The Health Impact of Social Community Enterprises in Vulnerable Neighborhoods: Protocol for a Mixed Methods Study

Background This 4-year research project focuses on 6 social community enterprises (SCEs) that operate in 5 neighborhoods in a Dutch city. Residents of these neighborhoods face problems such as poor average levels of physical and mental health, high unemployment rates, and weak social cohesion. SCEs offer residents social, cultural, and work-related activities and are therefore believed to help these persons develop themselves and strengthen the social ties in the community. Because of a lack of empirical evidence; however, it is unclear whether and how SCEs benefit the health and well-being of participants. Objective This paper outlines a protocol for an evaluation study on the impact of SCEs, aiming to determine (1) to what extent SCEs affect health and well-being of participating residents, (2) what underlying processes and mechanisms can explain such impact, and (3) what assets are available to SCEs and how they can successfully mobilize these assets. Methods A mixed methods multiple-case study design including repeated measurements will be conducted. Six SCEs form the cases. An integrated model of SCE health intervention will be used as the theoretical basis. First, the impact of SCEs is measured on the individual and community level, using questionnaires and in-depth interviews conducted with participants. Second, the research focuses on the underlying processes and mechanisms and the organizational and sociopolitical factors that influence the success or failure of these enterprises in affecting the health and well-being of residents. At this organizational level, in-depth interviews are completed with SCE initiators and stakeholders, such as municipal district managers. Finally, structurally documented observations are made on the organizational and sociopolitical context of the SCEs. Results This research project received funding from the Netherlands Organization for Health Research and Development in 2018. Data collection takes place from 2018 until 2022. Data analysis starts after the last round of data collection in 2022 and finalizes in 2024. Expected results will be published in 2023 and 2024. Conclusions Despite the societal relevance of SCEs, little empirical research has been performed on their functioning and impact. This research applies a variety of methods and includes the perspectives of multiple stakeholders aiming to generate new empirical evidence. The results will enable us to describe how SCE activities influence intermediate and long-term health outcomes and how the organizational and sociopolitical context of SCEs may shape opportunities or barriers for health promotion. As the number of these initiatives in the Netherlands is increasing rapidly, this research can benefit many SCEs attempting to become more effective and increase their impact. The findings of this research will be shared directly with relevant stakeholders through local and national meetings and annual reports and disseminated among other researchers through scientific publications. International Registered Report Identifier (IRRID) DERR1-10.2196/37966


Objective, problem definition and assignment
Consider the following factors: • the objective is clear and specific . The overall aim is realising health effects by focusing on multiple determinants/factors; • the problem definition/assignment is clear and verifiable and is consistent with the objective; • the value added to existing knowledge or practice; • the theoretical or empirical evidence presented in support of the problem definition/assignment.
The proposed approach and methods are broadly appropriate, and align with activities at local and regional levels in many western countries over the past ten years. The need for action and its significance is made, and this generally aligns with the research on the topic.
The emphases on (i) co-creation to mobilise existing networks and assets, and (ii) a broad intersectoral team are the most innovative aspect of this proposal, but the mechanisms by which this will occur could be described in greater detail.
The precise mechanism by which the community enterprises are theorised to lead to changes in social cohesion and safety is not clearly articulated, nor is how this will enhance health -but that is part of the justification for this research, and helps to explain the need for it. However these connections are described in the literature elsewhere.
The proposed translation of this project's activities and research findings is excellent. My suggestion is that in addition to transfer between sites and at the national level, that some consideration be given to dissemination internationally, as well as demonstrating the impact of research translation activities themselves. The findings will be relevant in many settings.

Strategy
Consider the following factors:

Research strategy
• clarity; • adequacy in terms of problem definition/assignment; • adequacy of chosen methods and analyses; • adequate inclusion prospectives of the target group • the target probative value should be at least 'initial indications of effectiveness'; • the way in which the strategy reflects the factors gender, age, ethnicity and socio-economic health inequalities; • degree of collaboration with intermediate and ultimate target group (the client perspective); • it may be that the scientific study of the effect of the intervention is at odds with the monitoring of integrated policy programmes. This should be mentioned explicitly, and the choices which are made as a result should be clear.
Implementation strategy • analysis of the context and community in which implementation is to take place; • extent to which target groups are mentioned; 840 -SEGV 1 2017 Beoordelaar: R.2017.1290 -Dossier: 50-53100-98-208 • the integrated approach (sum total of interventions) should be clearly described, even if it is not yet fully developed; • analysis of factors facilitating or hampering those activities; • local authorities are playing an increasingly important role in the development of integrated health policies; • prospect of structural incorporation in system; • adequacy of process and effect evaluation design.
The research approach is broadly feasible and appropriately targeted. There may be challenges with attribution of findings, for example will changes (positive or negative) in social cohesion and safety be attributable to this project? The case study approach partially addresses these concerns, but they warrant further consideration.
A small concern is the relatively limited number of participants under research objective 1 activity 2 (questionnaires among participants). Will 60 per year over four years have sufficient statistical power to detect change? A component of the research design that is under-described is how will data on knowledge transfer itself (research objective 3) will be collected, analysed and reported.
The sites are appropriately selected with reference to "levelling up" approaches to addressing health inequalities, which recognise need and variation between them. The community assets that will be leveraged for the project are alluded to but not specified in great detail.
The Implementation Strategy seems sound, no specific comments.

Project group
Consider the following factors: • relevant expertise; • familiarity with area in question; • prior activities and products.
The project group have good experience ad represent a diverse and appropriate team for the scope of the project. This project builds upon their prior related work between the social enterprises, government agencies, and the municipal government. The only apparent weakness is demonstrating the involvement of the researchers in activities with the project partners.

Feasibility
Consider the following factors: • will it be possible to achieve the objective(s) using this strategy? • availability of facilities/staff; • realistic phasing and timetable; • analysis of factors which may positively or negatively impact the feasibility; • feasibility of the collaboration with relevant stakeholders and intermediate target groups.
Some aspects of the project will require more detailed planning (in particular research objectives 1 and 3), but the overall approach and team suggest the project is feasible. The scope of the project is realistic within the timeframes identified. The involvement of students is appropriate and will be beneficial.

Overall quality assessment
This is a useful project that has the capacity to make a contribution to local, national and international knowledge. The design addresses some of the potential challenges in attributing changes to the project, but more work may be required on this point. Further attention to investigating and demonstrating the impact of this project on policy and practice as part of its design will enhance its overall public value.

Budget
I think the budget is modest when considering the number of sites (4) and the scope of the research. The team have leveraged existing activities and the use of students, with considerable in-kind contributions. I think this risks 840 -SEGV 1 2017 Beoordelaar: R.2017.1290 -Dossier: 50-53100-98-208