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Health Promotion and the Healthy / The Social City / The Perspective of Local Politics

Christa Böhme, Klaus-Peter Stender

(last update 15 February 2015)


Municipalities - the Central Actors in Health Prevention and Promotion

The increase in chronic diseases, the ever clearer connections in the public´s perception between poverty and health, and the overall crisis in the healthcare and health-insurance system have fired up the discussion surrounding the role of health prevention and promotion in general and in particular the potential role cities and towns play in this endeavor. How to best supervise and coordinate the local stakeholders while instituting health promotion that pays attention to the social disadvantages and special circumstances among the population as well as their personal life setting (community needs, health-related community work) have become the major topics of health prevention and promotion at the local level.

The municipalities are the central agents in the field of health promotion. Based on the health laws in place at the state level, they are responsible for actually delivering health services and promoting health. These tasks, however, are only partially directed explicitly toward health concerns, since in many cases health is only implicitly mentioned. For example, urban development plans, traffic planning, the establishment of nursery schools and kindergarten, educational offers or promotion of economic growth all have repercussions to the health of citizens. For this reason health prevention and promotion are not left completely to the local health offices, but also involve other administrative bodies - sport, youth welfare, social welfare, education, environment, urban development, economic development. Besides the local government other stakeholders from the local economy and civil society are also part of the effort to promote health. Yet the potential for conflict can run high: These groups are organized as separate entities, whereas health promotion very much depends on integration and cooperation above and beyond all boundaries. Health promotion affects the entire communal life. Thus, interdisciplinary/intersectoral cooperation is both the goal and the sore spot. The challenge is to discover and use the existing resources in the city/town and the respective organizations that lie behind them to further health-related goals.
The municipalities also play an active and creative role in health prevention and promotion, although they stand to profit greatly from such health-promoting policies. The promotion of health, however, it not just a matter for local administrations, but also depends on the decisions and plans laid out at the national and state level.

The importance of the municipalities in shaping health behavior has grown through the Setting Approach. In the lifeworld of the local community citizens can be approached in their direct surroundings as target groups to participate in strengthening health-related skills and in creating health-promoting conditions. “Community” is understood in this context as the comprehensive living system that contains other subsystems such as nursery schools, kindergarten, schools, living quarters, sports clubs or firms. The national prevention law now being planned directly addresses this matter of the lifeworld of living quarters as action field. The statutory health insurance companies have also chosen the local level as the place to set up health interventions: “The community is a particularly well-suited setting for health promotion since the community lifeworld plays a major role in the lives of the residents, and since socially disadvantaged and health-challenged persons can be sought out in their everyday surroundings without stigmatization. Here, too, target groups can be reached that otherwise, whether in institutions of childcare, schools or firms, are not present, such as the unemployed and elderly” (Handbook Prevention, Common and Uniform Fields of Action and Criteria of the Central Associations of Health-Insurance Providers on the Implementation of §§20 and 20a SGB V of 21 June 2000 in the newest version of 10 December 2014).

As early as 1998, in its report “Goals, Benefits and Control of Community Health Services,” the Communal Joint Office for Administrative Management (KGSt) made the demand that health play a greater role in local politics and be realized locally. Rhetorically at least, there is much agreement that the community level is the proper one for establishing health prevention and promotion since it is possible to establish an integrated plan that comprises the health of citizens throughout all phases of life, from birth to old age.

The conflict between the chance to better health on the one hand and the economic gloom found in many cities and townships on the other hand is considerable. A large number of municipalities are severely limited in their actions by the lack of a proper tax base and increasing social costs. Some communities can only barely keep their administration running. The press releases of the German Association of Cities see many cities already on life support. This is thus the background to the efforts being made to achieve “healthy cities.”

Healthy Cities

A “healthy city” in the definition of the WHO is one in which the health and well-being of the citizens are taken into consideration as part of the decision-making process (health impact assessment). In this sense, any city can become a “healthy city” by steadfastly committing itself to health and by cooperating with the many stakeholders in the community to develop structures and processes leading to sustainable improvements.

In order to better support this concept, in 1986 the European Office of the WHO established the International Healthy Cities Network, which has enjoyed great success ever since. Initially 10 cities took part in this international experiment for the promotion of health in the city, whereas today, according to the WHO, in Europe alone 30 countries (2014) with over 1,400 cities and towns participate in the national healthy city networks. Worldwide the number of “healthy cities” lies in the thousands.

In 1989, 11 municipalities formed the Healthy City Network, to which today (2014) some 75 cities and counties belong, representing over 20% of the entire German population. The city councils of the municipalities participating in this network have each passed a resolution committing themselves to putting health at the center of their local politics. The following 9-point program is especially important if a city is to join the network:

  • The city council must agree to the resolution
  • An office and a responsible person must be set up to deal with this subject
  • A policy of health promotion sustained through collaboration across all departments must be developed, e.g., by disseminating information from the various departments and by organizing conferences on the subject of health promotion
  • Establishing health promotion must be one of the criteria in all public planning and decision-making
  • The participation of all citizens must be enabled, and the proper structures to support and coordinate the tasks must be created
  • Reports must be prepared on health and social themes
  • Participation in network activities (e.g., member meetings, symposia)
  • Information transfer and interfacing to the higher-level network
  • Regular reports every 4 years outlining the experiences gained at the local level, and at the latest every 4 years a reconsideration by the responsible political committees

Healthy cities can profit greatly from the exchange of information and experiences. Those cities and towns that have become involved in the healthy city movement and have successfully implemented it locally also develop activities for “more health,” including building up the necessary infrastructure and instruments. Here are some approaches employed and other examples:

  • Communication: discovering and analyzing health potentials and problems and presenting them to the public
  • Health conferences: These instruments serve to increase cooperation and participation by uniting various institutions within a municipality such as doctors, employers, educational institutions, labor unions, private initiatives, health insurance companies, self-help groups, even city officials and welfare organizations, the goal being to address the subject of health promotion and prevention and implement it in the community.
  • Local health-related frameworks: These represent developmental plans in which the municipal departments or public institutions establish the framework and individual projects for improving the overall health situation, which they then continue to foster in the future. This includes defining the concrete goals, steps and timetables, resources, responsibilities and avenues of evaluation.
  • Medical health centers: These are the places where all citizens can go to get answers to their questions concerning health, social affairs and self-help; where they can get counseling or become active themselves and interact with other stakeholders and enjoy offers of concrete measures. Examples are departments within the health and social welfare offices, counseling services for the elderly or chronically ill, information and contact offices for self-help groups, volunteer agencies and adult-education centers.
  • Neighborhood health centers: These are low-threshold contact points for citizens wishing to contribute to community affairs as well as receive health-promotion offers for individual target groups. This often occurs in cooperation with activities stemming from the social development in the respective quarter.
  • Health-promotion activities at schools and daycare facilities: On themes such as design of schoolyards or playgrounds, establishment of school kiosks and cafeterias, promotion of fitness offers.
  • Improved offers for the chronically ill: Among other things, information brochures or internet presence, cooperation between hospitals and outpatient facilities.
  • Activating public relations: Among other things, health marketplaces, health fairs, special newspaper sections on healthy cities, healthy and forward-looking cafeterias.

The Social City and Health-Promoting City Development

The results of many studies of social and local affairs since the 1990s point to tendencies of increasing segregation, which means ever greater social and urban fragmentation. The triggers for this development lie, among other things, in the on-going economic and political restructuring processes, reflected in the terms globalization, deindustrialization, increased importance of information technology and knowledge-based services as well as deregulation. The effects of such structural change may be found in the increasing tendency toward divisions in society with respect to access to market and employment, income, consumer trends and lifestyles.

These developments have their physical fallout in the fragmentation going on in cities because of the small-scale segregation processes that cause individual quarters to rise and fall in value. Selective migration from one district to the other and the decline of some socially disadvantaged groups because of the job market is precipitating inequalities in the social space. Those areas that are “losing” the economic and political support are becoming socially marginalized and cut off from the overall societal and municipal processes. These areas are then characterized by a mixture of complex interactive problems, among other things, problems related to the social, economic, infrastructural and urban planning as well as health conditions and disadvantages (social inequality).
It was against this background that in 1996 the Committee of the Ministers and Senators of the 16 German federal states responsible for city planning, urban development and housing (ARGEBAU, since 1999 called the Ministers Conference for Housing and Urban Development) initiated a “Common Initiative for the Social City.” The goal of this action was to combine individual attempts at solving the problems that had arisen because of the complex local situations and to create integrated approaches to developing disadvantaged neighborhoods. Some of the individual states also introduced their own programs in this area. In 1999 the National Federal Program “Social City” was started with the expressed goal of stopping the “downward spiral” of disadvantaged neighborhoods and drastically improving the lot of the persons living there. The core elements of this program were a clear attention to individual areas, resource pooling (both material resources and know-how), broad activation and participation by all involved stakeholders both within and outside of the political administration, as well as establishing the necessary management and organizational forms to realize this program.

Despite the complex social and environmental health risks and problems present in such neighborhoods, the field of “health promotion” did not come into focus until later in time. The Association of Statutory Health Insurance Companies offered its support by recommending cooperation with the program “Social City” to its members. The Federal Centre for Health Education (BZgA) as well as the State Agencies for Health set up a cooperation entitled “Health Equality” in order to achieve a stronger orientation toward social space and to interface with the program “Social City.” One result of these efforts, among other things, was the study guide “Becoming Active for Health,” a practical collection of tools for planning, implementing and evaluating health promotion in individual neighborhoods, for collecting and publishing good examples of neighborhood-oriented health promotion as well as a number of national and state-wide events on these themes. In addition, from 2006 to 2010 the Federal Ministry of Education and Research (BMBF), as part of the program “Health Research: Human Research” (focal point: prevention research), sponsored a number of research projects on the subject of “Neighborhood Health Promotion.” The Academy for Spatial Research and Planning recently published a position paper entitled “Environmental and Health Aspects of the Program Social City - A Plea for Increased Integration.”

Wherever comprehensive approaches to health promotion in city development have been or will be implemented, whether as part of the program “Social City” or not, the following six quality criteria have proved to be able to predict the success of these endeavors:

  • Neighborhood database: An analysis of the specific state of health in each neighborhood is one of the basic prerequisites to developing quality-oriented measures of neighborhood health promotion. It would appear wise to collect indicator-based data on environmental and social health effects, on the state of health of the neighborhood residents and on the state of healthcare and health potentials. These data can then be complemented by other qualitative data comprising assessments by the local stakeholders and the residents.
  • Integrated developmental and action concepts: These are important instruments for furthering healthy and health-promoting neighborhood development. They offer orientation and, inasmuch as the concept has the support of local politics, planning security. They also offer the chance to interact directly with the neighborhood stakeholders and residents concerning developmental tasks and important measures.
  • Cross-department cooperation: Health-promoting neighborhood development generally affects a number of different local departments, depending on the size and specializations present in the respective local administration, for example, health, youth and family, environment, sport, social affairs, education, urban development. Setting up and developing health promotion within neighborhoods thus demands a cooperation that goes beyond the individual departments.
  • Health-related networks in the respective neighborhoods: The creation of health-related networks in the respective neighborhoods is often the first step to setting up activities of neighborhood health promotion. The goal of such networking is to enable cooperative health promotion in the sense that as many stakeholders as possible from the realm of health be involved in the action alliance of the respective neighborhood (i.e., providers of health and community services, schools, childcare facilities, sports clubs, self-help groups, physicians, midwives, health insurance companies, local political offices).
  • Local coordination of health promotion: An important motor for the complex task of coordinating and supervising the process of establishing health promotion on a neighborhood basis may be found in a local coordination office for health promotion. Like the neighborhood management found in the program “Social City,” such a local coordination office can contribute to systematically establishing self-supporting and sustainable structures in the neighborhood. The main tasks lie in coordination and moderation, networking, project development, activation and participation, public relations and reporting.
  • Neighborhood-specific project development and implementation: The potential spectrum of possible spheres of activity for health-promoting neighborhood development is broad, going from classical health themes such as nutrition, exercise and sport, stress management, prevention of drug addiction, violence and accidents, pregnancy and parenthood, to more architecturally based fields such as living and living spaces, environment and traffic. Which of these various themes lie at the forefront of a particular project depends greatly on the specific needs of the respective neighborhood.

References:
Akademie für Raumforschung und Landesplanung (Ed.) (2014): Umwelt- und Gesundheitsaspekte im Programm Soziale Stadt - Ein Plädoyer für eine stärkere Integration. Hannover (Positionspapier aus der ARL 97).
Bär G/Böhme C/Reimann B, Kinder- und jugendbezogene Gesundheitsförderung im Stadtteil, Difu-Arbeitshilfe, Berlin 2009.
Böhme, C/ Kliemke C/Reimann B/ Süß W (Eds.), Handbuch Stadtplanung und Gesundheit, Bern 2012.
Boos-Krüger A/Pallmeier H, Gesundheitsförderung in der Sozialen Stadt, in: Alisch M (Ed.), Lesen Sie die Packungsbeilage. Sozialraumorganisation und Gesundheitsinformation, Opladen 2009.
Bundestransferstelle Soziale Stadt beim Deutschen Institut für Urbanistik im Auftrag des Bundesministeriums für Verkehr, Bau und Stadtentwicklung (BMVBS), vertreten durch das Bundesamt für Bauwesen und Raumordnung (BBR), Statusbericht zum Programm Soziale Stadt, Berlin 2008.
Bundeszentrale für gesundheitliche Aufklärung (Ed.) (2010): Kriterien guter Praxis in der Gesundheitsförderung bei sozial Benachteiligten. Ansatz - Beispiele - Weiterführende Informationen. 4th ed. Cologne.
Gesundheit Berlin (Ed.), Aktiv werden für Gesundheit - Arbeitshilfen für Prävention und Gesundheitsförderung im Quartier, Vols. 1-5, Berlin 2008.
Reimann B/Böhme C/Bär G, Mehr Gesundheit im Quartier. Prävention und Gesundheitsförderung in der Stadtteilentwicklung. Edition Difu, Vol. 9, Berlin 2010.
Stender KP, Gesundheitsförderung im Rahmen der Integrierten Stadtteilentwicklung, in: Gesundheitsförderung in den Quartieren der Sozialen Stadt, hrsg. von Gesundheit Berlin e.V. 2009, pp. 91-96.
Trojan A/Süß W/Lorentz C/Nickel S/Wolf K, Quartiersbezogene Gesundheitsförderung. Umsetzung und Evaluation eines integrierten lebensweltbezogenen Handlungsansatzes, Weinheim/Basel 2013.

Internet addresses:
www.gesunde-staedte-netzwerk.de
www.knp-forschung.de
www.gesundheitliche-chancengleichheit.de
www.gesundheitsziele.de
www.staedtebaufoerderung.info/StBauF/DE/Programm/SozialeStadt/soziale_stadt_node.html
www.stadtteilarbeit.de
www.svr-gesundheit.de (Sachverständigenrat zur Begutachtung der Entwicklung im Gesundheitswesen)

Links: Setting Approach


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