Research: Participation in the Mamant Netball League as a health promoter through social capital

Background: The Israeli Mamanet League (mothers’ Cachiboll), in which 6000 mothers participate in over 90 towns and cities across Israel, is a community model that incorporates both physical activity for all and competitive sport.

Objective: To assess whether participation in Mamanet League improve health behaviors, wellbeing and social capital among the players and their family members.

Study progress: At the beginning of the third year (January-February, 2019), we continued the sampling of the Mamanet participants and control group as part of the prospective cohort study (stage 5-6). We reached 194 Mamanet participants and 133 women in the control group in time 3 (T3). All of them completed an online questionnaire. We also took repeated measurements of the family questionnaires (T2) during March-April 2019. The sample in T2 included 115 Mamanet participants and their family members, and 207 women and their family members in the control group. In addition, we continued the sampling of Mamanet League Arab participants (stage 5-6); We reached 68 Mamanet participants and 81 women in the control group during October 2018-January 2019.

Once we completed the data collection, we started stage 7 and performed the statistical analysis for both the prospective cohort and participants’ family members. We also continued doing further analysis for the cross-sectional sample (04-07/2019). The data analysis included descriptive statistics to describe the Mamanet participants and control groups' socio-demographic characteristics. Bivariate analyses were conducted using t-tests and repeated measure analysis to identify differences in health, wellbeing and social capital between the Mamanet and control groups, as well as the differences within the groups across the different times of measures. Multi-variable regression analysis was conducted in order to identify variables predicting health and wellbeing, and the mediating effect of social capital among Mamanet participants and their families compared to the control groups.

During stage 8 (08-12/2019), we discussed the results and reached conclusions regarding the effect of participation in the Mamanet League. The results showed positive associations between participation in the Mamanet League and some of the health behavior measures, health indicators, wellbeing and social capital across the three measuring points. We concluded that interventions that include group competitive sports are beneficial for improving social capital among participants and their families.

Background:

The purpose of this study was to examine the associations between participation in the Mamanet League with health behaviors, wellbeing, and social capital. The study included four separate research components:

1. Qualitative study: In-depth interviews with Mamanet League participants and their families.
2. Quantitative cross-sectional study among Mamanet League participants from the Jewish sector.
3. Prospective cohort study among Mamanet League participants from both Jewish and Arab sectors at 3 time points.
4. Quantitative study among Mamanet League participants and their family members (a spouse and a child over the age of 8) at 2 time points.

1. Qualitative findings among Mamanet participants and their families:
   Findings from the qualitative interviews among mothers participating in Mamanet (n=15), their spouses (n=10) and children (n=8), raised 5 main themes: 1.1. Mamanet’s contribution to a healthy lifestyle: Participants, spouses, and children reported that by joining the league, the whole family became healthier both physically and mentally. Participants and spouses reported a change in their energy, wellbeing, and social life; 1.2. Mamanet’s contribution to social and personal capital: Participants reported that Mamanet helped them develop social skills and enriched their social lives. In addition, participants reported that Mamanet activity contributed to a more positive perception of life. Others recommended bonding within the groups to reduce the tension that resulted from competitiveness; 1.3. Mamanet as a source of family cohesiveness: Participants and their families reported that Mamanet activity encouraged them to engage in family activities, and as a result, they became more involved with their families; 1.4. Barriers to healthy lifestyle: Barriers to implement a healthy lifestyle included trying to balance work and home. This was especially difficult for single mothers. Some participants reported that the main barrier was psychological and they found it difficult to commit to doing PA. They reported that Mamanet encouraged them to exercise; 1.5. Mamanet’s contribution to a sense of community: Mamanet players and their families reported that they participated in Mamanet community events, contributing to social involvement, giving them a sense of satisfaction and gratitude.
2. Findings of the quantitative cross-sectional study:
   There were a total of 1,340 participants in the study, of whom 1,032 are Mamanet League participants and 308 are women who served as a comparison group. Eighty five percent of Mamanet participants rated their health as ‘excellent’ or ‘very good’. Thirty two percent reported eating fruits and vegetables several times a day, and another 30% once a day. Most Mamanet participants claimed they never drink soft drinks (43%) or drink them less than once a week (33%). Mamanet participants' positive perception of health on a scale of 1-6 was high (mean=5.18, standard deviation [SD]=0.75). Means for psychosomatic symptoms (on a scale of 1-5) and depression (on a scale of 1-4) were low (Symptoms: mean=1.98, SD=0.62; Depression: mean=1.60, SD=0.39). Social capital (on a scale of 1-5) was above mid-scale (mean=3.62, SD=0.61). Significant differences were found between Mamanet participants and the control group in positive perception of health, psychosomatic symptoms, depression, and social capital variables, all in favor of the Mamanet participants.
   Hierarchical multiple regressions were calculated in the total sample to assess the extent to which the socio-demographic and social capital predicted the perception of health, eating and drinking habits, psychosomatic symptoms, and depression. Regression results revealed that Mamanet participants reported better health (coefficient=0.17, p<.001) and less psychosomatic symptoms (coefficient=-0.22, p<.001) than women in the comparison group. Body mass index (BMI) was negatively related with the perception of health (coefficient=-0.20, p<.001). Social capital was positively related with a positive perception of health (coefficient=0.16, p<0.001) and eating habits (coefficient=0.12, p<.001), and negatively related with drinking sweet drinks (coefficient=-0.09, p<.01), symptoms (coefficient=-0.13, p<0.001), and depression (coefficient=-0.33, p<0.001). Social support was found to be positively related with a positive perception of health (coefficient=0.12, p<.001) and eating habits (coefficient=0.11, p<.001), and negatively related with depression (coefficient=-0.38, p<.001). Trust was negatively related with drinking sweet drinks and symptoms (coefficient=-0.10, p<.001). No associations were found between social involvement and the dependent variables.
3. Findings of the prospective cohort study:
   The purpose of the cohort study was to examine the associations between participating in Mamanet League, healthy behaviors, and social capital. The measurements of health indicators, health behaviors, and social capital were conducted in three different times among Mamanet participants (n=478): at the beginning of the study (T1), after 6 months (T2), and after 12 months (T3). Among the control group (n=333), the questionnaire was answered twice, 18 months apart.
   Differences between the Mamanet and control groups at T1 and T3: Mamanet participants reported a better health status, less psychosomatic symptoms and depression, participating in more PA, and more positive perceptions of health compared to the control group in T1 and T3. Mamanet participants also reported a higher frequency of alcohol consumption and smoking marijuana compared to the control group in T1 and T3. Trust level, social involvement, and the total social capital score were higher among Mamanet participants compared to the control group in T1 and T3.
   Differences between T1 and T3: Among the control group, the reported health status deteriorated between T1 and T3. Frequency of PA increased between T2 and T3 among Mamanet participants. However, healthy eating decreased among Mamanet participants between T2 and T3 (P<0.001). There was a decrease in alcohol consumption among Mamanet participants between T2 and T3. An increase in social involvement and social capital in general was observed among Mamanet participants between the three measuring times. There were no changes in PA, nutrition, substance use, or social capital among the control group between T1 and T3. 
   The hierarchical multiple regression analysis showed that after adjusting for age, income, and BMI, participating in the Mamanet League predicted better self-reported health (coefficient=0.23, p>.001) and less somatic (coefficient=-0.30, p>.001) and depressive symptoms (coefficient=-0.32, p>.001). A better self-reported health score was also associated with lower BMI. Experiencing fewer somatic symptoms and lower depressive symptoms were associated with higher family income. Lower depressive symptoms were associated with higher social capital. The analysis revealed a negative relationship between social capital and symptoms only for the control group (coefficient = -0.16, t = -2.73, p = .007), suggesting that women in the control group who had higher social capital reported lower levels of symptoms.
   Findings among the Arab Mamanet participants: The sample from the Arab population included 68 Mamanet participants and 81 women in the control group. Most of the participants had been involved with Mamanet for less than 12 months (62.7%). The average age was 40.38 years (SD=6.73). Most Arab participants were Muslim (88.2%), married (94.1%), and resided in a large city (53.7%). Differences were found between Mamanet participants and the control group in reported psychosomatic symptoms. Mamanet participants reported on less symptoms compared to the control group (p<0.0001). Mamanet participants also reported doing more PA (P<0.0001), eating more fruits and vegetables (P<0.0001), and having more personal (p=0.006) and social capital (P<0.0001). They also reported higher social involvement compared to the control group (P<0.0001). Only 32.8% reported family involvement in Mamanet activities, and 63.1% reported that their family supported their activity in Mamanet.
   Among Mamanet participants, age was negatively associated with drinking energy drinks and fruit juices (p<0.01) and positively associated with social involvement (p<0.01). Women living in a city reported eating more fruits and vegetables (p=0.004) and drinking less energy drinks (p=0.02) compared to women living in a village. Women with high income reported less depressive symptoms compared to those with an average income (p=0.01). Women with high income also reported eating more fruits and drinking less energy drinks compared to those with a low income (p=0.03). A longer duration of participation in Mamanet was associated with being more physicly active (p=0.01).
4. Findings of the quantitative study among Jewish Mamanet participants and their family members:
   This study was conducted among Mamanet League participants and their family members (spouses and children), compared to the control group, across two time points, 12 months apart. The sample included 115 Mamanet participants and their family members (total of 38 families) and 207 women who did not participate in Mamanet and their family members (total of 69 families), as a control group.
   Differences between groups (Mamanet vs. control): Spouses' BMI was higher among the control group compared to the Mamanet group in T1 (p=0.005) and T2 (p=0.03). In T2, Mamanet participants, spouses, and children reported better health compared to those in the control group. In T1, children in the control group reported more screen time (mean=7.63, SD=6.77) compared to the Mamanet participants’ children (mean=5.31, SD=3.38; p=0.007). Children in the control group reported doing more PA compared to Mamanet participants’ children in T1 (P=0.04) and T2 (P=0.009). Spouses in the T2 control group also reported doing more PA compared to Mamanet spouses (P=0.01). Spouses in the Mamanet group reported healthier nutrition consumption compared to the control group in T1 (p=0.04) and T2 (p=0.03). Eating habits among Mamanet participants and their spouses were healthier compared to the control group in T1 and T2 (P(mothers)=0.02, P(spouses)=0.01). Children from Mamanet participants reported more family activity compared to the control group in T2 (p<0.001).
   Differences between T1 and T2: Differences between T1 and T2 were found in Mamanet children's BMI in T1 (t1Mean=17.43, SD=3.08) vs. T2 (t2Mean=18.15, SD=3.10; p=0.001). Mothers in the control group, reported on a poorer health status between T1 and T2 (p=0.05), and spouses reported more screen time between T1 (mean=3.93, SD=2.53) and T2 (mean=4.39, SD=3.12; p=0.05). No differences were found between T1 and T2 in reported health status and screen time among the Mamanet group. There was an increase in the amount of PA among Mamanet participants (p=0.02) and an increase among the women (p=0.01) and spouses (p=0.06) in the control group. Women in the control group also reported healthier eating habits at T2 compared to T1 (P=0.04). Children in the control group reported less family activity at T2 compared to T1 (P<0.001). No differences in family activity were found in T1 or T2 in the Mamanet group.
   

The current study included eight different steps, all of which have been completed. At the first stage of the study, we formulated the research tools. The protocol for the in-depth interviews was built, as well as the questionnaires for Mamanet participants, their families, and the control group participants. The questionnaires were translated into Arabic by a professional translator for distribution among Arab participants. The second stage included the qualitative data collection: in-depth interviews conducted with 15 Mamanet participants, seven spouses, and children. The interviews were held in participants' homes. Each interview took between 45-60 minutes.

The third stage of the study included analyzing the findings of the qualitative interviews and creating a final design of the quantitative questionnaire (2017). The in-depth interviews were analyzed by identifying and retrieving recurring topics, ideas, and insights based on participants' responses. The responses were categorized into key themes, such as: "Mamanet’s contribution to healthy lifestyle", "Mamanet’s contribution to social and personal capital", "Mamanet as a source of family cohesiveness", "Barriers to healthy lifestyle", and "Mamanet’s contribution to a sense of community". Based on these themes, the online questionnaires for the quantitative part of this study were formed. The questionnaires included information about frequency of PA, eating healthy, social capital, substance use, and wellbeing. During the fourth stage, we distributed questionnaires for the quantitative cross-sectional study among veteran Mamanet participants. The sample included 1,032 Jewish Mamanet participants and 308 women served as a comparison group with similar socio-demographic characteristics.

The fifth and sixth stages included distributing questionnaires at T1, T2 and T3 among Mamanet participants and their family members in each newly formed Mamanet team and among the control groups, for the prospective cohort study. For the control group, a matching sample was taken from an Internet panel that included 100,000 people, in accordance with the socio-economic and geographic characteristics of the sample of Mamanet participants. The Mamanet sample included 478 participants in T1, 169 participants in T2, and 204 participants in T3. Loss to follow up between T1 and T2 was 64.6%, and was 57.3% between T1 and T3. The control group included 333 participants in T1 and 133 participants in T3; loss to follow up was 60%. We conducted a comparison between the initial respondents and those who were lost to follow up and found no significant difference between the groups in age, number of children, BMI, marital status, religiosity, or education. The only difference was in family income, where the women who dropped out had a lower average income.

The questionnaire was delivered online to Mamanet participants at the beginning of the study (T1), after 6 months (T2) and after 12 months (T3). Among the control group, the questionnaire was performed twice: T1 was at the same time as the Mamanet group and T2 was 18 months after. The families' survey was conducted at two time points with 12 months apart. The Mamanet sample included 69 mothers, 69 children, and 63 spouses in T1, and 39 mothers, 39 children, and 37 spouses in T2. Loss to follow up among participants and children was 43.4%, while among spouses was 41.2%. The control group included 84 mothers, 84 children, and 84 spouses in T1, and 69 mothers, 69 children, and 69 spouses in T2. Loss to follow up was was 17.8%.

The seventh and eighth stages included the quantitative data analysis and writing of this report. The quantitative analysis was performed separately for each study formation: 1. Cross sectional study; 2. Prospective cohort study; 3. Quantitative study among Mamanet family members.

The dependent variables of the study included:

1. Frequency of PA on a scale of 1-5 (1=not at all, 5=7+ hours a week);
2. Nutrition: information about the amount of sugar in one’s diet, consumption of soft drinks, fruit and vegetables consumption, etc., was measured on a scale of 1-7 (1=never, 7=3 times a day or more);
3. Substance use was measured by asking about smoking, alcohol, and drug habits, including frequency of smoking (1=everyday, 4=never smoked), number of cigarettes smoked a day, motivation to stop (yes/no/maybe in the future). Frequency of alcohol and drugs consumption was measured on a scale of 1-7 (1=not at all, 7=more than twice a week);
4. General health status was measured on a scale from 1-6 (1=very bad, 6=excellent);
5. BMI was calculated according to participants' reported weight and height;
6. Attitudes towards health were measured using three questions on a scale of 1-4 (1=not important, 4=very important) such as: "How important is it for you to feel in good shape?" and "How important is it for you to feel energetic?";
7. Psychosomatic symptoms (headaches, stomach aches, anger, dizziness, etc.) were measured on a scale of 1-5 (1=rarely, 5=almost every day);
8. Depressive symptoms were measured on a scale of 1-4 (1=rarely, 4=almost every day) by questions like: "During the previous week how often did you feel depressed?";
9. Social capital was measured by reporting on social involvement (volunteering, reciprocity, and social support) on a scale of 1-5 (1=not at all, 5=very often) and included 8 questions. Trust in one’s social environment was measured with four questions on a scale of 1-6 (1=not at all, 5=very often) like: "Do you consider most people to be trustworthy?"