"That's like therapy"-A qualitative study on socially disadvantaged women's views on the effects of a community-based participatory research project on their health and health behavior.

Background: Regular physical activity has positive effects on both physical and mental health. Nevertheless, socially disadvantaged women are often insufficiently physically active. Through needs-based physical activity offers, community-based participatory research (CBPR) projects have the potential to reach these women and increase the effectiveness of physical activity interventions by supporting women's empowerment, health, and health behaviors. This study aimed to examine socially disadvantaged women's views on the effects of long-term participation in Bewegung als Investition in Gesundheit (BIG, i.e., movement as an investment in health), a long-standing German CBPR project, on their health and health behavior. Methods: Semi-structured qualitative interviews were conducted with 30 participating women at five BIG sites across Germany between April and August 2022. The interviews were recorded, transcribed verbatim, and analyzed using framework analysis. Results: Women reported that participation in BIG classes contributed to their physical, mental, and social health. For many women, the positive effects on their mental and social wellbeing were most important. In addition to increased fitness and improved physical endurance, many participating women were able to expand their social networks, thus receiving further social support, and improve their self-esteem, self-confidence, and self-efficacy. Furthermore, participation in BIG physical activity classes positively influenced the health awareness of many women helping them to improve their activity level and diet over time. Conclusion: Our results suggest that CBPR projects, such as the BIG project, can increase physical activity among socially disadvantaged groups and contribute to their overall health and wellbeing. CBPR projects could thus be considered a key element of health promotion for this target group. Future interventional research is required to confirm and further explore the effects of CBPR interventions and to examine whether the effects can be replicated in other settings.

[Capabilities for Physical Activity in Older People: Development and Testing of a Measurement Tool]. / Messung von Handlungsmöglichkeiten (capabilities) für körperliche Aktivität: Entwicklung und Erprobung eines Messinstruments für ältere Menschen.

INTRODUCTION: Based on Sen's capability approach, this study addresses the operationalization of capabilities for leading an active lifestyle. By assessing capabilities, processes of change can be mapped and the development of interventions to promote physical activity in different population groups, e. g., older adults, can be supported. However, no standardized German-language instrument for measuring physical activity-related capabilities is available to date. METHODS: Building on an exploratory interview study (Sauter et al., 2019) that identified relevant physical activity-related capabilities in older adults, a standardized questionnaire with 41 items was designed. Two different question formulations were designed to query perceived capabilities for physical activity. The "think-aloud" method was conducted to validate the instrument. This involved recording all verbal comments made by participants while completing the questionnaire and conducting supplementary interviews for comprehensibility and applicability. The sample included 16 older adults (w=9, MW=66.3 years). RESULTS: Overall, respondents rated the instrument's usability and comprehensibility as good. For the questioning of perceived capabilities, the formulation "I have the possibility to..." was favored instead of "I perceive my personal opportunities as…". Difficulties in understanding and ambiguities were found in a few items. Thus, further changes were made to specify these questions with regard to unclear terms such as "walking paths". CONCLUSION: The questionnaire seems to be suitable to asses perceived capabilities for leading an active lifestyle in older adults. The final questionnaire is available in English and in German. Further research is needed to test the applicability of the instrument in other population groups and verify objectivity, reliability and validity.

Preferences of women in difficult life situations for a physical activity programme: protocol of a discrete choice experiment in the German NU-BIG project.

INTRODUCTION: The BIG project ('Bewegung als Investition in die Gesundheit', ie, 'Movement as Investment in Health') was developed in 2005 as a community-based participatory research programme to offer accessible opportunities for physical activity to women in difficult life situations. Since then, the programme has been expanded to eight sites in Germany. A systematic evaluation of BIG is currently being conducted. As part of this effort, we strive to understand the preferences of participating women for different aspects of the programme, and to analyse their willingness to pay. METHODS AND ANALYSIS: In this protocol, we describe the development and analysis plan of a discrete choice experiment (DCE) to investigate participants' preferences for a physical activity programme for women in difficult life situations. The experiment will be embedded in a questionnaire covering several aspects of participation in the programme (eg, reach, efficacy and further effects) and the socioeconomic characteristics of all active participants. After a thorough search of the literature, BIG documents review and expert interviews, we identified five important attributes of the programme: course times, travel time to the course venue, additional social activities organised by BIG, consideration of wishes and interests for the further planning of courses and costs per course unit. Thereafter, we piloted the experiment with a sample of participants from the target group. After data collection, the experiment will be analysed using a conditional logit model and a latent class analysis to assess eventual heterogeneity in preferences. ETHICS AND DISSEMINATION: Understanding women's preferences will provide useful insights for the further development of the programme and ultimately increase participation and retention. The questionnaire, the included DCE and the pretest on participants received ethical approval (application no. 20-247_1-B). We plan to disseminate the results of the DCE in peer-reviewed journals, national conferences and among participants and programme coordinators and organisers.

Corrigendum: "For me, it's just a piece of freedom"-Increased empowerment through physical activity promotion among socially disadvantaged women.

[This corrects the article DOI: 10.3389/fpubh.2022.867626.].

"For me, it's just a piece of freedom"-Increased empowerment through physical activity promotion among socially disadvantaged women.

Introduction: Community-based participatory research (CBPR) is an effective health promotion approach for reaching socially disadvantaged groups. However, there is limited evidence on how such interventions and their effects can be reproduced across time and place. The present study examines the effects of BIG (i.e., movement as an investment in health), a long-standing German CBPR project. Since 2005, BIG has aimed to empower women in difficult life situations to increase control over their health determinants and reduce social inequalities by promoting physical activity. One of BIG's key features is its implementation in several German municipalities since 2005. This study explores (a) whether participation could change women's empowerment, and (b) how increased empowerment affects other areas of women's lives. Methods: With a total of 63 interviewees (i.e., 40 participating women, 7 trainers, 3 project coordinators, and 13 stakeholders), we conducted 53 semi-structured qualitative interviews in five BIG communities between 2007 and 2011. Some interviews were conducted with two people simultaneously. The interview guide contained questions on various dimensions of empowerment (e.g., project engagement, increased self-efficacy, and developed competencies). Framework analysis was used for the analytical process. Results: BIG contributed to women's empowerment in various ways, including increased self-efficacy, social network promotion, competency development, and increased motivation to change physical activity behavior. Women who took on added tasks and became more involved in project planning also strengthened their organizational empowerment. Furthermore, increased empowerment had a positive influence on the women's quality of life, family, and professional lives. Conclusion: The novel findings helped in understanding the effects of a complex empowerment-based approach that promoted physical activity among women in difficult life situations. Future research should focus on the long-term effects of these programs and their transferability to other sites. Further effort is necessary in the area of public health policy.

Influences on the physical activity of Syrian migrants in Germany: results of a qualitative study.

Due to the ongoing Syrian conflict, Syrian migrants represent the third-largest group of immigrants in Germany. They are, therefore, potential addressees for health-promotion programs, such as physical activity (PA). Thus, this study aimed to explore the relevance of PA, how PA may change with increasing length of stay and what are the facilitators and barriers of PA in the host country. Using a longitudinal, qualitative study design, 30 semi-standardized qualitative interviews with Syrian migrants were conducted in 2018 and 17 migrants could be followed-up after 12 months in 2019 and were asked for changes in their PA-behavior. Interviews were conducted in German, English or Arabic, transcribed and translated into English if necessary. For analysis, an abbreviated version of the Grounded Theory was used. We identified three PA phases that Syrian immigrants underwent during their first years in Germany. Phase 1 includes bureaucratic matters. Health-promoting behaviors, such as PA, are not relevant. Phase 2 comprises the establishment of basic structures. PA can gain importance and (new) behaviors can be established. In Phase 3, immigrants feel under pressure to successfully complete an (academic) education in Germany. Feelings toward PA can become ambivalent. Overall, health-promoting behaviors, such as PA, are often of secondary priority and factors influencing PA are heterogeneous not only on an individual but also societal and institutional level. PA-programs should be advertised bilingually, offered low-threshold and at low cost in order to reach the target group. In addition, there is a high demand for mental health services.

Due to the ongoing Syrian conflict, Syrian immigrants represent the third-largest group of immigrants in Germany and are, therefore an important target group for health-promotion programs, such as physical activity (PA). To better understand, how important PA is for Syrian migrants, how their PA-behavior in Germany differs compared to Syria and what factors have an impact on PA, we conducted 30 interviews with Syrian migrants. After 12 months, we re-contacted the same 30 people, to ask for a second interview, of whom 17 agreed. All 47 interviews were conducted in German, English or Arabic, transcribed and translated into English if necessary. The interview narratives reveal that health-promoting behaviors, such as PA, are often secondary priorities. This is not only true for the beginning of migrants' stays in their host country, but also as the duration of their stays increases. Processing major life changes and traumatic experiences, meeting acculturation requirements and managing everyday life in a foreign country require migrants' full attention. Public health efforts must be more responsive to Syrian migrants' specific needs. Future research should continue to focus on Syrian migrants' living, working and social conditions and their impacts on health-related behaviors.

Capacity building in participatory stakeholder groups: results from a German research consortium on active lifestyles.

To implement sustainable health-promoting structures in a setting, various agents must work together. In the Capital4Health research network, participatory stakeholder groups consisting of key persons, stakeholders, representatives of the target group, and facilitating experts are assembled in five settings (child care center, school, company, rural community, nursing home). In a Cooperative Planning process, the various groups meet regularly to plan and implement strategies to promote physical activity across different settings. This study evaluates whether participatory stakeholder groups have been established and also examines the capacity-building processes that took place in these stakeholder groups. For process evaluation, 78 group meetings were documented in 16 different stakeholder groups using a semi-structured protocol based on established capacity-building domains. For outcome evaluation, six semi-structured interviews (1-2 per setting) with facilitating experts were conducted. Data were analyzed by content analysis. Across all settings, capacity-building processes were successful to a certain degree (e.g. problem assessment, resource mobilization). However, in most groups it was difficult to broadly assess problems, to establish sustainable networks, or to find persons with leadership characteristics. Also, irregular participation, lack of motivation to take over responsibility, and minimal institutional readiness for structural and personal changes often hindered the progress of the projects. Stakeholder groups can actively involve setting members in the development of physical activity promotion programs. It seems challenging, however, to sustainably establish such groups that continue working independently without assistance from a facilitating expert.

It is well known that public health programs are most effective when health experts, setting members and the target group work together in developing and implementing suitable interventions that fit the needs of the target group. Stakeholder groups are well suited to facilitate the regular exchange between the different agents and the health experts. Although stakeholders are experts in their various living environments, it is often necessary to expand various capacities in order to successfully plan, implement and maintain interventions in the long term. We are interested in what is required to successfully establish such stakeholder groups, and how the capacity-building processes will work in them, in order to understand which capacities are easiest to improve and in which domains it is more difficult. Therefore, we monitored 15 different stakeholder groups over a time span of 3 years; these were assembled in five settings (child care center, school, company, rural community, nursing home) and addressed interventions for encouraging a physically active lifestyle. In total, 78 group meetings were documented using a semi-structured protocol based on established capacity-building domains. Afterwards, we held interviews with the health experts involved to identify barriers and enablers of the group processes.

Factors influencing the nutritional behavior of Syrian migrants in Germany - results of a qualitative study.

BACKGROUND: Syrian migrants represent the third-largest group of foreigners in Germany and are therefore potential users of health promotion initiatives, including nutrition programs. It is little known how (healthy) nutrition is understood and implemented by this group and which factors influence their experiences related to food and eating in the host country. Thus, this study aimed to explore the importance of (healthy) nutrition, facilitators, and barriers of a preferred diet; nutritional changes in relation to the country of origin; and how nutrition may change with increasing length of stay. METHODS: Thirty semi-structured qualitative interviews with Syrian migrants (male = 16, female = 14, 18-35 years, length of stay 10-68 months) were conducted in 2018. Seventeen migrants could be followed-up after 12 months and were interviewed in 2019 again and were asked for changes in their nutritional behavior. Interviews were conducted in German, English, or Arabic, transcribed and translated into English if necessary. For analysis, an abbreviated version of the Grounded Theory was used. RESULTS: We identified six overarching themes that described influencing factors on a favored diet in Germany over the course of stay: (1) managing everyday life; (2) intercultural contact with local residents; (3) social context of cooking and eating; (4) ambiguity toward Arabic food; (5) mistrust toward certain types of food; and (6) influence of postmigration stressors. In general, the importance of nutrition is high among Syrian migrants. However, daily stressors, the lack of practical knowledge of how to cook favored dishes, and food insecurity in the new food environment make it difficult to obtain a preferred diet. With increasing stay, many developed a higher awareness of healthy eating, mainly due to a new independence or influences from the social environment in Germany. CONCLUSION: Results highlight the need for health promotion interventions to be more responsive to the specific needs of Syrian migrants, including nutrition. Syrian migrants differ in their capabilities, needs, and aims, and they should be addressed differently by health professionals, social services or migrant specific services. Future research should continue to focus on the living conditions of Syrian migrants and its influence on nutrition.

The Long-Term Public Health Impact of a Community-Based Participatory Research Project for Health Promotion Among Socially Disadvantaged Women-A Case Study Protocol.

Introduction: Community-based participatory research (CBPR) is considered to be of high potential for health promotion among socially disadvantaged groups. However, the long-term implementation and transfer of these approaches remain challenging, and the public health impact they achieve is difficult to study. This also pertains to the potential health effects and cost-effectiveness of CBPR. This study protocol describes the follow-up case study (NU-BIG) after 15 years of the BIG project ("movement as investment in health"), a project to promote physical activity among socially disadvantaged women. Through a participatory approach, BIG empowers the addressed women to plan and implement low-threshold physical activity offers. Since the project started in 2005, it was transferred to 17 communities in Germany. Materials and Analysis: NU-BIG intends to examine the long-term effects, including economic aspects, of the BIG project on individual and structural levels at all project sites, as well as its long-term implementation and transfer. NU-BIG is a cross-sectional and longitudinal study using a mixed method approach. For the longitudinal section, we re-analyze existing data from former BIG evaluations. For cross-sectional data collection, we use questionnaires and conduct qualitative interviews and focus groups. Women who take part in BIG program offers are part of the research team and will use the photo-voice approach to report on the effects of BIG. The study population consists of about 800 women who participate in BIG project offers and 50 persons involved in the implementation of the BIG project at local sites. Discussion: The expected results from NU-BIG are highly relevant for studying the long-term public health impact of CBPR. In particular, this project intends to answer questions on how the transfer of such projects can succeed and which factors determine if a CBPR project can be sustained at the community level. Eventually, these results can contribute to the further development of participatory approaches to provide effective health promotion among socially disadvantaged groups. Conclusion: Although CBPR is seen of having the potential to reduce health disparities, there is still a lack of research on its long-term effects and public health impact. NU-BIG aims at generating knowledge about the economic effects, reach, efficacy, adoption, implementation, and maintenance of a CBPR project. The expected results could be of high interest for BIG and other CBPR-projects.

Exploring how Syrian women manage their health after migration to Germany: results of a qualitative study.

BACKGROUND: In the recent years, the number of Syrians living in Germany increased drastically due to the massive displacement caused by the Syrian conflict. Syrian migrant women in Germany are challenged by both the migration process and the changing of social roles. Seeking out healthcare may be hampered by linguistic and cultural barriers, but the new context may offer opportunities for health and well-being (free access to health care, civil/human rights). Little is known about how Syrian women manage their health after their resettlement in Germany. METHODS: In depth interviews in Arabic were conducted with 9 Syrian women who were recruited through purposive sampling (18-55 years, migrated in 2011-2017, different education levels), focusing on capabilities to control one's health and to navigate the German healthcare system, and social/environmental barriers and facilitators to effectively manage their health. Interview transcripts were analysed using qualitative content analysis. RESULTS: The women reported their health to be impaired by post-migration stressors, such as perceived discrimination, loss of social status and worrying about the future. Many interviewees felt disempowered and incompetent to successfully and actively navigate the German healthcare system, lacking information and not understanding their rights and options under the health insurance plan. The language barrier added to feeling vulnerable. Many women experienced doctors declining to treat them for capacity reasons; when treated, they often did not feel taken seriously or were dissatisfied with the emotional/cultural aspects of care. If possible, Arabic doctors were sought out. Some women, however, described improved resources for health, and appreciated better women's rights as a source of power. CONCLUSIONS: The lack of information about the structure and offers of the German healthcare system, language and culture specific barriers as well as socio-cultural challenges are undermining the ability of Syrian women to manage their health effectively after their resettlement in Germany. Providing tailored information on the German healthcare system, creating a health-literacy supportive environment, and improving cultural sensitivity in healthcare provision could help Syrian women better utilize medical care offered in Germany.

'Wait and wait, that is the only thing they can say': a qualitative study exploring experiences of immigrated Syrian doctors applying for medical license in Germany.

BACKGROUND: Due to the civil war in Syria, many Syrian citizens have had to flee their country during recent years, among them many physicians. Germany is among the preferred immigration countries. Immigrant Syrian physicians could help overcome the prevailing shortage of medical specialists in Germany. This study explores the experiences and perceptions of Syrian physicians of the licensure process and job application. The study aims at understanding barriers in integrating Syrian doctors into the German health care system. METHODS: We conducted 20 semi standardized interviews with Syrian doctors (n = 17 m; n = 3 f) living in different federal states in Germany. The interviews dealt with the procedure of the accreditation process, its speed and challenges, the interactions with authorities, and the job application process; they were transcribed verbatim. A detailed content analysis was performed. RESULTS: All interviewees described the licensure process as a complex, lengthy, ever-changing and non-transparent procedure, which is perceived as a partly unfair, sometimes arbitrary bureaucracy. They often feel at mercy of Government employees and report experiences with reviewers who ask for absurd and impossible accomplishments, refuse to give information, and act at random. As a consequence, the interviewees describe themselves as depressed, irritated and/or in despair. According to the interviews, informational and practical support from official institutions was scarce. Instead, the Syrian doctors relied on peers or, in some cases, German friends to understand the requirements and seek information about the licensure process. To find a job placement, it was very helpful, if not essential, to have a German acquaintance establishing contact with possible employers. All three interviewed female doctors reported that their wearing a Hijab led to episodes of discrimination in their job search. CONCLUSIONS: The study points towards the necessity to establish an official information source which provides immigrant doctors with accurate and detailed information about the licensure process, e.g. required documents, estimated waiting times, regulation for courses and exams, criteria regarding credentials, sources of help, etc. Additionally, it seems advisable to consider providing help with regard to the job search and sensitize hospital management for cultural and religious diversity to avoid discrimination.

Capacity Building in Community Stakeholder Groups for Increasing Physical Activity: Results of a Qualitative Study in Two German Communities.

Community capacity building is an essential approach for health promotion, combining a participatory approach with the view to community ownership. Little research focuses on practical capacity building strategies and monitoring. Our paper looks into involving stakeholders in facilitated group discussions as a specific strategy for fostering capacity building processes. These processes focused on physical activity (PA) promotion in two German communities (ACTION4men). Along the dimensions of capacity building suggested in literature (e.g., problem solving, resource mobilization, leadership), we implemented two participatory stakeholder groups (1/community). These groups were motivated to develop and implement PA interventions for men >50 years. For measuring capacity building processes, a semi-standardized monitoring instrument was used to document all group meetings. Additionally, we conducted semi-standardized interviews with group participants and drop-outs to capture their perspectives on capacity building. All documents were analyzed using thematic analysis. We successfully established stakeholder groups that planned and implemented a range of local measures meant to increase PA among older men. In one community, the process was sustainable, whereby the group continued to meet regularly over years. Capacity building was successful to a certain degree (e.g., regarding participation, problem assessment, and resource mobilization), but stalled after first meetings. Capacity building processes differed between the two communities in terms of leadership and sustainability. The developed interventions mainly addressed the access to organized sport courses, rather than tackling walkability or active transport. The theoretical capacity building approach was successful to develop and implement programs aimed at promoting PA. The actual capacity building processes depend upon the composition of stakeholder groups and inherent power relations.

How Health Promoters Can Assess Capacity Building Processes in Setting-Based Approaches-Development and Testing of a Monitoring Instrument.

Background: Health promoters often use stakeholder groups to jointly plan and implement local interventions. Stakeholder groups should take over responsibility to later run the health promotion program independently. Monitoring this process of capacity building can help health promoters improve the quality of the process. Instruments for the systematic assessment of capacity building among stakeholder groups are scarce. The goal of this study was to develop, and pilot test a generic assessment instrument for setting-based capacity building. Methods: We drafted a semi-standardized monitoring instrument to be used in stakeholder groups in various settings. This "EVA-protocol" (short for evaluation protocol) was based on capacity building domains e.g., leadership, resource mobilization. It was pilot implemented in a research network on increasing an active lifestyle in various settings. The respective health promoters documented 78 meetings of 15 different stakeholder groups. We performed feedback interviews and member checking among the facilitating health promoters, asking for comprehensibility, length, usability and perceived benefits of the instrument. Findings: Data collected in the "EVA-protocol" helped the facilitating health promoters understand the development of competences and capacities in the stakeholder groups and identify factors that favor or hinder the capacity building process. The instrument was rated as user friendly, but it was remarked that it is best filled out by two persons and reflected upon by those to offer the greatest benefit. Not all projects could afford this procedure due to lack of time/staff resources. Conclusions: The drafted instrument can serve as quality management tool for health promoters who facilitate participatory stakeholder groups in different settings and intend to build capacities for sustainable health promotion structures.

German senior citizens' capabilities for physical activity: a qualitative study.

Sen's capability approach (CA) has found its way into health promotion over the last few years. The approach takes both individual factors as well as social and environmental conditions into account and therefore appears to have great potential to explore opportunities for ('capabilities') and barriers to active lifestyles. Thus, our objective in this study was to investigate which capabilities senior citizens perceive to have available to them in order to be physically active. In Southern Germany, we conducted 26 semi-standardized interviews with senior citizens aged 66-97, as well as 9 interviews with key persons who have close contact to senior citizens in their work life. We identified 11 capabilities which the interviewees considered as important in leading an active lifestyle. They could be grouped into four domains: (1) individual resources, (2) social interactions and norms, (3) living conditions and (4) organizational environment. Results highlight the need for health-promoting interventions that widen the range of capabilities on social and environmental levels in a way that individuals can freely choose to be as physically active as they like. The results make clear that interventions should not only target and involve older adults themselves, but also their families, nursing home staff or community representatives, because these groups are important in shaping older adults' capabilities for an active lifestyle.