Community action for health and well-being

4. Creating local networks

This section presents two examples of community networks to improve health and well-being at a local level. The first example describes the Health Network in Neighbourhoods initiative of the Government of Aragon in Spain and the Zaragoza City Council to consolidate actions in Zaragoza’s small neighbourhoods and districts and promote networking between public services and other social entities engaged in improving health and well-being of their communities. A process evaluation revealed positive short-term outcomes such as the participants’ knowledge of new entities and activities, the development of synergies, interaction to promote the use of health assets and the enhancement of community participation, recognising however some limitations in the evaluation process due to a lack of a comprehensive evaluation framework.

The second example illustrates the EPODE and JOGG methodologies, in France and the Netherlands respectively, which aim to fight against childhood obesity by implementing a local multistakeholder approach that involves a wide array of actors in the community – schools, families, associations. At the core of this approach is the belief that health is an ell-encompassing concept that must be promoted in all dimensions. Various econometric analysis demonstrate that EPODE and JOGG are particularly successful in targeting areas where overweight is most prevalent.

4.1. Establishing neighbourhood networks for community health – Aragon, Spain

4.1.1. Context

The Health Network in Neighbourhoods (Red de Salud en los Barrios) is part of a long-term work in community health and community action in Aragón (Gállego-Diéguez et al., 2016[17]). The initiative has its origins in 1996 with the creation of the Health Promotion Projects Network of Aragon (Red Aragonesa de Proyectos de Promoción de la Salud), which aimed to extend health promotion and education across the Autonomous Community of Aragon. The network was intended to integrate multidisciplinary working groups developing projects in various fields of health promotion. The Health Network in Neighbourhoods is aligned with the Health Plan of Aragón 2030 (Gobierno de Aragon, 2018[18]) and the Strategy on Health Promotion of the Spanish National Health System (Ministerio de Sanidad, Servicios Sociales e Igualdad, 2015[19]).

The Health Network in Neighbourhoods programme started in the summer of 2018, promoted by the Zaragoza City Council and the Regional Government of Aragon. The initiative had its origin in three neighbourhoods of Zaragoza: Arrabal, Casetas and Las Fuentes. The programme formally began with the creation of a promoting group, composed of management and technical staff from the Aragon Public Health Departments and the Zaragoza City Council, tasked with analysing and proposing a joint work programme tailored to the Zaragoza’s realities. Subsequently, a driving group was established in each participating neighbourhood.

From the beginning, these driving groups actively collaborated on various aspects of community health in the three neighbourhoods. The driving groups included public sector professionals from education, social and health services, representatives of district or neighbourhood councils, individuals linked to community resources, such as health councils or other participation platforms, and third-sector professionals. Each group produced an assessment report detailing demographics, socio‑economic information, health information, identified needs, community resources, and co‑ordination structures in each neighbourhood. Following this, each neighbourhood organised a conference to establish its Health Network. One year after the programme’s launch, a conference was held to conduct an early evaluation of the initiative.

4.1.2. Description

The Health Network in Neighbourhoods consists of various services and bodies from the public and third sectors, based in the neighbourhood, as an open space for relationships and with a certain sense of belonging. The network is designed to build community health capacity through horizontal relationships. The key to networking is to promote community health by facilitating a shared vision, increasing synergies and opportunities, and stimulating community empowerment.

The overall objective of the Health Network in Neighbourhoods is to improve health, well-being, and equity in the different neighbourhoods and districts of the city of Zaragoza by promoting community assets according to the local population’s needs. Its specific objectives are:

a. Addressing the main health determinants, considering the life cycle, support and resilience during life transitions (childhood, adolescence, migration, ageing) and promoting healthy environments by reducing health inequalities.

b. Strengthening the community orientation and networking of public services to improve the health and well-being of the local population.

c. Developing Health Network in Neighbourhoods as a system to promote community participation in various neighbourhoods of Zaragoza.

Participation in the network is a voluntary decision of individuals and associations active in the neighbourhood that share common values such as respect between entities, trust in their capacity to build co‑operative relationships, transparency and reciprocity, and the ability to share a common vision of neighbourhood health needs and health assets.

The organisation of the work in the neighbourhoods follows four steps:

a. Institutional commitment: Neighbourhood organisations, Department of Public Health and the municipal authorities explicitly declare their commitment to the programme through a contract of adherence.

b. Creation of the promoting group: The group includes representatives from the Department of Public Health and the municipality. Its goal is to analyse the situation in the neighbourhood and draft a proposal of work, subsequently submitted to Zaragoza municipal authorities.

c. Creation of the driving group: The cross-sectoral group of professionals with experience in community health who stimulates community action in the neighbourhood.

d. Creation of a health network: Initiated by the driving group, the network consists of local entities and citizens eager to engage in the health promotion initiatives.

These networks integrate both professionals and social agents who work directly on the ground in small environments, with defined objectives and inclusion criteria and voluntary participation.

An evaluation of the process was conducted one year after the programme was launched (Formento-Marín et al., 2022[20]). Results show that the planned phases of development for the analysis, prioritisation of needs, socialisation of activities and the creation of the driving groups and the Health Network were fulfilled.

The evaluation revealed positive short-term outcomes such as the participants’ knowledge of new entities and activities, the development of synergies, interaction to promote the use of health assets and the enhancement of community participation. However, the same report recognises some limitations in the evaluation process mainly due to a lack of an evaluation methodology and guidelines in the programme design.

The main limitation of the evaluation is the lack of benchmark or systematic collection of information about the situation before the programme started, making the interpretation of the results difficult. Another limitation is short time elapsed since the beginning of the programme and the time the evaluation was conducted, which does not provide information about the mid- and long-term impact of the programme. As of 2024, from the three original networks, two are still active and are fully autonomous. Other networks are being organised.

4.1.3. Relevant lessons

The Health Network in Neighbourhoods initiative in Aragon offers valuable insights for other countries in developing its community health action strategy. Aligned with Aragón’s Health Plan and the broader Community Health Strategy, this programme ensures consistency and a structured approach to health promotion. One of the key strengths of this framework is its inclusive approach, which integrates public, and third-sector actors, involving professionals from various fields. This inclusivity promotes comprehensive and well-rounded health initiatives.

The programme’s strong local focus, particularly at the neighbourhood level, addresses the most relevant geographic areas for community action. This local approach is further enhanced by the vertical co‑ordination between the public health professionals, District Council, and the Health Network. Support from the Department of Public Health and Zaragoza municipal authorities also boosts the programme’s effectiveness, providing a model of integrated governance that can be interesting for other countries.

However, several challenges observed in Aragon must be considered for successful adaptation in other countries. The geographic coverage of the programme remains limited; as of 2024, the programme has not been successfully extended to other neighbourhoods, indicating a need for more time and effort. The Aragon Government’s limited resources further constrain the proactive expansion of the Health Network in Neighbourhoods.

For other countries to maximise the benefits of a similar approach, it is crucial to ensure detailed planning for role assignments, and secure adequate resources for broader implementation. Balancing inclusivity with practical action plans and effective resource management tailored to each country’s context will be essential in overcoming these challenges.

4.2. Multistakeholder collaboration against childhood obesity – France and the Netherlands

4.2.1. Context

Ensemble Prévenons l’Obésité des Enfants (EPODE, in English Let’s Prevent Child Obesity Together) is a methodology to fight childhood obesity through health initiatives that involve the community and collaboration of various actors – schools, neighbourhoods, sports centres, and associations. The idea underlying this all-encompassing approach is that it is only through a healthy environment in its entirety that children can acquire sustainable and healthy habits. First piloted and evaluated in France (Borys et al., 2013[21]), the EPODE methodology was subsequently introduced in 21 other countries, of which 16 OECD and 5 non-OECD countries (Kobes, Kretschmer and Timmerman, 2021[22]). In the Netherlands, the EPODE methodology was implemented and developed over the past 12 years as Jongeren Op Gezond Gewicht (JOGG, in English Youth at Healthy Weight), to foster healthy practices among young people. Econometric evaluations demonstrated that EPODE and JOGG are particularly successful in targeting areas where overweight is most prevalent (Borys et al., 2013[21]) (Kobes, Kretschmer and Timmerman, 2021[22]).

4.2.2. Description

The organisational structure of EPODE operates both at the central and at the local level. The central co‑ordination team is responsible for training local teams, who are then tasked with implementing the EPODE approach by mobilising the local community: healthcare professionals, local business and food industry, parents and families, school and teachers, sport and recreation clubs. Multiple stakeholders support and inform the functioning of the central co‑ordination team – institutions, ministries, sports groups, non-governmental organisations, private companies, as well as an independent scientific committee (Borys et al., 2013[21]).

The backbone of the EPODE methodology rests on four pillars (Borys et al., 2012[23]):

• Political commitment. Formal political commitment is sought from representatives at all levels of government, both local and central.

• Resources. Sufficient resources must be secured to fund central support services and evaluation, and contributions from local organisations are necessary to fund implementation at the level of the community.

• Co‑ordination and support. Support services at the community level facilitate planning and co‑ordination across agents.

• Evaluation and monitoring. Continuous monitoring and evaluation practices are initiated at central, local and individual levels, and in some rare cases even at the level of the school. The collected data is composed of mostly measurable indices, like a child’s body mass index (BMI).

One of the country-specific applications of the EPODE methodology is the JOGG foundation in the Netherlands, which operates in 221 out of the 342 Dutch municipalities. JOGG is funded by the Ministry of Health, Welfare and Sport, and disposes of a budget of EUR 10 million a year.

JOGG has an organisational structure similar to that of EPODE, thus involving a central and local team within municipalities. At the central level, JOGG is composed of a team of 60 staff members, including 12 region-specific advisors who provide guidance on the pillars of the approach and 13 advisors who provide theme‑specific guidance to municipalities. These advisors assist municipalities in the transition toward the JOGG approach by training local teams from the municipalities. The local team then implements the approach in practice in daily life, seeking guidance and advice from the JOGG advisors when necessary (for example, on how to secure funding for projects by soliciting private‑public partnerships). The central JOGG team also hires external experts – such as “JOGG team-fit coaches” – who are tasked with visiting the municipalities to provide advice on how to make food catering or facilities better suited to health objectives. Remaining staff at central level is composed of teams that specialise in the dimensions that affect a child’s environment – school, sports and leisure time, neighbourhood for example – on a national level. These teams are also in charge of securing country-wide partnerships with, for example, caterers or national supermarket chains to take their responsibilities for healthier choices. Such outcomes have positive effects even on the communities that are not part of JOGG – a noteworthy positive spillover of the activities of the JOGG foundation.

To implement the JOGG approach locally, a municipal government signs a contract with JOGG. The regional advisors of JOGG then support the municipality in appointing a local team consisting of two individuals – the JOGG co‑ordinator and the JOGG policy advisor – and provide training on the JOGG approach as well as continuous advice for the local team. Both the local JOGG co‑ordinator and policy advisor are selected and paid by the local municipality. The local co‑ordinator is tasked with creating a web of local stakeholders who all collaborate in the pursuit of health objectives – schools, neighbourhood associations, catering facilities, sports associations, among others. The JOGG co‑ordinator is often newly hired by the municipality as the role is expected to spend about 16 hours per week working on implementing JOGG (Kobes, Kretschmer and Timmerman, 2021[22]). While the JOGG co‑ordinator is a specifically designed role for facilitating community participation, the JOGG policy advisor is tasked with advising the municipality on implementable policies in the various relevant policy areas: health in and for all policies. This role demands about four hours per week. The policy advisor is in general already working in a health-related position – in the regional public health institute or at a sports service company, for example – and uses this field-specific knowledge to provide the municipality with further policy advice.

4.2.3. Relevant lessons

The EPODE and JOGG approaches have several strengths that can be of use for the design of a community-based promotion of health strategies.

Firstly, the EPODE and JOGG approaches are structured in the provision of training to a local team on the part of a central team. This structure ensures that the implementation process is community-led, though guided by centralised know-how and health strategies. As mentioned above, both the central and the local JOGG teams are supported by health experts, in the form of external experts and policy advisors respectively. Such collaboration ensures continuous communication with scientific expertise, leading to the implementation of the most updated health guidelines.

Secondly, both EPODE and JOGG engage various stakeholders at the central and local level with the objective of fostering collaboration, in both practice and policy, for common health objectives. This approach is grounded in the belief that health promotion initiatives are societal processes, and that the definition of health is an all-encompassing one – a multidimensional educational process towards the acquisition of habits that improve quality of life and creating healthier environment.

However, the approach also requires a significant budget. The JOGG foundation itself operates with a budget of EUR 10 million for the central co‑ordination, advising local communities, and local implementation of projects building healthy environments. Participating municipalities need to provide additional funds to pay the local co‑ordination team, as well as potential costs accruing for initiatives. Further, while the EPODE approach has proven successful across many countries, it only targets one health problem, namely child obesity. Some adaptations will hence likely be necessary to target a wider array of health concerns and population groups. The JOGG approach has already evolved further on this aspect, as child obesity has often a multifactorial cause.