintain a physically active lifestyle
and were given the option of a reduced membership fee at the leisure
Appendix A.1 (continued)
472 K.E.F. Leenaars et al. / Preventive Medicine 81 (2015) 460–478

(continued)
Author, year,
country
Study design, method, aim Collaboration initiatives between the primary care and sport sector
centre for six months
- Aim: not mentioned
Trinh et al. [2012]
Canada
Longitudinal study: 101 patients filled in a questionnaire at baseline and after
six weeks and a web log for daily step count. Interviews with five physicians
and two community action site (CAS) representatives
Aim: explore the feasibility and potential impact of the pedometer and
partnership on patient PA levels
A six-week PA intervention
- Type of collaboration: referral scheme.
- Referral by physicians, and patients were provided with a pedometer, a
referral card to the CAS, and information about relevant community
services and walking routes
- Programme after referral: the CAS coordinator contacted patients by
telephone one week into the intervention to provide follow-up sup-
port
- Aim: not mentioned
Wiles et al.
[2008] United
Kingdom
Cross-sectional study, interviews with nine EoP participants, six fitness
instructors, two physiotherapists, and two focus groups with 15 physiothera-
pists
Aim: identify the views of patients, fitness instructors, and physiotherapists
about the appropriateness and acceptability of EoP schemes for people with
stroke
Exercise on Prescription (EoP)
- Type of collaboration: referral scheme
- Referral by physiotherapists to leisure centres
- Target group: stroke patients post-discharge from physiotherapist
- Programme after referral: fitness instructors working at leisure centres
are responsible for running the schemes
- Aim: not mentioned
Wormald et al.
[2006] United
Kingdom
Cross-sectional study: five focus groups with AL participants who had
attended at least one consultation with the AL advisor
Aim: explore participants’perceptions of the operation and effectiveness of
the AL service
Active Lifestyles (AL)
- Type of collaboration: referral scheme.
- Referral by health professionals to an AL professional
- Target group: patients aged over 12 years with a sedentary lifestyle, or
a physical or mental health problem
- Programme after referral: the AL advisor provides motivational sup-
port to help the patient become more active through behaviour change
strategies and individual lifestyle changes (max six visits). The AL
advisor can also refer patients to a range of organised activities, in-
cluding walking groups, green gyms, and ER class or gym schemes
- Aim: encourage patients to become more active and develop healthier
lifestyles\
Appendix A.1 (continued)
473K.E.F. Leenaars et al. / Preventive Medicine 81 (2015) 460–478

Initiative Method Facilitators of collaboration between primary care
and sport
Barriers to collaboration between primary care and
sport
Study
quality
ALbD
Baker et al.
[2012] USA
Questionnaire, interviews,
focus groups among key
partners
- Recruiting diverse partners and supporting rela-
tionships between those partners
- When partners recognised their common inter-
ests and contributed their strengths to the com-
mon goals, had diverse experiences and a variety
of distinct connections, and were open to
expanding their own perspectives, this positively
influenced success
- When new partners were invited to participate, it
was helpful to share the history of the partnership
and
to develop and use a partner orientation manual
- Local champions had the following characteris-
tics: visionary, charismatic, energetic, possessing
a take-charge attitude, passionate, well-known
and respected, well connected with a strong net-
work of resources, trusted by the community and
the partnership, competent, persistent, and polit-
ically savvy
- Local champions were described as ‘sparkplugs’
for initiation of partnership efforts and assisted in
sustaining efforts over time
- Ensuring each organisation has more than one
person involved in the partnership
- All organisations have consistent meeting atten-
dance
- Individual or organisation leadership changes
help bring new strengths to the project or over-
come former bureaucratic or regulatory road-
blocks
- Flexibility, creativity, and effective management
of conflict and friction by the project coordinator
were described as essential to group functioning
- Utilitarian model: less time was required to move
into implementation for partners’assigned pro-
ject tasks
- Collaboration model: time invested in building
relationships helped to address challenges or
disagreements
- Individual or organisational leadership changes
also had negative impacts, including loss of insti-
tutional memory, causing initiatives to stagnate
or lose momentum; an unsupported change in
the vision, mission, or approach; and the loss of
established key connections to media, residents,
community leaders, or others
- Inadequate staffing for initiatives, changes in
leadership, and weak leadership
- Time the partners have to commit to the
initiative, and the amount of overall time it takes
to see partnerships efforts led to intermittent en-
gagement of partners
- Lack of communication and cohesion among the
partners
- Lack of clear roles and responsibilities for
accomplishing tasks interfered with progress
- Financial and political barriers, including insuffi-
cient funds, funding cuts at state and national
level
- Utilitarian model: partners’skills, expertise, and
resources were not fully leveraged, relationships
among partners had not been cultivated deeply
enough to sustain the initiative
- Lead agency model: resulted often in lead agency
staff exhaustion or burnout, did not cultivate the
deep relationships necessary for shared owner-
ship and sustainability
- Collaboration model: progress was often slow
given that the initiative often moved in many
directions at once to meet the needs of all part-
ners at the table
High⁎
Collaboration
between a
community
health centre
and YWCA
Cashman et al.
[2012]
USA
Interviews with staff members
from both organisations
- The collaboration was a natural outgrowth of
both organisations’mutual and complementary
missions
- Integration of PA discussions into the patient visit
and a cultural shift in how PA is viewed
- Expanded opportunities through system change
and the ability to contribute positively to the
city’s health
- The partnership had given the YWCA ‘bragging
rights’and burnished their public image
- Budgetary implications and capacity and com-
munication issues need to be addressed in the
initial stages
- Communication between agencies and among
staff should be regular and frequent
- Need for training and diversity of staff. Staff
should be trained to make patients feel comfort-
able and welcome
- Having a single person responsible for pro-
gramme
- Leadership solving problems and not walking
away from a partnership
- Facility and programmes offered meet client
needs
- Requirement for patience
- Roll out the programme slowly
- Providers receive regular data on their patients’
usage
- Inadequate feedback about patients’use of the
YWCA
- Difficulties in setting priorities: which patients
should be referred?
- Resignation of YWCA staff members: preferred
not to work with low-income health-centre pa-
tients
- High patient usage stretched the YWCA’s limited
facilities and led to overcrowding
- Resignation of members because of the more di-
verse environment
- Stresses of success: YWCA reduced the number of
patients who could use the facility and suspended
acceptances of new referrals. The community
health centre was disappointed and concerned
that the successful programme was being
curtailed
High
VicHealth
Casey et al.
[2009] Australia
Interviews with 22
partnership members
- Trust among members and shared interests be-
tween members were facilitating factors for part-
nership formation
- Difference between the shared interest of profes-
sional organisations (interest in a programme
because it complements their work and core
Medium
Appendix A.2. Overview of barriers and facilitators in the initiatives between the primary care and the sport sector presented in this review.
474 K.E.F. Leenaars et al. / Preventive Medicine 81 (2015) 460–478

(continued)
Initiative Method Facilitators of collaboration between primary care
and sport
Barriers to collaboration between primary care and
sport
Study
quality
- Capacity of organisations to participate in
programmes (skilled staff or community groups
with pro-active committees of management)
- The opportunity to access grant funding facilitat-
ed partnerships because it provided resources to
develop relationships
- Communicating roles and responsibilities was
important for ensuring the implementation of
partnership programmes
- Managing partnerships and facilitating commu-
nication were considered to be key factors for
promoting effective partnerships between pro-
fessionals and volunteers
- Important to engage more than one person from
a sports club, especially key leaders that influence
or control the strategic direction of the club
- Engaging more than one person within organisa-
tions in the programme was a strategy used to
reduce the impact of staff turnover within part-
ner organisations on programme implementation
- Continuation of the programme because the real
and expected benefits of the programme could be
seen
business) and that of volunteer groups (need to
increase club membership and improve the de-
livery of their sport)
- Professional organisations had to spend time
convincing volunteer groups of the benefits of the
partnerships
- Unclear roles and responsibilities possibly
slowing the implementation of planned activities
- Staff turnover within professional organisations
slowed the implementation of planned activities
- Lack of agency capacity: professional agencies
found it difficult to engage sporting clubs in
health promoting programs
- Programmes lacked leadership and/or support
from senior management to provide direction to
programme officers
- Lack of staff skills and decision-making capacities
within professional organisations
VicHealth
Casey et al.,
2009a Australia
Interviews with 22
partnership members.
- Engagement of key stakeholders
- Formalisation of the partnership agreement
- Capacity to identify and develop sports and rec-
reation programmes
- Partnerships’formalised prior funding made
greater impacts in the short term on the imple-
mentation of sports and recreation programmes
- Engage organisations in project planning, create a
sense of ownership
- Range of organisations from various sectors that
each brought a different resource to the partner-
ships
- The stronger the commitment of organisations to
the partnership, the more likely they were to
commit additional resources
- Less formalised partnerships or less engagement
of key stakeholders at the time of initial funding
were limited to the development and implemen-
tation of ‘come and try’sports and recreation
events
- Sports and recreation programmes led by sports
and recreation bodies may result in higher levels
of programme implementation in the short term
- When similar organisations or types of volunteers
were brought together, the diversity of skills,
resources, and approaches to plan and implement
a programme was limited
- For programmes led by agencies outside the sport
sector, it was time-consuming and difficult to es-
tablish partnerships with sports volunteers (sport
clubs did not see the benefits for them)
Medium
SESPAN
Cheadle et al.,
2010a USA
Key informant interviews - The SESPAN organiser was perceived as effective
in carrying out her work (has a lot of energy,
passionate about the work, good sense of the
community’s needs, she connects very well,
knows everyone in the area, a strong advocate)
- The SESPAN organiser played a significant, if not
crucial, role in the development of the physical
activity programmes and Healthy and Active
Rainier Valley Coalition (HARVC) (a huge impact:
co-founded HARVC, instigator full of ideas)
None mentioned Medium
CN-Diabetes
De Civita and
Dasgupta, 2007
Canada
Analyses of the actual reported
experiences of a specific
diabetes management pilot
- Stakeholders recognised the need for coordinated
diabetes care
- Compatibility: the CN-diabetes multidisciplinary
team operated within an existing community
health centre and attempted to work with the
existing group and solo practices within the CN
area. The programme therefore built upon an
existing structure
- Physicians observed that patients participating in
CN-Diabetes appeared to have more
diabetes-related knowledge and were more will-
ing to make lifestyle changes
- Family physicians, nurses, and patients acknowl-
edged the importance of the CN-Diabetes inter-
vention programme
- Collaboration among all members of the team re-
lied heavily on the adaption of the
diabetes-specific software; limited use of this
system by physicians may have hindered the
communication process
- A greater level of mobilisation of community in-
terest in the programme might have led to com-
munity pressure for continued funding for the
programme
Medium
Romp & Chomp
De Groot et al.
[2010] Australia
Key informant interviews - Bringing together the big ‘players’from across the
Geelong community to work together
- The intervention strategy of training allied health
professionals to support the health promotion
activities in the kindergartens was viewed
positively
- Lack of processes and protocols that could have
facilitated better partnerships and overcome
philosophical differences between partners about
the project
- Perception that some partners tried to hold onto
the ownership and branding of their own project
- Lack of project leadership due to high staff turn-
over
- Lack of resources and funding available for pro-
ject implementation
High
(continued on next page)
Appendix A.2 (continued)
475K.E.F. Leenaars et al. / Preventive Medicine 81 (2015) 460–478

(continued)
Initiative Method Facilitators of collaboration between primary care
and sport
Barriers to collaboration between primary care and
sport
Study
quality
- Lack of organisational structures and manage-
ment support
- Ambiguity about roles and responsibilities
- Lack of meetings of the higher level reference
group
- Inability to make independent decisions; this was
seen to have slowed down processes
- Some committee members’lack of skills and
knowledge about capacity building and health
promotion
The BeweegKuur
Den-Hartog et al.
[2014] The
Netherlands
Interviews and focus groups
with stakeholders
- Short communication lines
- Perceived health benefits for patients and en-
gagement of new partners strongly motivated
partners
- An enthusiastic coordinator or linchpin
- Having enough time was key to development of
trust among alliance partners and for the plan-
ning and implementation of the BeweegKuur
programme
- The alliance partners brought in their profession-
al expertise and appreciated the input and exper-
tise of other partners
- Discussing the adoption of broader goals was
perceived as a success by the alliances
- Lack of major partners like municipalities, wel-
fare organisations, GPs, and local sports facilities
- Local sport facilities did not participate in the al-
liances because the care and sports sectors have
different cultures. Differences in preferred meet-
ing time (day or evening) and target groups
- Sports sector was not familiar with BeweegKuur
participants: comprising obese or overweight
people, often in combination with low
socio-economic status
- The GPs’role was experienced as both crucial
(referral of patients) and hard to secure (limited
time)
- GPs perceived the BeweegKuur as an extra task
without an extra allowance
- Limited flow of patients from primary care to
local sports facilities
- Uncertainty about funding hampered the devel-
opment of alliances
- The fixed protocol sometimes hindered joint dis-
cussion and the development of aims and
objectives
High
Swim for Health
Evans and Sleap,
2013 United
Kingdom
Interviews with key
stakeholders
None mentioned - Communication difficulties, particularly between
steering group members operating at a strategic
level and those delivering services
- Stakeholder support was limited if programme
goals did not match organisational goals
- There was a lack of trained staff to offer new
activity types such as aqua circuit ‘aquafit’or fit-
ness swimming and aqua gym
- Poor participant uptake in new services offered
was evident
Medium
GPERS
Foley et al.
[2000] Scotland
Interviews with GPs and
leisure personnel
- Funding and development of a specified post was
a fundamental priority
- The referral process thus provided a welfarist and
commercial benefit for leisure, paraphrased as a
‘spin-off in terms of service’
- Limited reporting of patient progress. Once pa-
tients had entered the scheme, progress evalua-
tion was informally ‘self-reported’to GPs or ‘you
never hear about a patient’
- The lack of periodical reporting was, for the ma-
jority of practitioners, a fundamental flaw in the
overall process
- Communication failures were compounded by GP
confusion over the actual process of activity pre-
scription operation within leisure facilities. Some
GPs were ‘unsure’of the procedures at the facili-
ties and ‘uncomfortable’with ‘leisure industry
people’with limited medical knowledge
- Many GPs were ‘worried’about patients and the
ability of ‘leisure people to keep them [patients]
motivated’
- Leisure personnel believed that any confusion
was on the part of the bio-medical professions,
and they were aware of divisions within the GP
community. For them, this was best resolved by
selecting the ‘GPs that are very keen’and ‘work
on a word of mouth methodology in an attempt
to encourage GPs to be more open minded’
- Many GPs and other bio-medical professionals
were cynical of leisure, who they regarded as
‘having a different agenda’and being driven by a
‘bums on seats policy’rather than any social
objective
Medium
Bogotá’s Ciclovía
Recreativa
Meisel et al.
[2014] Colombia
Questionnaire among
organisations in the network
- The organisations considered most important by
others are most likely to cooperate, collaborate,
or form partnerships
- Organisation structure/bureaucracy, lack of time,
lack of formal agreements were indicated as the
main barriers to working with others
High
A six-week PA Telephone interviews with High
Appendix A.2 (continued)
476 K.E.F. Leenaars et al. / Preventive Medicine 81 (2015) 460–478

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(continued)
Initiative Method Facilitators of collaboration between primary care
and sport
Barriers to collaboration between primary care and
sport
Study
quality
intervention
Trinh et al.
[2012] Canada
CAS representatives and
physicians
- The collaboration provided physicians with a
better understanding of services and support
available to their patients
- The intervention laid the groundwork for a rela-
tionship between physicians and CAS
- The intervention increased the physicians’
awareness of the usefulness of the pedometer
and the various resources available in the com-
munity
- Remuneration from the government for lifestyle
counselling, the availability of resources (pedom-
eters and CAS support), and documentation of
the positive effects of the intervention acted as
key influences on ongoing implementation
- Physicians’lack of time the greatest challenge for
implementation and uptake of the interventions
- Communication could have been improved:
○CAS received very few enquiries and were un-
certain about the referral process
○Physicians did not receive feedback from the
CAS as to who had connected with the site and
how they were progressing
EoP
Wiles et al.
[2008] United
Kingdom
Interviews with patients,
physiotherapists, fitness
instructors, and focus groups
with physiotherapists.
None mentioned - Physiotherapists were apprehensive about fitness
instructors’knowledge of neurological conditions
and of appropriate exercise programmes for peo-
ple post stroke
- Physiotherapists would invariably attend the first
session to provide input into the exercise pro-
gramme developed by fitness instructors
- It was time-consuming for the physiotherapists
to attend the first meeting, but they also experi-
enced discomfort about being out of their familiar
territory and felt wary about giving too much
advice to fitness instructors
- Being paid by the session and the absence of
budgets within leisure centres to pay for their
training were barriers to fitness instructors par-
ticipating in training
High
⁎Brownson et al. (2012) describe the method used in Baker et al. (Baker et al., 2012), therefore we used Brownson et al. to assess the quality of Baker et al.’sstudy.
Appendix A.2 (continued)
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