Participation as a Core Principle of Community Health Promotion: General Account and Examples

Abstract

One of the key principles of the Ottawa Charta is participation. Community health interventions should involve the community, i.e., residents and local actors. In Hamburg, we tried to put this principle into practice during a project initiated by the municipal health service in a disadvantaged quarter with about 3000 inhabitants. The contribution starts with an account of the meaning of participation in health promotion (1) and gives an overview of participation methods in general (2). The next part contains a short account of our project (3). Five examples are presented in part four: a survey with key actors and two approaches to listening to residents’ perceptions of capacity building in the neighborhood. Another survey of residents was meant to explore the use of health promotion offers and the preparedness to get involved. The last example is the round table of local actors as a sort of steering committee for health promotion interventions (4). Key findings of the examples are: Surveys do result in valuable information for the local actors. The expressed willingness to participate is larger than the actual participation. Opportunities to participate (in surveys and at the round table) are welcome by local actors. In the last section we discuss the advantages, problems and some illusions concerning participation in health promotion (5).

1. Introduction

In as early as 1986, the WHO’s Ottawa Charter stressed the central importance of participation and civic involvement in the implementation of health promotion programs, policies, and activities. The normative demand for democratic involvement and the strengthening of civic communities, neighborhoods, and groups, but also of the individual citizen in terms of the development of personal competences and skills, pervades the entire text of the Ottawa Charter but is particularly emphasized in individual passages:

“Strengthen community action.

Health promotion works through concrete and effective community action in setting priorities, making decisions, planning strategies and implementing them to achieve better health. At the heart of this process is the empowerment of communities, their ownership and control of their own endeavors and destinies. Community development draws on existing human and material resources in the community to enhance self-help and social support, and to develop flexible systems for strengthening public participation and direction of health matters. This requires full and continuous access to information, learning opportunities for health, as well as funding support” [1].

Of course, this applies not only to the activation and participation of the envisaged target groups [2] in the population, but also to the leading actors in health policy programs and activities. Participation, sharing, civic involvement, cooperation, community action – whatever terminology is used or argued within this context – it tends to move away from the “top-down” approach and toward a more “bottom-up” approach. The advantages of bottom-up approaches are based on opportunities to participate and strong efforts to empower local communities. They have been demonstrated in a number of well-researched examples [3].

2. Methods and participatory instruments for community-based health promotion

The possibilities and methods for implementing this democratic right are as diverse as the levels of intensity of participation and civic involvement, if one wants to gradually approach the normative requirements as formulated by the WHO in its Ottawa Charter. In recent decades, different models, strategies, and procedures have been discussed, developed, and tested in practice in many policy areas and evaluated in subsequent scientific projects [4, 5, 6]. There is a wealth of experience from several decades of practical civic involvement and participation [3, 7], which has now also been extended to include the aspect of participation in health research [8, 9, 10]. A separate classification scheme is presented here as an example of the various similar models.

The ladder models for civic involvement in decision-making processes or participation in health promotion are helpful constructs for the discussion and evaluation processes involved in strategic planning of political programs and activities, which can also be transferred to programs for prevention and health promotion. The models try to make clear that real participation and involvement entail different levels of intensity with respect to authority to exert power. According to these models, it is therefore always necessary to determine how much decision-making power actually lies with the population groups involved and their legal actors in order to speak of participation, preliminary stages of participation, or nonparticipation. Participation is not understood as an either/or option but as a development process.

In addition to this normative and politically oriented assessment of participation and civic involvement, a number of practical and creative methods and procedures for the participation of citizens and/or professional actors have developed in recent decades within the framework of urban planning and redevelopment processes, from project development and action planning to the formulation and implementation of political programs in different fields of action and policy areas. In addition, significant momentum for the development and further development of procedures and methods also came from the field of health promotion and prevention, not least through the Gesunde Städte (Healthy Cities) project. The German Healthy Cities network has a so-called 9-Points-Program of self-commitments. This document has to be signed before becoming a member city. Point 5 requires that the city has to provide a framework that guarantees that all citizens “can participate in the shaping of healthy living conditions and environments.” Point 7 requires, that in the steering committees of the cities there has to be at least one representative of local citizen initiatives or self-help groups.¹

The list in Table 1 provides a brief overview, without evaluation initially, of what can be “done today” in the areas of civic involvement and participation in the interests of the above-mentioned ladder models. The extent to which political decision-making processes can be influenced or even shaped shall not play a role at this point. It is important to note that participation and involvement always also require that the citizenry, or the particular neighborhoods or groups of the community concerned, generally have to be activated in some form in order to “participate” in participatory processes. This means that the methods and procedures used are always also about activation for participation and about the participatory process itself.

Traditional methods and instruments	Creative methods and instruments
Oral or written surveying of a quantitative or qualitative nature Bodies, advisory councils, committees Round tables Networking institutions related to the particular fields of work District conferences Town hall meetings Consultations Working groups Initiatives and pressure groups And more	Planning cell Open space events Future workshop Focus groups Research into the lived environment Citizens’ exhibition Planning for real Suggestion box Neighborhood detectives Citizen tours/inspections And more

Table 1.

Traditional and creative methods of communication and involvement.

According to a study by the German Youth Institute [11] on the activation and participation of families, these methods and procedures can be differentiated between in terms of traditional and creative instruments of communication and involvement. These are listed in Table 1 and supplemented for this paper by a number of other known participatory instruments.

In the socio-political process, for example, at the municipal level, a mix of traditional and creative instruments is often found, depending on the needs, the subject matter, and the desired solution to the upcoming problems and decisions.

The individual techniques, procedures, and methods mentioned here cannot and should not be discussed at this point. The focus of our remarks is intended, rather, to be on examples of participatory community-based health promotion as addressed and implemented in a disadvantaged district of Hamburg-Eimsbüttel by the local health office.

The practical project, which is accompanied by continuous research, was entitled “Lenzgesund” (“Lenzhealthy,” tying in with the name of the district, “Lenzsiedlung” (the Lenz estate)).

3. General presentation of the practical project “Lenzgesund”

Almost in parallel to the district’s inclusion in the Senate “Social District Development” program, the Hamburg-Eimsbüttel Health Office also began to contribute to the district’s management in 2001 with its first health-promoting activities. These activities initially focused on the situation of young families and migrants, as the Lenzsiedlung is a large housing estate close to the city center that is home to very many children, mostly of foreign background.

Two years later, in the autumn of 2003, at the initiative of the health office, the first “Lenzgesund” round table was launched, which was intended, on the one hand, to contribute to networking among the actors and, on the other hand, to serve as an interface between the actors and the population. At the round table, three to four times a year, various institutions, and individuals from the health, education, and social sectors met in and around the Lenzsiedlung, with the aim of establishing health promotion and prevention as a priority field of action for district development.

A systematic prevention program entitled “Lenzgesund” was introduced by the health office in 2005, and has since been implemented and further developed together with other collaborative partners. The core of the dynamic concept of action is the organization and coordination of networked assistance around pregnancy, childbirth, and the first years of life, with the aim of improving health status with the active participation of the residents in the neighborhood. The idea is to make a small-scale contribution to equal social and health opportunities. The objectives in detail are:

• to improve the health situation in the neighborhood, especially for children and their parents;

• to develop a good health care structure in the vicinity of the settlement for the residents;

• to build and secure bridging structures between the available medical and social services and the health needs of the population;

• to promote networking activities within the framework of individual fields of action of the program; and

• to achieve collaboration between health and social care institutions and health promotion.

After several discussions at the round table (see below), the prevention program, which initially consisted of nine fields of action, was divided into seven fields of action (with individual subgoals and target groups) as well as two cross-cutting tasks that are to be integrated into all fields of action. These fields of action and cross-cutting tasks of the prevention program are:

1. Preparation for birth

2. Pregnancy/parenthood among minors (services for teenagers)

3. Support after birth and during the first year of life

4. Vaccination

5. Early assistance, early intervention, language support

6. Dental health care

7. Nutrition, exercise, and addiction

8. Cross-cutting task: strengthening health literacy

9. Cross-cutting task: preventing violence

The Hamburg Institute of Medical Sociology provided scientific support for this process of developing, testing, and implementing a systematic concept of action or a prevention program for a disadvantaged neighborhood as part of Federal Ministry of Research-funded prevention research.

In the following, individual methods and approaches will be presented for the activation and participation of actors and residents in the Lenzsiedlung that have been tested within the framework of collaborations between science and practice, though it must be said, in qualification, that the procedures and methods used mainly served to generate information and gain knowledge in the research process, but, as an important “side” aspect that should not be underestimated, always necessarily also involved the activation and participation of the particular groups of people surveyed.

The following two examples, the “Expert survey” and “Resident survey,” are to be seen against this background. The third example reports on successful participation culture in the context of capacity building and development for the implementation and dynamic further development of the prevention program through the “round table” in the Lenzsiedlung.

4. Examples of activation and participation in the Lenzsiedlung

Participatory approaches in community-based health promotion always include techniques and methods of activation and participation in equal measure, as basic elements, and are always also aimed at the main actors in question and the inhabitants of the community, district, or neighborhood. “Participatory” then means that not only the citizens or residents are to be involved in the events and to help shape them, but also, and especially, the professional actors in the field in question. This consideration is taken into account in the following presentation and discussion of methods of community-based health promotion taking place in the Lenzsiedlung in Hamburg-Eimsbüttel. The first section represents the participation of local actors but is only briefly examined because the procedure has already been described in more detail elsewhere [12, 13, 14, 15]. The second section concerns the participation of residents through focus groups as well as a (quantitative) survey. In these examples, the focus is on determining the development of capacities in the district. The third section focuses on the direct involvement of citizens in health promotion activities. In the fourth section, the “Lenzgesund” round table is outlined, that is, the collaborative committee on which local professional actors and residents together control the development of the practical project (with the support of research).

4.1 Survey of actors concerning capacity building in the neighborhood

With the help of a survey tool developed by the project, central actors from the health and social sector were asked about capacity building in the district. Capacity building has barely been used as a concept in Germany thus far. Nevertheless, capacity building has been explicitly listed for several years as a benefit dimension and intermediate target parameter for prevention and health promotion. This relatively new indicator – which is still defined to differing degrees of broadness in the literature – essentially refers to:

• the willingness and ability of institutions or professions to develop appropriate structures to be able to successfully offer and maintain a specific action

• the use and mobilization of appropriate resources and collaborative structures; and

• the development of adequate strategies for the implementation and evaluation of measures.

• The questionnaire developed by our team on “capacity building in the district” (Kapazitätsentwicklung im Quartier = KEQ) comprises five thematic complexes or dimensions, which were operationalized with 54 closed items (5-point scales):

• Public participation (level of civic participation, self-initiative of residents, promotion of civic participation)

• Local leadership responsibilities (extent of local leadership, social, and governance skills)

• Available resources (material resources, knowledge and information, social resources)

• Networking and cooperation (local and supra-local networking and collaboration, quality of networking and collaboration)

• Health Promotion (representing the existence and use of health-related infrastructure).

The first pilot study was conducted in June 2006. In addition to the assessment of the current situation (T1), a retrospective assessment of the situation was also to be made before the introduction of individual health promotion offers in May 2001 (T0). In addition to the level of approval, qualitative information was also requested to explain why the statements were judged to be of more or less relevance. Based on a list that was drawn up together with our practice partners, we called on 48 professional actors from the health and social sector (including district development, community work, education, and upbringing) from the area surrounding the Lenzsiedlung to participate in the survey. After sending or handing over the survey documents, only 27 questionnaires were actually evaluated (56% response rate) due to subsequent cancelations and/or short-term unavailability. The attempt to include socially engaged residents in the quantitative study with the same questionnaire was impractical because of the low level of participation; however, we have organized the residents’ participation in this issue with different approaches (− > 4.2).

In the following, the results for the five dimensions of capacity development at 3 points in time are summarized in a spider diagram (see Figure 1). The average scores are shown per dimension in 2001 and 2006, as well as for the T2 survey in 2008, and, in each case, they can range from 1 to 5 (= best score). The overall positive results for district development and health promotion in the district are to be emphasized: we attribute these, above all, to the general climate of engagement for the neighborhood as well as to the strong commitment and perseverance of individual actors from the health and social sector. There are also positive developments in the field of public involvement – understood as participating or sharing in the community life of the Lenz settlement (e.g., attending information events or neighborhood festivals, using public services). Many respondents attribute this to the more open “climate” in the district, which has been fostered most notably by the use of various activation techniques (e.g., resident surveys, information afternoons), as well as awards and accolades for the district management and the population. However, only partial progress is noted in self-selected initiatives and the assumption of more personal responsibility (primarily in the low-threshold area, such as childcare/fixed preparation).

Figure 1.

An overview of the capacity development dimensions (mean values: 1 = worst, 5 = best value) (own illustration).

However, the T2 survey in June 2008, still shows a certain growth or consistency of the values on the spider diagram, which means that, after the seven-year activity phase, stable capacity building and sustainable capacity development in the Lenz estate could be assumed.

All changes T0–T1 and T0–T2 are very pronounced (ES ≥ 0.8) and highly significant (p < 0.001). From T1 to T2, no statistically significant improvements can be detected, but only tendential ones.

Originally called “(Supporting residents through) health care services”.

Representation as a spider diagram proved to be particularly suitable for visualizing the results and discussing them with the inhabitants.

However, it must be pointed out that the extent of capacity building is assessed here by the responsible actors themselves, and, so, there is a risk of subjective distortion. For this reason, we also consulted the residents about capacity development, with the aim of validating the expert results.

4.2 Two approaches to the resident survey about capacity development in the neighborhood

In a pretest in the winter of 2010/2011, focus groups were carried out to involve the population. The objectives were:

• to triangulate results from previous expert surveys

• to further involve residents and attain information about how they perceive things

• to gain feedback on the “Lenzgesund” prevention program; and – fundamentally associated with the implementation of the focus groups

• to activate residents.

The focus groups consisted of several engaged residents of the Lenzsiedlung who had been selected and who initially worked through a discussion guide as an introduction. In a later step, individual items from the KEQ questionnaire were then discussed.

In addition to the focus groups a citizen survey (n = 157) was carried out in the Lenzsiedlung in autumn 2009. This was carried out not by us, but in collaboration with us by the provider of children’s and youth services “Lenzsiedlung e.V.,” and we were able to introduce some of the same items in the survey as in the KEQ questionnaire and compare them with the results from the focus groups.

It was interesting that the results of the focus groups and the quantitative survey of the population by Lenzsiedlung e.V. were sometimes almost identical. In general, the two surveys of the residents were not completely consistent with the expert judgments, and also differed from each other in some respects.

However, the most important aspect of all three approaches to measuring capacity development was reporting the results. On the one hand, this element of participation was implemented as part of events that were announced and held in the district. On the other hand – more importantly – the results were introduced and discussed at the “Lenzgesund” round table meetings in order to further develop individual fields of action or drive forward strategic planning for the program as a whole.

4.3 Involve and activate residents through a resident survey

The aim of the activating resident survey conducted by our project at the beginning of 2006 was to determine how citizens perceive, use and assess ongoing health promotion and prevention activities in the district, as well as which activities they could possibly participate in themselves or which they could reinitiate themselves. In addition, starting points for future projects were to be identified, and direct participation was sought. We, therefore, once again applied a classic tool in civic involvement, the activating survey.

Two-thirds of the interviews were conducted by means of surveying passers-by. In order to reach migrants with insufficient knowledge of German, about a third of the interviews were conducted by committed residents of the Lenzsiedlung, who interviewed their friends, relatives, and neighbors. Some of these interviews were conducted in Turkish, Farsi, or Urdu. A total of 157 people between the ages of 14 and 58 were interviewed. Due to the survey method, the survey is not representative but provides relevant insights into the views of the population. Selected results of the survey will be presented in brief below.

The existing services were relatively well-known to the respondents; on average, each resident was familiar with about five of the 15 services. The ratings were almost consistently “good” to “very good” (90%). Only for a few services was there a greater number of “moderate” or “bad” reviews.

In addition to the acceptance of the services, the barriers to use perceived by the residents were also of interest. As shown in Figure 2, it was deficient information that was most often assumed to be a barrier (40%). Disinterest and a lack of motivation were conjectured by almost a third (31%) of residents and a lack of time by another fifth (19%). An uncertain environment or lack of a sense of belonging playing a role was reported by 12% of respondents. Answers such as “Isolation,” “Mistrust” or “Is not the best area” went into this category. Language was conjectured as a barrier by 6%, while lack of money and poor (spatial) accessibility both played a subordinate role, with only two mentions each.

Figure 2.

Barriers to the use of the services (n = 157; multiple responses possible).

In order to determine what wishes the residents have for health promotion in the district, they were first asked which services they would like to see set up next. The most desired offers were “cooking courses for healthy eating,” “addiction counseling,” and “smoking cessation” as well as “psychological counseling” (44–37% of respondents).

Another question dealt with the willingness of the respondents to participate, which was answered by 144 of the 157 respondents. Of these, 40% stated that they could imagine actively participating in health-promoting offers. The latter clearly showed that there is great interest among the residents in getting involved and in co-creation. However, the actual participation (even at the presentation of the results) lagged significantly behind the expressed interest.

4.4 “Lenzgesund” round table participation structure

Round table – this is a metaphor intended to make it clear that no one can sit at the head of the table. Nobody is in charge. Decisions are made together. The “Lenzgesund” round table was held for the first time in autumn 2003 at the initiative of the Eimsbüttel health office in the Lenzsiedlung. It serves as an interface between the actors and the population and aims to establish health promotion and prevention with participation as an area of activity within the district development. Further overarching objectives of the health-promoting activities of the “Lenzgesund” round table are described in detail [16]:

• Providing information and knowledge about health care

• Encouraging motivation to follow a healthy lifestyle

• Activating the population and

• a particularly important concern – connecting the professional actors in the health and social sectors toward more informed and committed collaboration in everyday life and in the implementation of the prevention program.

At its first meetings, the round table more often organized small groups for special tasks, but there were no long-term working groups that were also active between the plenary sessions. Measures and projects were organized by and between individual institutions – in particular, the health office and the Lenzsiedlung Association.

The participation of the residents was envisaged in this initial conception of the round table. However, it became clear that the sessions were not interesting for them, as a collaboration between actors and institutions with regard to the implementation of health promotion and prevention services was becoming more and more important. Therefore, the development of professional concepts and professional decision-making processes mainly determined the discussion at the round table. In addition to the function of ensuring information exchange, the round table thus increasingly had the function of an advisory body.

The adoption of the Lenzgesund prevention program in January 2005 strengthened the structure of the round table as a result of the determination of objectives or fields of action and the establishment of permanent working groups. In June 2011, 10 to 12 institutions with 14 to 18 representatives formed the fixed core of the round table; others were only present occasionally (see Figure 3).

Figure 3.

Facilities at the “Lenzgesund” round table.

The “Lenzgesund” round table has significantly promoted networking among actors and their areas of activity, and thus the implementation of the prevention program. However, from the point of view of our practice partner, the Hamburg-Eimsbüttel Health Office, it cannot be expected to provide permanent and continuous monitoring and implementation for the program. It is more of an instrument of ideation and activation.

The experience of recent years shows that it is possible to activate a relatively large number of institutions and their representatives to exchange information and ideas. However, for many participants, this purpose was not sufficient for a permanent, regular engagement. Even so, there was a smaller group that was continuously involved. In addition, communication at the round table has developed into a series of sustainable working relationships in everyday life.

For the health office as the organizer of the “Lenzgesund” prevention program, this meant that, in addition to the networking committee, the “Lenzgesund” round table, it needed stable working alliances with other individual institutions. Such alliances developed with the “Lenzsiedlung” Association and in approaches with the “Rauhen Haus”, a further free provider of active social work in the district. The aim was also to strengthen collaborations with schools in the area surrounding the Lenzsiedlung.

Interesting information on the performance of the task and the role of the round table is gained from a survey of the participants. According to the respondents, the round table particularly fulfills the tasks of exchanging information, identifying problem areas, and developing goals, as well as the general management and further development of the prevention program (values 3.8–4.0 on a five-point scale, with the best value being 5).

In addition, the district diagnoses published as part of the research projects are considered important for the implementation of prevention and health promotion in the Lenzsiedlung [16, 17] and were made available and discussed at the round table, as they can be used to “provide better and targeted support.”

The importance of the round table was also assessed in the context of a further survey in the autumn of 2008, with the instrument for measuring KEQ already presented. Here, too, it can be seen that, compared to other networking structures in and around the district, the importance of the “Lenzgesund” round table in the area is evaluated as important to very important, i.e., it holds an outstanding position.

From our point of view, it can be said that the “Lenzgesund” round table, with its continuous and regular work, played an informative, orienting, motivating, moderating, and coordinating role. Unfortunately, the original intention to involve the residents directly in the meetings of the round table could not be realized because there were not enough interested residents to take part continuously.

The participatory approaches and project experiences presented in the community-based health promotion activities show the diverse possibilities of setting-related involvement and activation of actors and residents [18] using the example of the Lenzsiedlung.

5. Discussion

Participation can be realized to different degrees depending on the practical conditions within a health promotion program and the living conditions of the target group. The object is to find the appropriate level of participation based on the conditions [5].

This text presents examples of participation and involvement of key implementation actors as well as parts of the population of a disadvantaged neighborhood. Both the surveying of the main actors and the surveying of the population represented a complex approach of activating and involving different groups, following a systematic and complex procedure. For this, the corresponding resources must be to hand and available, as can certainly be the case in a project between science and practice. This was different with the “Lenzgesund” round table participatory mode also presented – which can also be designed and implemented within the framework of the standard tasks.

If one wants to classify the examples in the step models, one may say that the presented forms of surveys – in simplified terms – are about “being allowed to have a say.” In the model (Figure 4) they are to be classified as medium-to-high participatory approaches, all the way up to “partnership-based collaboration.” They do not reach the range of categories for which decision-making power must be handed over to the residents. The round table is also not a body endowed with authority and decision-making powers that decides on the services to be provided by other actors, institutions, or bodies. In the language of the ladder models, the round table is a partnership-based collaboration in the interests of consultation, involvement, networking, and voluntary prioritization by participating institutions for their health-related activities in this disadvantaged settlement.

Figure 4.

Classification scheme for various forms of sham-participation to real participation (“12-step ladder”) according to Trojan 2001 [19] (source: [20]).

Looking at the capacity-building process in its entirety and over time, the Lenzsiedlung saw a relatively large amount of civic involvement and social participation on a small scale at different levels, for example, the health talks for women, the many neighborhood festivals and meet-up initiatives, which were repeatedly awarded prizes for best neighborhood. If we take a look at the different traditional and creative participatory instruments, methods, and procedures mentioned at the start, it becomes clear that these usually fit with programs and (standard) activities that are equipped with special and sometimes considerable resources for participation and civic involvement. The possible participatory methods are, in each case, always strongly contextual, i.e., dependent on financial resources, the subject matter, the nature of the program, and, not least, the competence encountered among the citizens to be involved.

6. Conclusions

Civic involvement seems to be particularly pronounced when no very big decisions have to be made. For this context, there is a wealth of techniques and procedures that can be unpacked from the method tool kit. However, this idea of “always just being asked” (and, unfortunately, often without any consequences) does not necessarily promote participation in the long run.

A successful example of participation in terms of more concrete, manageable decisions include (in Germany, but similarly also in other countries) financial disposal funds, e.g., in the context of social district development. Here, the inhabitants of disadvantaged districts and neighborhoods can co-decide which money can be spent for what and, above all, how quickly and unbureaucratically this can be done (e.g., in the design of building entrances). This is where the particular success of this model lies. This example also shows that it is not so much a fundamental question of power that motivates those involved but, rather, the unbureaucratic implementation of participatory programming.

According to the Ottawa Charter and the actors and scientists who refer to it, civic involvement and participation are considered normative “must have” in community-based health promotion and prevention. No objection can be made to this normative requirement. It is simply that participation should not be elevated from norm to dogma. Not everything that comes from the top is bad just because it comes from the top (see, for example, the programs of urban social development!). Furthermore, participation must not become an end in itself, in the sense that it is practiced but has no consequences. This can then lead to frustration and disappointment and destroy the confidence that has already been built up. It is quite fatal if procedures and methods of participation can ultimately be turned against those involved, with the result that, under the guise of quasi-democratic legitimation, interests can be enforced that a majority of the citizens involved do not have.

7. Way forward

Of course, offers, and procedures for involvement and participation are generally positive, since they are already legitimate for democratic reasons alone. They should be implemented in health care regardless of whether there is empirical evidence on their effectiveness in managing disease and maintaining health.

Certainly, not all potential and possibilities of involvement and participation on the part of the population or the target group(s) were exploited in the implementation of the “Lenzgesund” prevention program. Participation and involvement naturally require professional management for their diverse procedures and forms in program development and implementation. At this point, however, the main actors already overloaded by the standard tasks are often overwhelmed from a technical and time perspective. In order to prevent nonuse, under-use, and misuse, it would be necessary to have municipal health promotion management that explicitly provides for the organization and implementation of civic involvement in the job description and also makes the necessary resources available for this purpose.

Acknowledgments

We would like to thank our colleagues Waldemar Süß and Karin Wolf (formerly Mossakowski) for the dedicated research work they have carried out over the many years of our three joint projects!

We thank the (former) Federal Ministry of Education and Research (BMBF) for funding the three projects:

1. BMBF research project “Capacity building for prevention and health promotion among children and parents in a disadvantaged neighborhood” (FKZ: 01 EL 0414), 2005–2008.

2. BMBF research project “Long-term evaluation and transfer potential of the” Lenzgesund “prevention program – development of practical aids for interventions, evaluation and monitoring of participatory health promotion in disadvantaged neighborhoods” (FKZ: 01 EL 0812), 2009–2012.

BMBF research project “Long-term evaluation of complex interventions in neighborhood-related health promotion and prevention measures – An investigation of community capacities ten years after the start of the Lenzgesund program” (FKZ: 01 EL 1410), 2014–2017.

Last but not least, we would like to thank the institutions, actors and residents of the Lenzsiedlung for their dedicated work toward the program’s practical implementation and during the accompanying research!

Conflicts of interest

The authors declare no conflict of interest.