Exploring learning communities’ actions and perceived impact on healthy weight approaches across Dutch municipalities | BMC Public Health

Part 1: action lists

In total, 609 actions were formulated. LC members formulated on average 4.0 (standard deviation 2.4) actions per LC member per meeting, and steering committee members formulated on average 1.4 (standard deviation 0.7) actions per member per steering committee meeting. Below we describe the extent to which these actions targeted the relevant topics (i.e., LPTs; Figs. 1 and 4) and the corresponding level on which they targeted them (i.e., system levels; Fig. 4).

Actions targeting leverage point themes

Figure 1 indicates per group (LC A, LC B, steering group) how many formulated actions targeted the LPTs across all meetings (see Additional file 4 for example actions per LPT).

HWA organizational structure

Over all groups (LC A, LC B, steering group), most actions targeted the network subtheme (n = 346 of 609 actions). Some actions targeted the municipal processes (n = 58), diversity of activities (n = 61), diversity of themes (n = 29), or communication strategies (n = 52) subthemes. The diversity of tasks subtheme (n = 6) was barely targeted. More specifically, the knowledge exchange (n = 148) and combined forces (n = 152) LPTs were targeted the most by both LCs. Further, all groups regularly targeted the financial resources (n = 24), messages about the healthy weight approach (n = 36), many diverse HWA events (n = 61), and range from specific to broad themes (n = 29) LPTs. However, LPTs such as compatible tasks fulfilled by various professionals (n = 6), faster process (n = 2), and limited perceived competition (n = 0) were barely targeted.

Collaboration between professionals

Some actions targeted the linking pins (n = 38), motivation and commitment (n = 45), and stimulating one another (n = 21) subthemes. More specifically, both LCs regularly targeted the central players and direct links within the network (n = 38), spur other professionals into action (n = 19), and energy commitment and support base (n = 28) LPTs. However, the other LPTs regarding motivation and commitment were barely targeted.

Citizen participation

Several actions targeted the reaching the target group (n = 49) and citizens’ motivation (n = 34) subthemes. More specifically, all groups regularly targeted the look for entry point (n = 19) and determine needs target group (n = 17) LPTs. However, LPTs such as referrals from care professionals (n = 1) and customization (n = 9) were barely targeted. Further, the existing contact moments with care professionals (n = 8) LPT was targeted almost solely by LC B.

Actions targeting new themes

The actions in the category other did not correspond to any LPT but were perceived to create HWA systems change encompassed 10 clusters (Fig. 1). Three clusters related mainly to citizen participation and were targeted mainly by LC A; these were exploring demand-oriented working (citizen participation), shaping the role of supporter for demand-driven work (citizen participation), and apply demand-driven working (citizen participation) more in regular work. Other clusters applied mainly in LC A were clarity on own role, scaling up (within municipality or to another municipality), self-reflection, and form joint vision/goal. Moreover, the clusters targeted in both LCs were monitor progress, connect integral, and making policy, interventions, or collaborations structural, of which the last two were also targeted by steering committee members. Altogether, LC A targeted these new clusters relatively often, whereas LC B barely did.

Actions targeting system levels

Figure 4 indicates that, in all groups, the majority of actions targeted system level events (n = 401 of 609 actions). The structures level was also targeted repeatedly (n = 253), whereas the system-level goals (n = 84) and beliefs (n = 30) were barely targeted. Actions regarding many LPTs and clusters roughly represented the system levels in a comparable pattern as shown in Fig. 4, such as many, diverse HWA activities and knowledge exchange. Still, some seemed to have slightly different patterns. For instance, actions regarding the central players and direct links within the network LPT targeted events (29%), structures (46%), goals (18%), and beliefs (6%). Most actions across all system levels were executed as expected or (much) more than expected: 75.3% for actions targeting events, 68.6% for structures, 70.7% for goals, and 80.0% for beliefs.

Successfully executed actions

Across almost all LPTs/subthemes, new themes, and system levels, most actions were perceived as successful (Fig. 1). Overall, 26.1% of the actions were perceived as much more or more successful than LC members had expected, 46.2% as expected, and 27.8% much less or less than expected (n = 598) (response 98.2%). Multiple simple ordinal regression analyses indicated two statistically significant models, suggesting that actions that targeted system-level events seemed more likely – whereas actions that targeted communication strategies subtheme seemed less likely – to be executed successfully compared with actions that did not (Table 2; Fig. 1). For example, actions that did not target system-level events were associated with a 0.406 decreased likelihood of the action being executed successfully compared with actions that did target system-level events (Table 2).

Different actions throughout LC meetings

Some types of actions seemed more or less likely to be formulated specifically at early, middle, or late LC meetings, compared with other LC meeting numbers (Table 3). Multiple simple binary regression analyses suggested that LC meeting number seemed to account for a significant amount of variance for several outcome variables (Table 4). Contrast analyses (Table 3) illustrate, for example, that statistically significantly more LC actions targeted events during middle (74.6%) and late (70.6%), compared with early, LC meetings (43.2%). This means that actions formulated in the middle or late LC meetings had a 1.793 increased likelihood of these actions targeting system-level events compared with the odds for the early LC meetings (Tables 3 and 4).

Part 2: LC members’ perceived impact

Perceptions about LC impact varied across LC members, as LC members stated that their experience ranged from a lot to only small LC impacts; and the types of impact mentioned were not recognized by all members. Overall, LC members perceived LC impact regarding three main themes: ideas about the next steps toward solutions, more collaboration, and working more effectively, which all consisted of subthemes (as illustrated in Fig. 5). These themes corresponded to subsequent impact levels that strengthened one another. For example, ideas about the next steps contributed to more collaboration; and both ideas and collaboration contributed to working more effectively.

Ideas about the next steps toward solutions

The LC provided members with ideas about the next steps to strengthen their HWA work, and this was perceived as an LC result. To get to these insights, four different elements were mentioned. First, LC members used the LC as a moment to stand still and think about taking the next step together with other members; this moment of reflection was valued, as it mitigated the day-to-day business. Besides, the LC was used as an advisory group where members took the opportunity to introduce their own messages or connect with people who could help with their own action. Second, throughout this process, the LC helped members to prioritize prevention and realize that small actions are important. This helped members to set priorities:

I think it helps me to see perhaps confirmation of certain ideas that may be going on somewhere in the background, like okay, yes, that is indeed useful to do. And then to prioritize that. So in that way it helps me to prioritize.… In addition, I can imagine that it can be a bit of a sticky factor for everyone to keep the theme on their minds all the time. (Policy advisors)

Third, throughout this process, LC members gained knowledge about local HWA relevancies relating to knowledge about HWA content (i.e., knowledge about what HWA stakeholders do), knowledge about HWA success factors (i.e., involving the target group requires personal contact and a question-centered way of working), knowledge about HWA problems (i.e., the target group, young adults, is barely incorporated in the HWA), and awareness of the HWA’s complexity. According to members, this knowledge originated from hearing research results and perspectives of members who were outside their direct work environment. Lastly, LC members mentioned that the LC contributed to a broader field of vision, for example by seeing the bigger HWA picture and understanding other HWA stakeholders better (i.e., increasingly speaking the same language and empathizing with one another):

That you now actually look a little more broadly than your own target group, but just really take a municipal look, okay, what can we all offer somewhere? (Practice professionals)

More collaboration between HWA stakeholders

Some ideas about the next steps related to collaborating with HWA stakeholders. The LC resulted in more collaboration between HWA stakeholders. Four aspects were mentioned as achieving this collaboration. First, members’ connection with HWA stakeholders ultimately contributed to collaboration:

So, you get closer to one another and that connection is an important point for me at least. What you see when you look here is that people often work next to one another and past one another and that in such a learning community you do get more connection with one another. (Citizen)

Through the LCs, members learned how to organize HWAs together (i.e., knowledge about the municipality’s policy choices) and created a broader network (i.e., contact with local public, working more with the municipality), because the LC brought members into contact with people whom they otherwise would not have met. Moreover, members shared the LC ideas with their own network, thereby further connecting members with HWA stakeholders.

Second, the LC enabled members to appreciate a more integral perspective on health and the HWA (i.e., looking more broadly at health and their target group). Consequently, members realized that they needed other stakeholders and therefore connected HWA elements during the LC, thereby further enabling collaboration. Third, members experienced a common HWA vision and gained trust in strengthening the HWA. Lastly, at LC meetings, members experienced more social support among themselves, energy to work on the HWA, and usage of one another’s expertise (e.g., knowledge about how others work on specific HWA themes), again further strengthening collaboration:

What I like is what I noticed last time: you pose a problem in the group, there are network partners around you who say oh hey, that’s what I’m here for, but I can help with that. (Practice professional)

It gives me energy. … You can then use the energy in the learning community directly for what will be rolled out in the municipality. (Health broker)

Working more effectively

Some collaborations related to working effectively. LC members worked more effectively (i.e., more efficient regular meetings) by applying three types of actions, where actions include for instance LC ideas, projects, or working methods. First, in line with increased collaboration, working more effectively was enabled through actions about mutual exchange. LC members had conversations with members outside the LC meeting, and LC members knew what the other members could offer. Second, various LC members applied a long-term view to envisioned actions (i.e., a prevention team was initiated in the municipality). Third, members partly organized their work more in line with citizens’ needs, thereby strengthening the position of citizen participation, and members considered this step crucial for effective work. The diversity of HWA stakeholders implied variety in the way in which members applied actions in their regular work. Examples included identifying citizens’ needs (practice professional), creating policy plans in which citizens could be involved (policy advisor), and tailoring advice to patients (care professional). Thus, members mentioned successful LC projects (e.g., published booklet, development of communication, initiatives copied from another municipality), and others indicated that they had adapted their behavior during regular work, such as consultations (i.e., referring more to neighborhood initiatives):

Well, for example, in our Healthy and Active Living Agreement we have included something for that, that in the process we are now going through around the Healthy and Active Living Agreement we will look at how we can involve citizens and target groups adequately. (Policy advisors)

Um well, in the last years, I have been looking a lot more, not what can I do for the patient, but what does a patient need to help him/herself. I think that is much more important and has become for me, and also not provide some standard exercises. But much more looking at what someone is doing and much more adapting exercising accordingly. (Care professional)