Based on the programme's conceptual framework and the existing empirical literature on community-based physical activity and women's health promotion, the present study addressed the following open-ended research questions.

These questions were formulated to explore the extent and nature of associations between participation in the Mamanet programme and multiple dimensions of health and well-being, without assuming the direction or magnitude of effects. 1.

To what extent does participation in the Mamanet programme influence participants' self-perceived physical health?

Together, these open-ended research questions provide a comprehensive framework for examining how structured, community-based sport participation may contribute to physical, psychological, social, and economic well-being among women from diverse sociocultural backgrounds in Israel.

The study's innovative research perspective integrates both health and economic frameworks to evaluate women's participation in community-based team sports, atypically examined from a purely public health standpoint. CBA and QALYs are combined with conventional health outcomes to yield substantial quantitative evidence regarding the measurable benefits of programmes such as Mamanet for individuals as well as society. Given the programme's demonstrated success within Israel's multicultural society, Mamanet may serve as a replicable model for promoting women's health and community cohesion in other multicultural or underserved populations worldwide. Its focus on inclusivity, social capital, and affordability makes it particularly relevant to low- and middle-income countries aligning with global efforts to achieve SDG 3 (Good Health and Well-being), SDG 5 (Gender Equality), and SDG 10 (Reduced Inequalities).

Physical activity (PA) is a key determinant of women's physical, mental, and social well-being. Regular participation contributes to reduced morbidity, improved functional capacity, and enhanced emotional stability across the lifespan. Yet, despite these benefits, women particularly those from minority and low-income backgrounds remain less engaged in organized physical activity due to sociocultural norms, caregiving responsibilities, and limited access to affordable opportunities (21, 22).

The social and emotional competencies acquired via athletics, including teamwork, leadership, and dispute resolution, are skills that enhance personal connections and facilitate professional achievement. Engagement in team sports provides an avenue for empowerment by fostering self-efficacy, resilience, and cooperative learning, thereby strengthening both individual and collective capabilities (23).

Israel provides a unique sociocultural setting for evaluating community-based health and sport interventions. The population is highly diverse, comprising Jewish, Arab, Druze, and other minority groups that differ in cultural norms, socioeconomic conditions, and health behaviors. This diversity exists alongside historical and political tensions that often constrain intergroup contact and shared civic participation (24). In this context, the Mamanet programme functions not only as a health-promotion initiative but also as a structured environment for intergroup engagement and social inclusion. The league's organization of mixed-ethnicity tournaments, bilingual communication (Hebrew and Arabic), and family-oriented community events enables meaningful contact across cultural boundaries. These elements align with intergroup contact theory (25), which posits that sustained cooperation under equal-status conditions fosters mutual understanding and reduces prejudice. Consistent with recent empirical evidence from community-based sport programmes in divided societies (18, 25), such encounters can strengthen social capital by enhancing trust, reciprocity, and shared identity. Thus, beyond its physical and psychosocial health benefits, Mamanet represents a culturally adapted mechanism that may foster social cohesion, well-being, and collective resilience within a diverse and sometimes polarized society.

Team sports offer psychological and social advantages for underprivileged populations by fostering an inclusive atmosphere where individuals from diverse backgrounds unite around shared objectives rather than social disparities. Such initiatives enhance self-esteem and reduce psychological distress among marginalized groups (15, 16).

Team-based sports also play a pivotal role in the development of social capital, creating enduring networks of trust, reciprocity, and mutual accountability that extend beyond the sports arena and contribute to community resilience (26, 27). This collaborative behavior promotes a culture of assistance and civic engagement, reinforcing social cohesion and collective efficacy (28, 29). Programmes like Mamanet demonstrate that diversity-oriented sports can effectively unite women from different cultural, social, and religious backgrounds, facilitating the dismantling of stereotypes, reducing prejudice, and promoting social integration (18, 25). Elevated levels of community social capital are strongly associated with better access to resources, healthier behavioral patterns, and greater perceived safety within the community, establishing a virtuous cycle of engagement and well-being.

The substantial physical, mental, and social advantages of team sports have led to increasing advocacy for their integration into public health policy. Governments and health organizations are encouraged to allocate resources to community-based sports initiatives that enhance participation and equity (21, 28). Greater engagement in team sports can markedly reduce chronic disease prevalence and associated healthcare costs (19, 20). Community programmes targeting women, youth, and at-risk populations can foster a healthier, more productive society that requires fewer medical interventions (22).

Collaboration among the health, education, and sports sectors is essential for sustaining the long-term benefits of community-based physical activity programmes. Integrating team sports into school curricula can promote lifelong engagement in physical activity, while healthcare providers may reinforce these behaviours through preventive or rehabilitative exercise prescriptions. Such intersectoral partnerships create the systemic foundation needed to scale inclusive and culturally adapted initiatives such as the Mamanet programme ensuring that sport-based health promotion is embedded within broader public health policy frameworks and remains accessible to diverse demographic groups, including older adults and women balancing caregiving and professional duties.

Mamanet, derived from the international game of Cachibol (a modified volleyball-based team sport), was established in Israel in 2005 with the explicit aim of encouraging mothers' participation in organized physical activity. The game involves six players per team and is played on a standard volleyball court with moderate-intensity aerobic effort combining movement, coordination, and teamwork. Beyond its physical component, Mamanet's structured weekly sessions and community-based teams promote social interaction, inclusion, and well-being among women from diverse cultural and socioeconomic backgrounds.

Mamanet now operates across more than 100 municipalities in Israel, integrating Jewish and Arab women through mixed tournaments, bilingual communication, and family-oriented community events. This inclusive design reflects a culturally sensitive adaptation of global team-sport models to local realities. As a result, Mamanet functions not only as a health-promotion initiative but also as a platform for intergroup contact, social trust, and empowerment consistent with intergroup contact theory (30).

Community-based physical activity programmes like Mamanet serve as effective CBIs by addressing barriers to participation, particularly those related to caregiving, affordability, and cultural constraints. Such initiatives embed health promotion within existing community networks, providing accessible, low-cost, and socially supportive environments (15, 27).

From an economic perspective, Mamanet demonstrates how localized, inclusive sports programmes can enhance productivity, reduce healthcare utilization, and improve cost-effectiveness outcomes. These findings illustrate the dual role of CBIs in fostering both population health and social capital, offering a scalable model for equitable public health promotion (18, 26).

Preventive health interventions are increasingly recognized for their capacity to generate long-term economic benefits by reducing healthcare expenditures, improving workforce productivity, and enhancing population well-being. These interventions, particularly when implemented through community-based platforms, offer governments an effective mechanism for alleviating the financial burden of non-communicable diseases (NCDs) while improving QALYs and social cohesion.

CBA, cost-effectiveness analysis (CEA), and cost-utility analysis (CUA) are essential tools for evaluating health programmes. CBA compares implementation costs with benefits such as reduced healthcare usage and enhanced productivity (31). The CEA focuses on cost per health outcome unit (e.g., life-years saved), while CUA incorporates QALYs, combining quantity and quality of life (32, 33).

Productivity gains are central to the economic case for women's participation in team sports. By reducing absenteeism and improving energy, confidence, and mental clarity, participation contributes to better workplace performance (14). These benefits are especially important among women balancing caregiving and employment, where stress and fatigue often undermine output and advancement. From a macroeconomic perspective, the impact of such programmes extends to healthcare budgets, gross domestic product (GDP) contributions, and intergenerational labour outcomes (34). Increased workforce participation among women who would otherwise be excluded or marginalized due to health or social isolation contributes directly to economic growth. When modelled using labour market simulations, team-sport interventions improve projected human capital indices and life satisfaction scores, indicators closely tied to national well-being (35). The estimated cost per QALY gained through participation in the Mamanet programme remains well below internationally recognized willingness-to-pay thresholds (USD 50,000–100,000 per QALY ( (19, 34), indicating that the programme delivers good value for money and is cost-effective from a public funding perspective (36). Integrating such programmes into national health insurance reimbursement mechanisms may reduce systemic barriers and encourage sustained participation. Subsidized fees and local leagues ensure access for all women. Sustained efforts and inclusive strategies are key to promoting gender equity in sports and enabling all women to benefit from participation.

These frameworks provide decision-makers with data-driven evidence for the efficient allocation of resources and the promotion of a gender-inclusive sports infrastructure (37). While traditional health metrics assess physiological outcomes, QALYs allow valuation of well-being improvements resulting from enhanced self-esteem, reduced depression, and greater social engagement (38, 39). In the context of women's team sports, these qualitative gains often translate into significant functional improvements in work, parenting, and community roles. CBAs also allow for the inclusion of indirect economic gains. For example, Mamanet participants often report fewer sick days, increased work attendance, and greater job satisfaction (14). These productivity outcomes, while sometimes underemphasized in public health literature, represent a critical source of cost savings and economic value. Moreover, improved emotional regulation and reduced stress levels contribute to a more stable workforce, particularly for women balancing employment with family responsibilities.

Willingness-to-pay (WTP) models are also employed to estimate perceived value by participants. Studies indicate that women in structured team sport programmes often report that the social and psychological benefits they gain exceed the actual monetary cost of participation, suggesting strong consumer surplus. This finding reinforces the case for subsidized or publicly funded programmes for lower-income populations who may otherwise be excluded from participation (40).

Another economic implication is the reduced reliance on pharmacological and clinical mental health services. Participants engaging in sustained team sport involvement report decreased medication use, fewer doctor visits, and reduced hospitalization rates (12). These outcomes translate into measurable savings for national health insurance systems and reduce burdens on overwhelmed mental health services. From a system-wide perspective, when sports interventions are adopted at scale, the cumulative financial savings can be substantial. Preventive models like Mamanet offer longitudinal benefits: reduced prevalence of chronic disease, improved population mental health, enhanced civic participation, and intergenerational transmission of healthy behaviours (8). Public investment in such models yields not only financial returns but enhanced resilience of health and social systems. It is also important to highlight the role of sports in promoting social mobility and labour market advancement. Team sports, by building confidence, discipline, and social networks, improve women's chances for promotion, leadership, and re-entry into the workforce. These macroeconomic effects, although slower to materialize, contribute meaningfully to gender equity, productivity, and national competitiveness.

The evaluation of preventive health interventions must consider both direct and opportunity costs to ensure a comprehensive understanding of their economic implications. Direct costs refer to expenses directly associated with participation, including registration fees, travel expenses, and necessary equipment. These practical costs are essential for assessing the affordability and accessibility of programmes, particularly for economically disadvantaged populations. According to the Centers for Disease Control and Prevention (CDC), direct expenditures encompass staff, fringe benefits, consulting fees, supplies, travel, and other contractual costs. The National Institutes of Health (NIH) similarly defines direct costs as those attributable to specific institutional activities. These standards underscore the importance of including direct costs in the financial analysis of health programmes. The World Health Organization emphasizes the need for cost-effective approaches to achieve health equity (22).

Opportunity costs, by contrast, represent the value of time participants might otherwise dedicate to paid work or personal responsibilities. This includes time spent attending medical checkups, health workshops, or community-based fitness programmes. Recognizing these trade-offs is vital to understanding the full economic impact of preventive interventions. As Culyer and Chalkidou (41) note, economic costs reflect the lost opportunity to apply resources elsewhere. Eime et al. (15) show that opportunity costs associated with community sports are outweighed by their health and social returns.

This research utilized a quantitative cross-sectional design to assess health, psychological, and social outcomes among women participating in Mamanet programmes. A stratified sampling method was employed to capture socioeconomic and geographic diversity among Arab participants across geographic regions and socioeconomic levels as defined by the Israel Central Bureau of Statistics (42).

The present study focused exclusively on Arab women participating in the Mamanet programme, which operates within Israel's multicultural context. While Mamanet as a national league includes both Jewish and Arab teams, the current sample comprised Arab participants only. This subgroup was selected to examine the programme's health, social, and economic impacts within a population often facing greater structural and cultural barriers to physical activity. Although intergroup dynamics were not directly analyzed, the broader multicultural framework of Mamanet characterized by bilingual communication and inclusive community engagement remains an essential component of its design. Future research may extend these findings by comparing outcomes across different cultural groups participating in the league.

The Ethics Committee of the Faculty of Health Sciences approved this study. All respondents were given explanations before data collection and were advised that participation was voluntary. The number of the ethics committee is AU-HEA-RT-20221225.

The study included 174 newly recruited Mamanet mother-players. The subjects completed questionnaires twice: in November 2023 (pre-test) prior to the Mamanet intervention and in August 2024 (post-test) following 10 months of Mamanet participation. Arab subjects were recruited in collaboration with Mamanet. The organization provided contact details of team captains, who distributed the study questionnaire through their team WhatsApp groups, a primary communication channel used among league members. This non-random recruitment strategy ensured that recruits were active members of Mamanet and had direct access to the online study materials. The approach leveraged existing team-based social structures to facilitate engagement and data collection at pre-test and post-test. The questionnaires in Hebrew and Arabic were digitized by Sekernet¹, uploaded to an online link and distributed via WhatsApp by the coaches. The link to the questionnaire was tested on a small group of recruits and then distributed to all subjects. The responses were transferred to Sekernet to assist the researchers in data collection.

The implementation of the Mamanet programme among Arab women incorporated several cultural and logistical adaptations designed to enhance accessibility and inclusion within Arab communities. All study materials and questionnaires were administered in Arabic through trusted local team captains. Participation costs were deliberately modest, and practice schedules were adapted to accommodate family and caregiving responsibilities. Activities were held in venues located within or near participants' residential areas to minimize travel burden and ensure social safety. These adaptations reflect evidence-based principles of culturally tailored physical activity interventions shown to increase adherence and perceived safety among women from minority or traditional societies (17, 43).

While Mamanet as a national league promotes intercultural inclusion between Jewish and Arab women, the current evaluation focused specifically on Arab participants, capturing the effectiveness of these culturally adapted components within that community.

The structured questionnaire was developed, integrating validated instruments from the scientific literature. Specifically, self-rated health was measured using the single-item general health question adapted from the SF-36 Health Survey (Framework IC., 1992). Depressive and somatic symptoms were assessed using the Patient Health Questionnaire [PHQ-9 (44)]. Physical activity levels were measured using the International Physical Activity Questionnaire (IPAQ) short form (45). Social capital indicators, including trust, reciprocity, and civic participation, were adapted from the Short Social Capital Assessment Tool (46) and from Putnam's social capital framework (47). Dietary habits were measured using items from the Mediterranean Diet Adherence Screener [MEDAS; Martínez-González et al. (48)].

The survey included measures of self-reported health status, BMI, chronic disease presence, psychosomatic symptoms, depressive tendencies, and indicators of social capital (trust, social involvement, support networks). Key metrics included self-reported health status (rated 1–6), psychosomatic symptoms on a 4-point scale, and social engagement frequency.

Economic evaluation applied a cost-benefit framework, assessing improvements in QALYs, reductions in healthcare costs, and enhanced social capital. Costs considered included direct (registration, travel, equipment) and opportunity costs (time).

Health outcome variables included general health perception (1–6 scale, converted to utility scores), mental well-being (7-point Likert scale), psychosomatic symptoms (8-item symptom checklist), and physical activity (International Physical Activity Scale), with WHO guidelines used to categorize activity levels into utility scores.

Social capital and community engagement were measured via six items, including volunteering and participation in community events, rated on a 5-point scale and converted into utility values reflecting potential reductions in service reliance. Participants also reported comorbidities (e.g., asthma, arthritis, hypertension, diabetes, cancer), which were used to assess potential medication cost savings based on improvements in reported health status.

All main variables were inspected for normality using Q–Q plots. Most variables met normality assumptions and were therefore analyzed using parametric statistics. Descriptive statistics (means, standard deviations, and frequencies) were used to summarize sociodemographic and outcome variables. Paired-sample t-tests were conducted to compare pre- and post-test scores, and effect sizes were calculated using Cohen's d following Morris and DeShon (49).

The physical activity variable, however, displayed a skewed distribution and violated the assumption of normality. Accordingly, it was analyzed using the non-parametric Wilcoxon signed-rank test, with results presented as median and interquartile range (IQR) rather than mean and standard deviation.

A CBA assessed health gains (via QALYs), social engagement (via utility-based service savings), and economic impacts (e.g., reductions in doctor visits, sick days, and medication usage). Physician visits and sick day reductions were monetized using standard Israeli rates (e.g., 200 ILS per doctor visit; 300 ILS per sick day). Medication cost reductions were calculated by applying condition-specific savings rates to self-reported health improvements.

Total programme benefits were aggregated across QALY improvements, social capital effects, and economic savings. Costs were calculated as the sum of direct (125 ILS registration), opportunity (based on 1.25 weekly hours × 40 weeks × 30.6 ILS), and travel/equipment (200 ILS/month travel for 10 months, 500 ILS/year for gear). The BCR was computed as total benefits divided by total costs, with BCR > 1 indicating economic viability.

To predict changes in health status, binary logistic regression was conducted. Improvement was defined as moving from “very bad,” “not good,” or “OK” to “good,” “very good,” or “excellent” from pre- to post-test. Only variables significantly associated with improvement were included in the model. All statistical analyses were conducted using SPSS version 29, with significance set at p < .05 (2-tailed).

The detailed and precise methodology for calculating health and economic outcomes, as well as the specific variables used in this analysis, is provided in an Supplementary Appendix. This Supplementary File elaborates on the step-by-step procedure for assigning utility values to various health and social indicators, calculating QALYs and estimating the economic impact of participation in Mamanet. By grounding these calculations in health economics theory and incorporating standard cost-benefit methodologies, the data in the Supplementary Appendix ensures transparency and replicability in assessing the programme's impact.

The study intervention included 174 subjects with a mean age of 43.1 + 5.7. Most participants were Arab-Muslim (75.3%, n = 131), in a relationship (86.2%, n = 150), and had either a professional certificate (32.2%, n = 56) or a high school education (28.1%, n = 49). Regarding employment, 54.0% (n = 94) were employed, 17.2% (n = 30) were self-employed, and 16.1% (n = 28) were identified as housewives. For additional information, refer to Table 1.

According to Table 2, a significant improvement in general health was observed: the percentage of participants reporting “very good” or “excellent” health increased from 59.2% (n = 103) at pre-test to 84.5% (n = 147) at post-test (p < 0.01). Psychosomatic symptoms significantly decreased from a mean score of 5.01 ± 4.41 at pre-test to 4.01 ± 4.02 at post-test (p = 0.01), with a small effect size (d = 0.23).

Median moderate-to-vigorous physical activity (MVPA) showed a non-significant change, increasing from 181.75 min [IQR: 61.00–243.00] at pre-test to 195.00 min [IQR: 120.00–300.00] at post-test (p = 0.15, Wilcoxon signed-rank test), with a small effect size (ES = 0.28). No significant change was observed in mental well-being scores (p = 0.09), with a negligible effect size (ES = 0.12).

Notwithstanding the promising results, a few limitations require caution. First, the research assessed changes mostly across a single intervention cycle (about 10 months), which may not suffice to detect effects, particularly those related to mental health that may necessitate a longer period to become evident (70). Additionally, the study's reliance on general mental well-being metrics may inadequately reflect specific dimensions such as anxiety, sadness, or self-esteem. Other uncontrolled confounders such as diet, external stresses, and simultaneous health regimens may have influenced the findings. Furthermore, since participants in Mamanet are self-enrolled, this may suggest a level of motivation or health awareness not representative of the broader female population.

Considering these limitations, further research is warranted. Extending follow-up assessments at intervals such as 12, 18, and 24 months would allow for evaluation of the persistence of physical and psychological benefits. Expanding mental health indicators to include specific psychological dimensions (e.g., stress coping, self-esteem) could elucidate why certain mental health indicators improved while others remained unchanged. Future studies should also deepen demographic analyses to explore how socio-economic factors beyond age and education may mediate programme effectiveness or present barriers to participation (13). Incorporating qualitative research methods, such as focus groups or interviews, could further identify contextual facilitators and obstacles, particularly cultural or familial variables that may inhibit women's sustained engagement (13, 71).

The multicultural context pertains to the programme setting; the analytic sample comprised Arab participants only, and intercultural integration was not measured and therefore cannot be linked to outcomes in this study.