Community action for health and well-being

5. Evaluating community action initiatives

This section highlights the importance of evaluating community action initiatives through the example of the German project Grünau Moves (GRÜNAU BEWEGT sich, 2019[24]), which demonstrates how a structured evaluation process can provide valuable insights into the effectiveness and impact of community health interventions. Evaluations indeed help to understand what works and what does not, allowing for continuous improvement and adaptation of strategies to better meet community needs. The Grünau Moves project illustrates the benefits of using comprehensive evaluation frameworks to assess interventions.

5.1. Setting-up and evaluating project to address child obesity in a disadvantage urban district – Germany

5.1.1. Context

The Grünau Moves project was initiated to address the progressive rise in childhood obesity and improve the overall quality of life in Leipzig, Germany. Running from January 2015 to December 2019, the project specifically targeted Grünau, a socially disadvantaged area of the city of Leipzig, where socio‑economic factors significantly contribute to health disparities (Baar et al., 2013[25]). The project was a collaborative effort involving various institutions, including the Leipzig University (Paediatric Clinic), the Leipzig University of Applied Science, the Department of Health of Leipzig, and the statutory health insurance fund AOK PLUS. The initiative aimed to introduce behavioural changes, such as increased physical activity and balanced diets, to reduce the prevalence of overweight among children and adolescents and improve the quality of life in the intervention area. By focusing on these disadvantaged areas, the project sought to create equal opportunities for health and well-being among all children, regardless of their socio‑economic background.

5.1.2. Description

The Grünau Moves project was structured around a comprehensive approach that included a variety of stakeholders from different sectors (Igel et al., 2016[26]). The primary goals of the project were grouped into two main areas. At the individual level, the project aimed to introduce changes in the movement and dietary patterns among children and adolescents in Grünau, thereby decreasing obesity and improving overall well-being. At the environmental level, the project sought to improve the network among local actors, create a co‑ordinated structure for health promotion measures, build qualifications and pool actors, develop a joint health promotion strategy on-site, and design healthy living environments all around the neighbourhood, including schools and nurseries. Additionally, the project focused on promoting healthy design practices within the public realm. This goal was initially not highlighted, because child obesity might be associated with shame, stigma and discrimination and because of the experience that health was not an issue for most of the community members. Instead, emphasis was placed on active listening and empowering community members in expressing their needs and interests in the context of creating supportive and healthy environments for children. The objective was only to support community in assessing its needs and help them in addressing them in the context of creating more health environments for children. As child obesity is a social problem the project sought for social solutions. Therefore, a social worker with focus on community work was crucial for the project.

The projects were managed by two boards (Igel et al., 2016[26]). The advisory group, which met annually, comprised representatives from universities, municipal authorities (social welfare, education, health, city planning), and a health insurance company. Additionally, there was a second group that met more regularly. This group included the operational team executing the project, the health office of the City of Leipzig, and a representative from the health insurance company. The design of the project was based on two models. The first one, the PRECEDE‑PROCEED model, is a comprehensive structure for planning health promotion and other public health programmes. It involves multiple phases from identifying health problems and their determinants to designing, implementing, and evaluating public health programmes. The second model, the intervention mapping approach, complements the PRECEDE‑PROCEED model by providing a systematic framework for developing health promotion programmes based on theoretical and empirical evidence, linking needs assessment with programme planning to efficiently address the targeted health issues.

The project began with a detailed preparatory phase in 2014, officially launched in January 2015 and was implemented over a five‑year period (Igel et al., 2016[26]). The implementation was divided into three main phases: analysis of the starting situation, intervention development and implementation, and evaluation.

In the first phase (PRECEDE) of the Grünau Moves project, a comprehensive analysis of the social and health conditions in the intervention area was conducted. This phase aimed to identify key factors influencing childhood overweight and associated behaviours and to understand the norms and values of the district. The analysis was carried out in collaboration with local actors, facilitating relationship-building and knowledge transfer between science and practice.

At the individual level, data sources such as nursery and school entry screenings, mass screenings conducted by the Leipzig Health Department, physical activity observations, and aggregated social data were used to describe health risks and resources. At the organisational level, nurseries and schools were assessed for their health promotion practices using semi-structured interviews. Focus group discussions with local actors were conducted to gather subjective perceptions and build relationships. At the environmental level, features of the built environment, such as playgrounds and food providers, were evaluated to understand their impact on health behaviours. Moreover, ethnographic and participatory methods like participant observations, walking tours, one2ones, PhotoVoice were applied to get a deeper insight in the community members’ “lifeworlds”.

Local community management played a crucial role in connecting with institutions and stakeholders in the area. These connections enabled the establishment of a health network – a local interest group dedicated to the healthy development of children. The network linked providers (e.g. sports clubs) with interested parties (e.g. schools, youth clubs, pharmacies, paediatrician, public health workers) and networkers (e.g. neighbourhood management, parents’ network). This facilitated needs assessments, intervention development and implementation, and co‑ordination of actions within the neighbourhood.

In the second phase (first step of the PROCEED), based on the findings from the analysis phase, specific interventions were developed and implemented. The examples of the specific actions are (Igel et al., 2020[27]):

a. Active to School and Back – enhancing physical activity among children by redesigning public spaces. Children participated in planning and implementing the designs, which included colourful markings on sidewalks to encourage walking and playful interaction. This initiative not only increased physical activity levels but also improved self-efficacy among children through participation in the project.

b. Grünau Football Cup – an annual event that encouraged regular physical activity among children through sports. It involved co‑operation between day-care centres and local football clubs, providing children with opportunities to engage in regular sports activities and fostering self-efficacy.

c. PlaySpace Grünau – 8 weeks of physical education with a focus on active outdoor space exploration, encouraging children to use their environment and engage in physical activities outside the traditional school setting. It aimed to increase physical activity levels and make active living a norm in the community.

The last phase (second step of the PROCEED), evaluation, was designed as a quasi‑experimental control group study with a combined longitudinal and cohort design. The method was chosen because standard randomise control group designs are not possible in the evaluation of complex interventions that address the multiple dimensions of health, including social, epidemiological, educational, and environmental factors. The intervention area (Grünau) was compared to two control areas in Leipzig with similar socio‑economic characteristics. The process evaluation documented the progress and implementation of the project, noting any variations and necessary adjustments, and provided a basis for interpreting the results. All activities were recorded, including details about content, timing, target groups, attendance, and resource allocation. An advisory board consisting of representatives from municipal government, trade, commerce, health insurance funds, education, and sports provided practical and critical support, while a scientific advisory board offered guidance on methodological and ethical questions.

Initially, evaluations of all interventions were intended to follow the RE‑AIM framework,1 analysing extent, effectiveness, adoption, implementation, and maintenance. This structure aims to assess the internal and external validity of each intervention, allowing for generalisation of the results. The evaluation measured changes at multiple levels, including environmental features, institutional practices, and individual health outcomes. Due to resource limitation, some interventions were instead evaluated using standardised pre‑post observations (SOPARC, quantitative) and non-standardised observations. While the RE‑AIM framework served as a guiding structure, its application varied across interventions based on available resources and access to data.

The evaluation indicates that the intervention led to a significant increase in the proportion of children reporting daily outdoor activity. Additionally, children involved in the intervention were more likely to regularly participate in sports clubs, with participation increasing from 34% to 44%. However, the intervention did not result in a significant reduction in the proportion of children who were overweight. One possible explanation for this outcome is the relatively short evaluation period, comparing results from 2016/17 to 2018/19, and the relatively small sample size used in the study. Due to its complexity, the project requires nonnegligible financial and human resources. Project costs included EUR 200 per month for maintaining the contact point at the district,2 EUR 6 per month for the website, and EUR 30‑50 per month for consumables and information materials. Various interventions in institutions and public spaces cost, on average, EUR 1 200 per year (or EUR 240 per project). Family health days and other events ranged from EUR 50‑500 per event (GRÜNAU BEWEGT sich, 2019[24]). The project also engaged from 1.5 to 2 social workers, each with a focus on community organizing and qualifications in public health promotion, empowerment of children and deprived families. These resources only include people directly engaged in the community projects and do not consider resources devoted to the evaluation process.

The conclusions from Grünau Moves project evaluation was outlined in Ten Statements on Health Promotion (GRÜNAU BEWEGT sich, 2019[24]). According to the document, community-based health promotion must respect diverse perspectives on health across individual life plans, adopt a “lifeworld” approach by understanding participants’ personal contexts before defining health goals, and highlight the added social and personal benefits of health-promoting activities, such as empowerment and social integration. Health promotion should work inclusively within accessible community settings, address local needs by gathering in-depth community knowledge, and leverage interdisciplinary approaches. Health promotion must also be participatory, fostering trust within the community, and ensuring sustained financial and staffing support beyond funding cycles. Additionally, interventions should follow evidence‑based impact models and use defined evaluation indicators. Advocacy for health equity and engagement in broader political processes is crucial to address social health inequalities effectively. Finally, political backing is essential to achieve lasting change in health equity.

5.1.3. Relevant lessons

The Grünau Moves project offers valuable lessons for other countries in developing strategies for community action in health. One key strength of the project was its comprehensive approach, addressing both individual behavioural and environmental factors (Igel et al., 2017[28]). This dual focus led to significant improvements in physical activity levels among children with a potential to decrease obesity rates in the longer run. Emphasising collaboration and community involvement, the project engaged various stakeholders, including schools, healthcare providers, public health authorities, and local organisations, creating a supportive network that enhanced the effectiveness and sustainability of the interventions. The use of participatory methods, such as focus groups and community surveys, ensured that interventions were tailored to the specific needs of the community.

The project’s robust evaluation framework, employing the RE‑AIM structure, provided a thorough assessment of its reach, effectiveness, adoption, implementation, and maintenance. This comprehensive evaluation highlighted the importance of sustainable interventions and allowed for a detailed understanding of the project’s impact. Additionally, the project’s development within the PRECEDE‑PROCEED framework facilitated ongoing refinement and improvement of the initiatives launched, ensuring they remained responsive to community needs.

Adapting this approach to context in other countries may present certain challenges. One significant challenge is the complexity and resource‑intensive nature of such a comprehensive approach, requiring substantial time, financial resources, and co‑ordination among various stakeholders. Many researchers were involved in the project since the beginning, but it is not a typical situation for the community projects. Additionally, ensuring sustainability over the long term could be difficult without careful planning and resource allocation. Finally, while the use of a quasi‑experimental design is appropriate for evaluating complex interventions, it may not be suitable for assessing all community projects.

Notes

← 1.  The RE‑AIM (Rach, Effectiveness, Adoption, Implementation, Maintenance) framework was developed to improve the adoption and sustainable implementation of evidence‑based interventions in a wide range of health, public health, educational, community, and other areas. See https://re-aim.org/ for more details.

← 2.  The contact point took a form of a local “project office” to get in contact with the community, present the projects’ outcomes and meet with members of the health network.