Personal, Social, and Environmental Mediators Associated With Increased Recreational Physical Activity in Women and Girls in the Kingdom of Tonga

in Journal of Physical Activity and Health

Background: The purpose of this paper was to identify personal, social, and environmental mediators of recreational physical activity (PA) in a 6-month netball-based intervention for women and girls in Tonga. Methods: Tonga Netball’s “low-engagement village program” was implemented in 10 villages and aimed to increase the recreational PA levels in women and girls through a comprehensive, structured community-level netball program addressing key barriers to participation. In a mixed-methods approach, these mediating barriers were identified through qualitative interviews based on the socioecological model. Quantitative measures for mediators and recreational PA were then developed, and data from 301 women and girls were collected. Standard mediation analyses methods were then applied. Results: Program participation appeared to significantly increase PA levels. Statistically significant personal mediators were body issues, preferring competitions, and clothing. Social mediators were support from sports council, community leaders, friends, and church. Environmental mediators were travel time and access to balls, bibs, and umpires. Conclusion: A comprehensive community-level program addressing key participation barriers can increase recreational PA among women and girls in Tonga. Triangulating these results with mediation analyses of variables on the causal pathway can strengthen our understanding of causation and inform funding prioritization for critical program components in similar contexts.

The World Health Organization (WHO) estimates that 41 million people die annually from noncommunicable diseases (NCDs), the equivalent to 71% of global mortality.1 Cardiovascular diseases account for the majority of the NCD burden, causing 17.9 million deaths annually, followed by cancers (9.0 million), respiratory diseases (3.9 million), and diabetes (1.6 million).1 Tobacco use, the harmful use of alcohol, unhealthy diets, and physical inactivity are the 4 primary risk factors for NCDs.1 Physical inactivity is the fourth leading risk factor for global mortality, contributing to over 5 million deaths per year.2 In addition to being an independent risk factor for NCDs, physical inactivity also contributes to other risk factors, including hypertension, hyperlipidemia, overweight/obesity, and poor mental health.3 Over 85% of “premature” deaths from NCDs occur in low- and middle-income countries.1,4,5

One of those countries is the Kingdom of Tonga, a Pacific Island nation with a population of just over 108,000.6 In Tonga, the prevalence of obesity and overweight are 67.6% and 90.7% respectively, and 98.7% of the population are at high or moderate risk of NCDs.7 The data from the 2014 WHO STEPS Surveillance report for Tonga indicate that women only participate in an average of 8.2 minutes per day of recreational physical activity (PA), which was a quarter as much as Tongan men.7 Further, the data indicate that the PA of Tongan women is predominantly completed in the vocation (71.5 min/d) and transport (32.1 min/d) domains.7 The Kingdom of Tonga has increased its investment in prevention policy to curb their NCD epidemic. This includes the establishment of the Tonga Health Promotion Foundation, the first independent health promotion body in the Pacific islands, and the implementation of the Tonga National Non-Communicable Disease Strategy 2015–2020.8 Tonga’s diplomatic partners have assisted in this investment, with a large proportion coming from Australia and New Zealand. For example, the Australian government has invested AUD $10 million since 2015 through the Tonga Health Systems Support Program, aimed at improving community health services and delivering preventative health measures targeting NCD rick factors.9 Australia also provides funding through the “Pacific Sports Partnerships” (PSP) program.10,11 PSP is the Australian government’s sport for development program, which, since 2009, has contributed over AUD $39 million to 15 sports across 9 Pacific Island countries to design programming targeting health, social, and diplomacy outcomes. One of those Pacific Islands is Tonga, where the PSP program provides funding to 5 national sporting federations to design and implement sport-based PA programming, which aims to address the primary risk factors associated with NCDs, particularly physical inactivity.11,12

For interventions to be effective in achieving a sustained increase in PA, the design stage is a critical component, as previous evaluation results have been inconclusive.1315 A previous suite of reviews has found that different face-to-face and remote PA interventions had a variable effect on PA behavior.1618 Further, a review of mediators of PA behavior change19 included 22 eligible studies, half of which failed to find an intervention effect. A more recent systematic review of mediators for PA behavior change concluded that “many of the included interventions were not effective for changing targeted mediators.”20 More specifically, it has been argued that, although there is a clear link between PA and positive health outcomes,21 the low efficacy and effectiveness of some programs may be due to a lack of knowledge regarding the actual mechanisms that lead to these outcomes.22 This is of particular pertinence in low- and middle-income countries such as Tonga, with a population of relatively physically inactive women,7 and where the efficient allocation of limited health resources is paramount.

In 2013, member states of the WHO agreed to a 10% relative reduction in the prevalence of insufficient PA by 2025. This agreement was one of the 9 global targets in the WHO Global Action Plan for the prevention and control of NCDs 2013–2020.23 A progress article published in 2018 found that the average change across all 65 countries (including Tonga) was less than 0.01%, meaning, “if current trends continue, the 2025 global PA target will not be met.”24 The report concluded that “policies to increase population levels of PA need to be prioritized and scaled up urgently.” Therefore, current strategies and policies are inefficient at increasing PA, and mediation studies are crucial for improving these strategies by generating evidence of the underlying mechanisms for behavior change in different contexts and populations.

Therefore, the purpose of this study was to apply a mixed-methods approach to identifying personal, social, and environmental mediators for increasing PA through a 6-month sport-based PA intervention for women and girls in Tonga.

Methods

The study design has been adapted from a previously published protocol.25

Intervention Design

In 2016, the Tonga Netball Association, supported by Netball Australia, was funded through the Australian Government’s PSP Innovation Fund to trial a comprehensive approach to engaging women and girls in recreational PA through netball. Netball is a ball sport played by 2 opposing teams of 7 players each. Each team attempts to score goals by passing a ball down a court (usually a 30-by-15-m rectangular space) and throwing it through raised goal rings at either end. Netball is predominantly played by women, who typically wear a skirt and top with lettering on the back that denotes their position on the court.26 The “low-engagement village program” aimed to increase the PA levels of women and girls in villages with limited access or opportunity for recreational PA through a comprehensive community netball program addressing key barriers/facilitators to participation. These mediators for participation were identified through preintervention interviews with key stakeholders (program coordinators, funders, community leaders, and participants) during the formative evaluation stage.27 The initial interviews were conducted with previous contacts of Netball Australia, and snowball sampling was then used across the different stakeholder types until saturation was reached. The data collection in this phase used the socioecological model for PA to guide the design of semistructured interview questions.28 Specifically, the interview guide examined intrapersonal, interpersonal, and social norms, and physical environment factors associated with women and girls participating in recreational PA. The interviews were conducted by the authors of this paper and included 17 women and 3 men. The data were compiled in-country, and an explorative thematic analysis was completed by the authors of this paper in consultation with key personnel from both the local delivery agency and the funding body.

The program was implemented in 10 villages identified in consultation with the Ministry of Internal Affairs, Tonga Health, and the Tonga Netball Association as accessible population groups with minimal previous exposure to netball and low participation in organized PA. The program included the following components:

  1. Buy-in: Engaged the Tongan government, town officers, sports councils, and church leaders in the design stage to ensure “buy-in” at the community level.
  2. Capacity building (management): Identified and trained a local netball focal point in each target village to facilitate programming.
  3. Capacity building (skill development): Delivered coaching and umpiring workshops to a junior local focal point in each village.
  4. Funding: Provided funding to local focal points for petrol and administrative expenses associated with programming.
  5. Infrastructure: Negotiated the use of a common community space with town officers in each village, marked out a netball court, and erected goal posts.
  6. Equipment: Distributed netball equipment (bibs, balls and bags, and whistle) through local focal points.
  7. Infrastructure: Negotiated the use of an uncovered common community outdoor space with town officers in each village, marked out a netball court, and erected locally constructed basic goal posts.
  8. Communication: Held weekly phone calls with each focal point and undertook regular “spot checks” to monitor progress.
  9. Competition: Designed a structure to integrate target villages into national netball competitions. Specifically, target villages started in a separate grade, participating among themselves, with a promotion/relegation system potentially allowing villages to progress up into top-tier competitions.

Study Design

The study was quasi-experimental, with pre–post measures of the outcomes of interest and identified mediators taken at the baseline in April and 6 months after the program started, which corresponds with the local dry season. Due to logistical, ethical, and funding limitations, the inclusion of a control group (eg, control village) was not possible. Therefore, the researchers used the qualitative data collected during the intervention design phase to develop a logic model and relevant quantitative measures as part of a process evaluation that enabled mediation analysis and to further substantiate claims of causation from the intervention on the primary outcome of total recreational PA.

Participant Selection

Intervention participation was open to all women and girls in the participating communities. The data were collected from women within the participating villages. Streets in each village and then households on each street were selected randomly to select the study participants. If there were no women at home in the selected households, the data collectors returned at a later time on up to 3 occasions before another household on that street was randomly selected. The selection of study participants was completely independent of the netball program delivery. This was designed to capture the broad impact of the netball program on the village, rather than just focus on women known to be participating.

The women in this study were aged 18–64 years (mean = 32.25, SD = 9.92). All were from the most populous island, Tongatapu; 96% had completed high school as their highest education level; 80.1% were homemakers; 10% were unemployed; and 4% were students.

Measures

The researchers developed quantitative indicators for each of the identified mediating factors. The data collection instrument was translated into Tongan by a local translation team and translated back into English for quality control. The questions were then pretested for face validity with 15 Tongan participants from various demographics and further refined accordingly. The English version of the final measures are shown in Table 1.

Table 1

Independent Variable, Dependent Variable, and Mediator Measures and Their Associated Data Collection Instrument

MeasureQuestion
Physical activity (dependent variable)Recreational component of the global physical activity questionnaire
Netball participation (independent variable)Total numbers of times per week the participant played netball (including competition, practice, and social play)
Body issuesI am worried about playing netball because of my body … (strongly disagree, disagree, neutral, agree, strongly agree)
Low skill levelI am worried about playing netball because of my skills … (strongly disagree, disagree, neutral, agree, strongly agree)
Preferring competitions over social sportI prefer netball programs to be focused on preparing for competitive tournaments … (strongly disagree, disagree, neutral, agree, strongly agree)
Don’t have exercise clothingI am worried about playing netball because I don’t have the right clothes … (strongly disagree, disagree, neutral, agree, strongly agree)
Support (sports council, town officers, community leaders, church, friends, family, men [family]).How supportive are the following people of you playing netball? … (very unsupportive, unsupportive, neutral, supportive, very supportive)
Support from Tonga NetballThe Tonga Netball Association is supportive of our village … (strongly disagree, disagree, neutral, agree, strongly agree)
Confidence in village to self-organizeHow confident are you that members of your community can independently organize netball activities? (not confident to confident on a 100-point single-item scale)
Presence of other adults participatingThere are lots of adults in my community who play netball regularly … (strongly disagree, disagree, neutral, agree, strongly agree)
Travel timeThink about the netball activity you do the most. How long does it take you to get there? … (less than 5 min, 5–9 min, 10–14 min, 15–19 min, 20–24 min, 25–29 min, 30 min or more, N/A)
Access to balls and bibsWe have easy access to balls and bibs in my village when we want to play netball … (strongly disagree, disagree, neutral, agree, strongly agree)
Village netball organizerThere is someone in my community who is good at organizing netball … (strongly disagree, disagree, neutral, agree, strongly agree)
Access to umpiresWe have good netball umpires when we play … (strongly disagree, disagree, neutral, agree, strongly agree)
Access to courtWhere do you usually play netball in your village? … (permanent space set aside, open area where we can put goal posts, don’t have anywhere)
Knowledge of rulesHow well do you know the rules of netball? … (I don’t know any of the rules, I know some of the rules, I know most of the rules, I know all the rules)

Data Collection

Three local data collectors were trained by researchers prior to baseline measures, with repeat training conducted again prior to data collection at 6 months. The data were collected using iPads with iSurvey software installed. The data were collected from approximately 30 women in each of the 10 villages, and in total, the data were collected from 301 women at the baseline and 274 at 6 months.

Data Analysis

The global PA questionnaire data were scored according to the published analysis guide. All responses to the items with Likert scales were treated as ordinal data on a linear scale, and responses on the visual analog scales were treated as continuous variables.29 The data were analyzed with SPSS (version 24.0; IBM Corp, Armonk, NY). Descriptive statistics were used to calculate mean scores for each variable at the baseline and 6 months in Table 2. A paired samples t test was used to calculate change scores and confidence intervals (CIs) in Table 2. To assess for mediation, we used the method devised by Baron and Kenny,30 depicted in Figure 1.

Table 2

Mean Values for Pretest, Posttest, and Change Scores for Physical Activity, Netball Participation, and Mediators

VariableRangeBaselineFollow-up (6 mo)Change
Scores (SD)Confidence intervals
Physical activity 18.16 (63.037)421.31 (223.650)403.339 (242.628)374.483 to 432.196
Netball participation 0.02 (0.294)4.10 (1.291)4.080 (1.296)3.926 to 4.234
Individual mediators
 Knowledge of netball rules1–41.29 (0.534)1.98 (0.217)0.701 (0.572)0.633 to 0.769
 Body issues1–51.44 (0.572)1.43 (0.566)0.007 (0.816)0.090 to 0.104
 Low skill level1–51.67 (0.935)1.53 (0.790)0.157 (1.183)0.016 to 0.298
 Prefer competitions over social sport1–51.78 (0.996)2.20 (1.435)0.416 (1.796)0.202 to 0.630
 Inappropriate clothing1–51.51 (0.641)1.47 (0.664)0.040 (0.919)0.069 to 0.149
Interpersonal (social) mediators
 Sports council (support)1–52.99 (0.829)4.37 (0.623)1.416 (1.202)1.273 to 1.559
 Town officers (support)1–53.63 (0.860)4.65 (0.574)1.036 (1.023)0.915 to 1.158
 Community leaders (support)1–52.73 (0.937)4.26 (0.590)1.555 (1.195)1.413 to 1.697
 Church (support)1–52.47 (1.223)4.22 (0.537)1.763 (1.382)1.598 to 1.927
 Friends (support)1–52.64 (1.401)4.39 (0.552)1.774 (1.404)1.607 to 1.941
 Family—living with (support)1–52.55 (1.372)4.43 (0.643)1.891 (1.493)1.713 to 2.068
 Men in your family (support)1–52.30 (1.199)4.39 (0.671)2.077 (1.387)1.912 to 2.242
 Tonga netball (support)1–52.50 (1.240)4.20 (0.482)1.675 (1.391)1.510 to 1.841
 Confidence in village to self-organize1–10028.25 (22.942)75.80 (9.853)46.354 (24.352)43.458 to 49.250
 Presence of other adults participating1–52.68 (1.376)4.04 (0.447)1.361 (1.556)1.176 to 1.546
Physical environmental mediators
 Travel time1–84.70 (3.494)2.08 (1.040)2.398 (3.799)1.946 to 2.850
 Access to balls and bibs1–51.81 (0.872)3.97 (0.448)2.186 (1.015)2.065 to 2.307
 Village netball organizer1–52.48 (1.282)3.48 (0.965)0.996 (1.525)0.815 to 1.178
 Access to umpires1–51.93 (0.970)3.33 (1.014)1.427 (1.636)1.232 to 1.622
 Access to court/open field/none1–32.58 (0.534)1.56 (0.497)0.996 (0.457)0.942 to 1.051
Figure 1
Figure 1

—Method of mediation analysis devised by Baron and Kenny.30

Citation: Journal of Physical Activity and Health 17, 11; 10.1123/jpah.2019-0630

This method follows 4 steps:

  1. 1.The first step was to establish an association between the independent variable (eg, netball participation) and the dependent variable (eg, PA) (path A to B in Figure 1). A regression model was used to test and estimate the effect of netball participation on PA. The association was controlled for age and socioeconomic status (SES). It was not necessary to control for gender, as all participants were women.
  2. 2.The second step was to establish a relationship between netball participation and potential mediators (path A to C). A linear regression model was used for each mediator (controlling for age and SES).
  3. 3.The third step of mediation is separated into 2 parts:
    1. The first part is to establish whether potential mediators were associated with PA, controlling for baseline (path C to B), age and SES.
    2. The second is to examine the association between netball participation and PA, while controlling for mediators, age, and SES (path A to B controlling for C). This determines if the relationship between the netball participation and PA was substantially reduced when controlling for potential mediators.
  4. 4.The fourth step uses the Sobel test, which determines whether the reduction in the relationship between netball participation and PA was statistically significant. The Sobel test uses a formula (z value=abb2sa2+a2sb2) in which a = the path from netball participation to the mediator, sa = the standard error of a, b = the path from the mediator to PA, and sb = standard error of b.31

Ethical Approval

This study was approved by the La Trobe University Human Research Ethics Committee (13-073). Approval to evaluate the “low-engagement village program” was also granted by Netball Australia, Tonga Netball Association, as well as by village elders and community leaders of villages/towns included in this evaluation.

Results

The first step of mediation is to establish an association between the independent variable (netball participation) and dependent variable (PA). When the netball participation change scores were compared with the PA change scores, a significant effect was identified, F3,273 = 70.807, β = 0.651, P ≤ .001.

The second step of mediation was to examine the association between treatment condition (netball participation) and changes in hypothesized mediators. As shown in Table 3, mediators that failed the second step (ie, not statistically significant) were low skill level, support from Tonga Netball Association, having confidence in the village to self-organize, and the presence of other adults participating in netball.

Table 3

Effect of Netball Participation on Mediator Variables

VariableBetaP valueUnstandardized BConfidence interval
Individual mediators
 Knowledge of netball rules0.160.0080.0710.019 to 0.123
 Body issues0.279<.0010.1760.103 to 0.248
 Low skill level0.029.6390.026−0.083 to 0.135
 Prefer competitions over social sport0.432<.0010.5990.449 to 0.749
 Inappropriate clothing0.319<.0010.2260.145 to 0.306
Interpersonal (social) environmental mediators
 Sports council (support)0.450<.0010.4180.321 to 0.514
 Town officers (support)0.345<.0010.2720.184 to 0.360
 Community leaders (support)0.392<.0010.3610.261 to 0.462
 Church (support)0.308<.0010.3280.208 to 0.448
 Friends (support)0.299<.0010.3240.201 to 0.447
 Family—living with (support)0.342<.0010.3940.265 to 0.524
 Men in your family (support)0.274<.0010.2940.171 to 0.416
 Tonga netball (support)−0.117.052−0.126−0.253 to 0.001
 Confidence in village to self-organize−0.016.789−0.306−2.556 to 1.944
 Presence of other adults participating0.062.3030.075−0.068 to 0.218
Physical environmental mediators
 Travel time0.288<.0010.8440.508 to 1.181
 Access to balls and bibs0.327<.0010.2560.169 to 0.344
 Village netball organizer0.271<.0010.3190.183 to 0.455
 Access to umpires0.401<.0010.5060.369 to 0.643
 Access to court/open field/none−0.157.010−0.055−0.097 to −0.014
 Knowledge of netball rules0.160.0080.0710.019 to 0.123

Note: Bold mediators failed the second step of mediation and were removed from further analysis.

The third step of mediation is shown in Table 4 and is separated into 2 parts:

  1. 1.The first is to establish whether the mediators were associated with PA, controlling for baseline (first 4 columns).
  2. 2.The second is to examine the association between exposure and outcome variables, when controlling for mediators (last 2 columns).
Table 4

Effect of Mediator Variables on PA Controlling for Baseline, and the Association Between Exposure and Outcome Variables When Controlling for Mediators

VariableBetaP valueUnstandardized BConfidence intervalBeta exposure and outcome controlled for mediatorP value
Individual mediators
 Knowledge of netball rules0.027.5617.953−18.923 to 34.8280.647<.001
 Body issues0.300<.00161.72943.939 to 79.5190.568<.001
 Prefer competitions over social sport0.392<.00136.70628.472 to 44.9390.482<.001
 Inappropriate clothing0.170<.00131.04414.036 to 48.0520.597<.001
Interpersonal (social) mediators
 Sports council (support)0.311<.00143.50829.946 to 57.0700.511<.001
 Town officers (support)0.085.08314.031−1.831 to 29.8930.622<.001
 Community leaders (support)0.244<.00134.28620.945 to 47.6260.556<.001
 Church (support)0.149.00218.1056.621 to 29.5890.605<.001
 Friends (support)0.121.01214.4743.207 to 25.7420.615<.001
 Family—living with (support)0.083.0889.367−1.389 to 20.1240.623<.001
 Men in your family (support)0.045.3455.498−5.933 to 16.9290.639<.001
Physical environmental mediators
 Travel time0.249<.00111.0247.074 to 14.9750.580<.001
 Access to balls and bibs0.130.00821.4525.679 to 37.2260.609<.001
 Village netball organizer0.061.1966.749−3.511 to 17.0090.635<.001
 Access to umpires0.218<.00122.34512.479 to 32.2110.564<.001
Access to court/open field/none−0.029.534−10.597−44.089 to 22.8950.647<.001

Note: Bold mediators failed the third step of mediation and were removed from further analysis.

The fourth step was to determine whether the reduction was statistically significant. The Sobel test was used, and the results are presented in Table 5.31

Table 5

Sobel Test for Mediation

VariableaSabSbz valueP value
Individual mediators
 Body issues0.1760.03761.7299.0363.904<.001
 Prefer competitions over social sport0.5990.07636.7064.1825.864<.001
 Inappropriate clothing0.2260.04131.0448.6393.010.003
Interpersonal (social) mediators
 Sports council (support)0.4180.04943.5086.8885.076<.001
 Community leaders (support)0.3610.05134.2866.7764.116<.001
 Church (support)0.3280.06118.1055.8332.688.007
 Friends (support)0.3240.06214.4745.7232.277.023
Physical environmental mediators
 Travel time0.8440.17111.0242.0073.671<.001
 Access to balls and bibs0.2560.04521.4528.0122.423.015
 Access to umpires0.5060.07022.3455.0113.795<.001

Note: No variables failed the fourth test of mediation.

Discussion

The purpose of this study was to examine the impact of a netball intervention for women and girls in Tonga on recreational PA participation and to identify personal, social, and environmental mediators associated with any observed changes over a 6-month period.

Our results clearly suggest that the intervention had a large impact on the netball participation levels in the participating villages and that this correlated with large changes in recreational PA levels. Of particular note is that, prior to the intervention, many of the women in the villages were not participating in any recreational PA and, after 6 months, the mean volume of recreational PA was more than double the global recommendations for total PA.21 Despite the cross-sectional nature of these findings, statements of causation can be triangulated by the significant results in the mediation analyses of qualitatively identified determinants for netball and recreational PA participation. The implications of the mediation results are considered in more detail below.

Personal Mediators

The quantitative analyses indicated that addressing body image issues is a critical component of the program. Body image concerns have been widely recognized as both a barrier to and a reason for PA participation.32 This question identified concerns from the women about the ability of their bodies to cope with the rigors of playing netball, as well as potential public embarrassment about their bodies. This aligns with a substantial evidence base that identifies low levels of physical self-efficacy as a major barrier to participation in recreational PA, particularly for women.3335 Self-consciousness about body image also links with the finding that having inappropriate clothing was a significant mediator for participation. Clothing that enables women to move comfortably and also covers their body in a way that is culturally sensitive to local norms has been previously identified as a critical factor in encouraging PA.3638 This is often addressed through the provision of team uniforms in sport for development programs that have a competitive element, which appeared to be another important mediator in our analyses. This finding is in contrast to the majority of the existing evidence, which indicates that women are often less motivated by competitive PA endeavors and may actually be deterred by competitive sport as a form of PA.37,39,40 However, in a context where women’s sport and PA have previously received little support and the local population have limited previous reference points for noncompetitive recreational PA, we have interpreted this finding as an indicator that women want their desire to participate in netball to be taken seriously. The vast majority of sport for development interventions in similar settings also have a competitive component because a noncompetitive approach to sport is initially conceptually foreign to the local communities.41 Adding to this, the Pacific Islands are known to be highly passionate about sport and their respective countries being represented through sport on the global stage. It is therefore not unrealistic to draw from this that this cultural aspect would likely filter down into grassroots sport in these settings. This finding can be leveraged in future programming by gradually increasing the competitive aspects of an intervention (eg, training, intervillage competitions) and eventually integrating grassroots programs into community and national pathways for each sport.

The finding that low skill level was not a significant mediator is consistent with previous studies that suggest this is more important for men than women.42 Specifically, the physical self-efficacy for women tends to be more related to their body image as described above, while boys focus more on skill level and sporting success. Similarly, knowledge of the rules was not a significant mediator in our study. Although developing sports knowledge and skills will always be a key component of “sport-plus” sport for development interventions, based on our results, it would appear that a large focus on skill development may not be as critical as the other abovementioned factors when aiming to increase participation in recreational PA.

Interpersonal (Social) Environmental Mediators

Our findings that support from sports councils, community leaders, church leaders, and friends were mediators of recreational PA in women and girls in Tonga are strengthened through insights from Tongan society. First, the findings can be partially explained by Geert Hofstede’s cultural dimensions theory, in which the concept of collectivist versus individual cultures is explained.43,44 Specifically, collectivism is a social value characterized by an emphasis on cohesiveness among individuals and the prioritization of the group (or country) over the individual. While no collectivism score is available for Tonga, that of neighboring Pacific Island country Fiji is 14, described as “incredibly low,” meaning Fiji is considered a strongly collectivistic society.45 Therefore, with geographical and cultural parallels, Tonga can likely be characterized as a collectivist culture and has been described as such outside of academic literature. In these settings with tightly connected social structures, gaining support from hierarchical social, governance, and religious leaders and organizations is key to securing the buy-in of participants in programming. Second, Tonga maintains a strong community focus (eg, sharing and giving of resources is commonplace), protection of culture (eg, Tongans have a word for “their way”—anga fakatonga), and prioritization of family (eg, property cannot be sold in Tonga, but is passed down family lines). Further to this, 98% of Tongans identify as Christian, with Sunday being a day of church and rest, enforced by law. Therefore, the decision to participate in recreational PA is likely to be strongly influenced by church, community, and social interaction, as these are not seen as separate domains. This indicates that community and church leaders are crucial stakeholders in the design stage of future PA interventions in Tonga.

As a side note, our findings that support from men did not mediate PA is also notable, but unsurprising. Gender is the primary determinant of an individual’s position in the social and familial hierarchy in Tonga. Women are highly respected, as demonstrated through familial interactions. Furthermore, the lack of significance for several of the other interpersonal mediators (eg, town officers, immediate family, other adult community members), which were identified during the formative qualitative interviews, is indicative of the heterogeneity of the broader evidence in this area. Specifically, there is evidence that personal self-regulation mediators have the strongest link to participation,19 with a more variable and often negligible contribution from interpersonal mediators.34

Physical Environmental Mediators

A systematic review of the mediators of PA33 found significant mediation for PA by perceived environmental barriers. We found that access to balls and bibs was a critical mediating factor for participation. While this may seem like an obvious finding, when taken in the context of the large change in netball participation that did occur during the program, this result provides an important reminder of the scarcity of basic sports equipment in low-income settings and the potential impact of providing them in local communities. Similarly, the significance of travel time as a mediator is consistent across the literature,38,46 but may be particularly pertinent in socioeconomic settings where there are limited public transport options and private transport is often limited to walking. This finding highlights the value of sport for development programs investing in the provision of transport to/from activities for the participants and support personnel. This includes umpires, whose provision was also identified as a significant mediator for participation. We interpret this finding as a need for guidance when learning the rules of a new sport, which is also linked to the embedded desire for organized competition, as discussed previously. It is possible that, as netball becomes more widely understood and accepted in the participating villages, organic recreational play that is noncompetitive and does not require an umpire may become more common.41

The nonsignificant findings that indicated that a village netball organizer and access to a dedicated netball space may not be important mediating factors for participation were unexpected and warrant further investigation. It is possible that the relatively small geographical spread of the participating villages that enabled regular access by dedicated staff from Tonga Netball diminished the relative importance of having local netball organizers, who were often from neighboring villages or worked elsewhere. The rural setting of the participating villages also meant that there was an abundance of nonspecific green space cleared and available for recreational PA, which may have undermined the need for a dedicated netball court. In any case, we interpret these finding with caution and advise against any major changes to these components of the delivery model, given the emerging evidence for the role of local champions and dedicated recreational space in the sport for development sector.47

Strengths and Limitations

While our results produced key findings for recreational PA policy and practice in an underresearched (eg, low- and middle-income countries) but overburdened (eg, low PA and high NCDs) setting, key strengths and limitations should be considered. First, the tight partnership between practitioners and evaluators was a strength in ensuring both evidence-based program design and appropriate rigor in study design. Specifically, the embedding of a formative evaluation into program design was crucial to identify and address key program barriers prior to implementation. The subsequent study design allowed for these barriers to be examined more rigorously, analyzed for mediation, and used to produce results crucial for future program development in this setting. We used the standardized global PA questionnaire to measure PA. However, despite other measures not being globally standardized, we undertook significant effort to address this. This included measures being translated into Tongan, as well as being translated back into English, to ensure cultural adaptation and clarity of content. Further, measures were pretested with 15 Tongan participants and refined accordingly.

The lack of a control group is a weakness in this study. This was primarily due to ethical considerations of using funding in this way, in a setting with already minimal financial resources. Despite this, our mixed-methods approach of conducting qualitative interviews to inform the development of a logic model and subsequent mediation metrics enabled the triangulation of our pre–post measures for the primary outcome of recreational PA participation. Further, pragmatic program design (with formative evaluation), study design, and data collection, such as that presented in this paper, provides real-world evidence of program effect and key mediating factors for interventions in settings that have a critical need for evidence to improve policy and practice.

Conclusion

We identified the key mediators of recreational PA among women and girls in Tonga, producing key insights for practice and policy. Specifically, programs need to be comprehensive, with a built-in formative evaluation proactively addressing barriers across multiple levels of the socioecological model prior to implementation. This “cocreation” design between local program-implementing organizations, foreign design organizations, and evaluation experts is crucial in settings with limited resources for refining programs in the future. Current evidence shows that PA interventions are often ineffective, efforts to address global physical inactivity have been stagnant, and 85% of global noncommunicable disease burden occurs in low- and middle-income countries like Tonga. Therefore, mediation studies revealing the underlying mechanisms for success or failure, such as these, are crucial for designing and scaling up effective programming and policies.

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If the inline PDF is not rendering correctly, you can download the PDF file here.

Keane, Negin, Ding, Bauman, Jegasothy, and Richards are with the Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia. Richards is also with the Faculty of Health, Victoria University of Wellington, Wellington, New Zealand. Sherry is with the Swinburne University of Technology, Hawthorn, VIC, Australia. Schulenkorf is with the Business School, Sport Management, University of Technology Sydney, Sydney, NSW, Australia.

Keane (lewis.keane@sydney.edu.au) is corresponding author.
  • 1.

    Forouzanfar MH, Afshin A, Alexander LT, et al. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388(10053):16591724. doi:10.1016/S0140-6736(16)31679-8

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  • 2.

    Reis RS. Scaling up physical activity interventions worldwide: stepping up to larger and smarter approaches to get people moving. Lancet. 2016;388(10051):13371348. PubMed ID: 27475273 doi:10.1016/S0140-6736(16)30728-0

    • Crossref
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    World Health Organization. Global Health Risks: Mortality and Burden of Disease Attributable to Selected Risks. Geneva, Switzerland: World Health Organization; 2009.

    • Search Google Scholar
    • Export Citation
  • 4.

    Hwang CK, Han PV, Zabetian A, Ali MK, Narayan KM. Rural diabetes prevalence quintuples over twenty-five years in low- and middle-income countries: a systematic review and meta-analysis. Diabetes Res Clin Pract. 2012;96(3):271285. PubMed ID: 22261096 doi:10.1016/j.diabres.2011.12.001

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    • PubMed
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    Ford ND, Patel SA, Narayan KMV. Obesity in low- and middle-income countries: burden, drivers, and emerging challenges. Annu Rev Public Health. 2017;38(1):145164. doi:10.1146/annurev-publhealth-031816-044604

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    • Export Citation
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    World Health Organization. WHO STEPS—Tonga Country Report. Manila, Philippines: World Health Organization; 2014.

  • 8.

    TongaHealth. National Strategy to Prevent and Control Non-Communicable Diseases 2015–2020. Nuku’alofa, Tonga: Tonga Health Promotion Foundation; 2016.

    • Search Google Scholar
    • Export Citation
  • 9.

    Waddington C, Dodd R. Independent Progress Report of the Tonga Health Systems Support Program (THSSP). Canberra, Australia: AusAid—Health Resource Facility; 2013.

    • Search Google Scholar
    • Export Citation
  • 10.

    Department of Foreign Affairs and Trade. Sport for Development in the Pacific—Pacific Sports Partnerships (PSP) Program. Canberra, Australia: Australian Government; 2019.

    • Search Google Scholar
    • Export Citation
  • 11.

    Keane L, Negin J, Latu N, Reece L, Bauman A, Richards J. ‘Governance’, ‘communication’, ‘capacity’, ‘champions’ and ‘alignment’: factors underpinning the efficacy of integrating Sport-for-Development within national development priorities in Tonga. Sport Soc. doi:10.1080/17430437.2019.1678590

    • Search Google Scholar
    • Export Citation
  • 12.

    Holden D, Vella L. Independent Evaluation: Pacific Sport Partnerships (PSP) and Asia Sport Partnerships (ASP). Canberra, Australia: Independent Evaluation; 2018.

    • Search Google Scholar
    • Export Citation
  • 13.

    Zhang Z, Sousa-Sa E, Pereira JR, Okely AD, Feng X, Santos R. The associations between environmental characteristics of early childhood education and care centers and 1-year change in toddlers’ physical activity and sedentary behavior. J Phys Act Health. 2019;16(11):10001006. PubMed ID: 31476735 doi:10.1123/jpah.2019-0066

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  • 14.

    Scheerman K, Raaijmakers K, Otten RHJ, Meskers CGM, Maier AB. Effect of physical interventions on physical performance and physical activity in older patients during hospitalization: a systematic review. BMC Geriatr. 2018;18(1):288. PubMed ID: 30470205 doi:10.1186/s12877-018-0965-2

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    Resaland GK, Aadland E, Moe VF, Kolotkin RL, Anderssen SA, Andersen JR. Effects of a physical activity intervention on schoolchildren’s health-related quality of life: the active smarter kids (ASK) cluster-randomized controlled trial. Prev Med Rep. 2018;13:14. PubMed ID: 30456052

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16.

    Foster C, Richards J, Thorogood M, Hillsdon M. Remote and web 2.0 interventions for promoting physical activity. Cochrane Database Syst Rev. 2013;(9):CD010395. doi:10.1002/14651858.CD010395.pub2

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17.

    Richards J, Thorogood M, Hillsdon M, Foster C. Face-to-face versus remote and web 2.0 interventions for promoting physical activity. Cochrane Database Syst Rev. 2013;(9):CD010393. doi:10.1002/14651858.CD010393.pub2

    • PubMed
    • Search Google Scholar
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  • 18.

    Richards J, Hillsdon M, Thorogood M, Foster C. Face-to-face interventions for promoting physical activity. Cochrane Database Syst Rev. 2013;(9):CD010392. doi:10.1002/14651858.cd010392

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19.

    Rhodes RE, Pfaeffli LA. Mediators of physical activity behaviour change among adult non-clinical populations: a review update. Int Journal Behav Nutr Phys Act. 2010;7(1):37. doi:10.1186/1479-5868-7-37

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 20.

    Murray JM, Brennan SF, French DP, Patterson CC, Kee F, Hunter RF. Mediators of behavior change maintenance in physical activity interventions for young and middle-aged adults: a systematic review. Ann Behav Med. 2018;52(6):513529. PubMed ID: 29672666 doi:10.1093/abm/kay012

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 21.

    World Health Organization. Global Recommendations on Physical Activity for Health. Geneva, Switzerland: World Health Organization; 2010.

    • Search Google Scholar
    • Export Citation
  • 22.

    Baranowski T, Jago R. Understanding the mechanisms of change in children’s physical activity programs. Exerc Sport Sci Rev. 2005;33(4):163168. PubMed ID: 16239832 doi:10.1097/00003677-200510000-00003

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23.

    World Health Organization. Global Action Plan for the Prevention and Control of Non-Communicable Diseases 2013–2020. Geneva, Switzerland: World Health Organization; 2013.

    • Search Google Scholar
    • Export Citation
  • 24.

    Guthold R, Stevens GA, Riley LM, Bull FC. Worldwide trends in insufficient physical activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with 9 million participants. Lancet Glob Health. 2018;6(10):e1077e1086. PubMed ID: 30193830 doi:10.1016/S2214-109X(18)30357-7

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25.

    Richards J, Sherry E, Philpott O, Keane L, Schulenkorf N, Bauman A. Evaluation protocol: netball to promote physical and mental health in Samoa and Tonga. J Sport Dev. 2016;4(7):111.

    • Search Google Scholar
    • Export Citation
  • 26.

    International Netball Federation. Rules of Netball. Manchester, UK: International Netball Federation; 2020.

  • 27.

    Bauman A, Nutbeam D. Evaluation in a Nutshell—A Practical Guide to the Evaluation of Health Promotion Programs. Australia: McGraw Hill Education; 2014.

    • Search Google Scholar
    • Export Citation
  • 28.

    Salmon J, King AC. Population approaches to increasing physical activity and reducing sedentary behavior among children and adults. In: Crawford D, Jeffery RW, Ball K, Brug J, eds. Obesity Epidemiology: From Aeitiology to Public Health (pp. 186207). 2nd ed. New York, NY: Oxford University Press; 2010.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 29.

    World Health Organization. Global Physical Activity Questionnaire (GPAQ) Analysis Guide. Geneva, Switzerland: World Health Organization.

    • Search Google Scholar
    • Export Citation
  • 30.

    Baron R, Kenny D. The moderator–mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. J Pers Soc Psychol. 1986;51(6):11731182. PubMed ID: 3806354 doi:10.1037/0022-3514.51.6.1173

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31.

    Sobel ME. Asymptotic confidence intervals for indirect effects in structural equation models. Sociol Methodol. 1982;13:290312. doi:10.2307/270723

  • 32.

    Allender S, Cowburn G, Foster C. Understanding participation in sport and physical activity among children and adults: a review of qualitative studies. Health Educ Res. 2006;21(6):826835. PubMed ID: 16857780 doi:10.1093/her/cyl063

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33.

    Kelly S, Stephens J, Hoying J, McGovern C, Melnyk BM, Militello L. A systematic review of mediators of physical activity, nutrition, and screen time in adolescents: implications for future research and clinical practice. Nurs Outlook. 2017;65(5):530548. PubMed ID: 28823500 doi:10.1016/j.outlook.2017.07.011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34.

    Lubans DR, Foster C, Biddle SJ. A review of mediators of behavior in interventions to promote physical activity among children and adolescents. Prev Med. 2008;47(5):463470. PubMed ID: 18708086 doi:10.1016/j.ypmed.2008.07.011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35.

    Taymoori P, Lubans DR. Mediators of behavior change in two tailored physical activity interventions for adolescent girls. Psychol Sport Exerc. 2008;9(5):605619. doi:10.1016/j.psychsport.2007.09.001

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 36.

    Abbasi IN. Socio-cultural barriers to attaining recommended levels of physical activity among females: a review of literature. Quest. 2014;66(4):448467. doi:10.1080/00336297.2014.955118

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 37.

    Siefken K, Schofield G, Schulenkorf N. Laefstael jenses: an investigation of barriers and facilitators for healthy lifestyles of women in an urban Pacific island context. J Phys Act Health. 2014;11(1):3037. PubMed ID: 23249672 doi:10.1123/jpah.2012-0013

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 38.

    Siefken K, Schofield G, Schulenkorf N. Inspiring pacific women for lifestyle change: an attempt to halt the spread of chronic diseases. In: Schulenkorf N, Adair D, eds. Global Sport-for-Development: Critical Perspectives. London, UK: Palgrave Macmillan; 2013:216242.

    • Crossref
    • Search Google Scholar
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