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    How the Plants for Joints multidisciplinary lifestyle intervention achieved its effects: a mixed methods process evaluation | BMC Public Health


    Group sessions

    In total, 95% of participants were satisfied with the group sessions (Supplementary table 5, Additional file 6). Focus group participants expressed satisfaction with the content, amount and duration of the sessions, and ability to ask questions. In the questionnaire, only seven participants indicated dissatisfaction or disagreement with three or more questions about the usefulness of the group sessions. When asked about the specific sessions 60% of participants felt session three (information about processed foods and physical activity introduction) was most useful for making lifestyle changes followed by session one (49%; cooking workshop) and session four (38%; exercise test and relaxation exercises) (Supplementary table 6, Additional file 6). In total, 40% of the participants indicated none of the sessions were the least useful, or in other words, all were seen as useful. Coaches also felt the group sessions were an extremely useful part of the whole intervention (Supplementary table 5, Additional file 6), whereby the cooking workshop and exercise test were especially important (Supplementary table 6, Additional file 6).

    Group setting

    The group setting was perceived as an essential, if not the most important part, of the lifestyle intervention, according to focus group participants. Participants and coaches felt the group sessions were fun and an opportunity to share experiences and tips, ask questions, and support and motivate each other. The coaches also noted the advice shared between participants often carried more conviction than advice provided by the coaches. The group setting also gave participants a sense of social pressure, which was generally motivational, yet some felt discouraged if they did not experience similar positive results.

    “…I don’t think I could have done this whole change without doing it together with a group…we really did it with each other and stood for it together…No, I don’t believe I could have done it that way individually.” (#416, FG 2)

    In all focus groups, participants indicated the form in which the group sessions were held (live, online, or hybrid) impacted their satisfaction. Yet, the overall perceived usefulness was similar across all forms of the intervention. Participants with the hybrid form preferred live interaction, yet they, and those with the online form, found the online sessions a good alternative during the COVID-19 pandemic and enjoyed not having to commute. Coaches stated a hybrid form would have been ideal, allowing for live interaction while reducing travel needs, thus increasing feasibility and attendance. Informative sessions, including nutrition and sleep, as well as relaxation exercises, were viewed as suitable for online use, while live guidance of physical exercises would be preferred.

    Group dynamic

    Group dynamic varied per group and depended on various factors. Overall, 86% of participants felt they were part of the group and 76% felt they could talk to their group members about things that were important to them (Table 3). In the focus groups participants who did not feel connected to their group members often indicated missing this aspect of the intervention, although not everyone felt the need for group connection.

    Table 3 Mixed method results for the perceived group dynamic according to participants

    One of the main factors influencing group dynamic was whether the group sessions were held live, online, or in a hybrid form. Participants who followed the live intervention felt more connected with their group (19% (live) vs. 49% (online) did not feel connected with their group) and each other (52% (live) vs. 19% (online) had a personal connection with other participants in their group) than those following the hybrid and online versions (Supplementary table 7, Additional file 6). Participants also felt it was easier to share important things in the live and hybrid forms compared to the online version. Similarly, the coaches indicated the group dynamic was better in groups which had spent more time together live.

    Group diversity, including age, diagnosis, occupation, and living situation, was generally well-received by participants, and provided a wide range of perspectives and advice, which participants found valuable. However, some expressed a desire to have at least one other participant with the same diagnosis to share common experiences. Coaches noticed significant variations in knowledge, ability, and bodily complaints among participants. They felt more individualized guidance, particularly in the movement component, could improve the intervention’s effectiveness. Additionally, coaches viewed gender diversity and larger group sizes (around 8 participants) as beneficial for the group dynamic.

    Tools, activities, and guidance

    Of all the tools and activities offered, participants considered the Fitbit tracker and the dietary information in binder as the most useful. Comparingly, the fasting protocol, individual consultation with the physical therapist, and WhatsApp group were seen as the least useful. Further details on participants’ and coaches’ views and experiences of the tools and activities used in the intervention are described in Supplementary table 4, Additional file 6.

    During the focus groups participants looked back positively on the guidance received during the intervention and felt the coaches were enthusiastic, patient, helpful, understanding, friendly, and easily accessible. Multiple participants stated the coaches’ enthusiasm, feeling heard, and being taken seriously were motivational factors.

    “…I thought everyone was nice and engaged and enthusiastic. And I also think that’s kind of what makes this successful, that people are enthusiastic and genuinely interested in you and want to work with you.” (#760, FG 1)

    Additionally, participants were satisfied with the ability to ask questions as well as the answers and information received by the coaches (Supplementary table 5, Additional file 6). Participants felt the guidance was pleasant without feeling pressured or pushed. A few participants also appreciated that many of the coaches ate a plant-based diet themselves, allowing the coaches to share personal experiences and practical tips. The perceived usefulness of the various behavioral change techniques used is described in Supplementary table 3, Additional file 6.


    The feasibility of eating more unprocessed and plant-based foods varied per individual and depended on various factors including previous diet, affinity for cooking, intake of sufficient protein and iron, costs, and social support. For those who were already eating more plant-based or cooking frequently themselves the transition was easier, although even some heavy meat-eaters indicated the transition was not difficult.

    “…I was a huge meat eater, 2.5 to 3 kilos of cheese per week, lots of eggs, lots of dairy products. I have to say, it amazed me that from day one I stopped with that and went completely vegan. It didn’t take me any effort at all.” (#461, FG 4)

    Participants expressed cooking plant-based, but specifically unprocessed, was more time consuming and required more creativity. One participant felt the cost of food was higher, while others indicated it was the same or even cheaper depending upon the products purchased. Also, participants stated eating at restaurants and during vacation was often more difficult.

    Overall, social support strongly impacted the feasibility of the intervention for participants. Of those with a partner (74%) or children (72%), 89% of partners and 76% of children started to eat a more plant-based diet while 47% and 38% started moving more, respectively. Both participants and coaches stated involvement of partners or children made it easier to follow the intervention as participants felt supported and it was more practical.

    “…I was supported well by my wife, who joined me and made dishes with me. Yes, that has been a very big support, because I am basically a man of straw as far as that goes. So, I’m very happy that she helped me.” (#714, FG 1)

    Factors affecting exercise and stress management behaviors included previous habits, symptoms and disease activity, and the COVID-19 pandemic. While COVID-19 was advantageous for some, having more time to cook and reduced travel time with online meetings, others felt staying active was harder and they were less stimulated to move due to working from home, closed gyms, and canceled group workouts. The coaches also indicated the COVID-19 pandemic increased participant’s stress, especially those with rheumatoid arthritis using immunosuppressive medication. Lastly, the coaches felt overall motivation of the participants was high, and higher than that of an average patient outside the intervention.

    Overall intervention satisfaction

    Focus group participants indicated the intervention was “very good”, “fantastic”, “very complete”, and a “positive experience.” Participants found the information on lifestyle topics, including the rationale for healthy lifestyle changes, and insights given on monitoring their progress and how to listen to their bodies, the most important part.

    “…I found it very complete, that it really covers all aspects. Because it’s all important, relaxation is important, exercise is important, taking small steps forward is important, nutrition is important. But social contacts are also important. So I do think [it covered] the big picture.” (#303, FG 3)

    When asked how likely participants were to recommend the intervention to others with their diagnosis, they gave an average response of 9.2 (SD 1.4, n = 102), whereby 10 was “very likely.” Multiple participants were grateful for the intervention because it reduced their symptoms and they felt fitter. Yet, others indicated they were satisfied with the intervention even though it had no perceived impact on their symptoms.

    “I am very grateful to have been able to participate. And for me it has also been very rewarding. I would actually like everyone to be able to participate in this kind of intervention. I also really hope that rheumatologists throughout the Netherlands will be…inspired to…at least give people with rheumatism this option, to participate in such an intervention. Yes, that would be nice.” (#602, FG 4)

    Coaches were satisfied with the intervention and scored it 7.5 out of 10 points (highest score). Important components of the intervention were the multidisciplinary approach, a larger reach due to the group setting, emphasis on making long-term lifestyle changes, providing insight and education, and encouraging participants to actively do and experience new things.

    “…The content is very solid. I like the variety. The holistic view of all parts of your health, not just the food, that’s just really good.” (#294, Dietitian)

    On the other hand, due to the scale and variety of the intervention, some participants did not have the time or capacity to address all the intervention’s components. While the intervention encouraged participants to change their lifestyle all at once, various coaches indicated it may be more useful to make smaller changes over a longer period.

    Sport coaches were satisfied with the practical information given, group discussions, and lessons on protecting one’s physical boundaries. Also, movement exercises, during the sessions and as homework, were seen as one of the main stimuli for participants to be more active. Yet, sport coaches wanted more feedback from the participants to tailor sessions better. Lastly, education and group exercises were seen as important components of the relaxation and sleep components of the intervention. Yet, due to the vastness of the intervention there was little to no time to focus on behavioral change of these components.

    Perceived effectiveness

    The intervention helped participants to eat a more plant-based (92%) and less processed diet (86%), move more (79%), be better equipped to ensure a good night’s sleep (66%), and relax better and more consciously (72%) (Supplementary table 8, Additional file 6). Participants’ intentions to continue to follow the intervention in the future are described in Supplementary table 8, Additional file 6. Many participants found the intervention effective for improving health outcomes. Some experienced effects within a couple weeks, while for others it took multiple weeks or months, or they did not perceive any or only some effects.



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