‘Lenzgesund’: A Long-Term Community Health Promotion Programme in a Deprived Neighbourhood and Its Evaluation

The contribution will present a highly visible health promotion programme in a deprived urban neighbourhood, initiated in 2004 by the health authority of the Hamburgian district Eimsbüttel. Its focus was on capacity building in cooperation with local actors/parties and residents. During 2005 and 2017, the programme, called ‘Lenzgesund’, was researched by a team of the Institute of Medical Sociology. The research aimed at giving feedback to the actors about how well they achieved their goals. For this purpose, we had to develop and test new approaches to evaluation. KEQ (Kapazitätsentwicklung im Quartier/capacity building in residential quarters/ neighbourhoods) is the acronym of a newly developed questionnaire for measuring community capacities being considered as relevant for health. KEQ can be seen as an intermediate outcome parameter for health promotion programmes and activities on the community level. Another innovative approach to evaluation was an audit of the programme through experts from outside Hamburg in order to have a more neutral external view. The first paragraphs will present the practical programme and its development in phases from 2004 to 2012. In the second part, we will give a short account of the two main approaches to long-term evaluation of the programme.


Introduction
A frequent criticism of health education interventions (nowadays usually also referred to as health promotion measures) relates to the fact that merely behavioural changes in individuals are encouraged and that the mostly minor successes are not sustainable.The Ottawa Charter for Health Promotion (1986) [1] proposed a new focus: emphasis should be placed on changing relationships, making structural improvements at a local level and the participation of residents.This concept was later defined as Healthy Public Policies [2] and has proven to be at least partially effective in exemplary studies [3] as well as in a more recent review [4].
The following is a report about a community health promotion programme in this sense.The first part of the article (sections 2-4) deals with the 'Lenzgesund' action programme (named after the neighbourhood's name of 'Lenzsiedlung') implemented by the public health authority in one of the larger boroughs of Hamburg.The second part (sections 5-8) consists of an account of accompanying research from a total of three projects and the action programme's evaluation by the Institute of Medical Sociology at the University Medical Center Hamburg-Eppendorf.
The detailed presentation of this programme and its accompanying research results is legitimised mostly by the fact that it won the Academy's quality award for public health in 2014 [5].

Start of the Lenzgesund prevention programme
In the Hamburg borough of Eimsbüttel, the local public health authority began its work on health promotion and reporting measures in the second half of the 1990s.After a series of projects designed 'top-down' during the initial phase (including school vaccination projects and regular information events on health and environmental issues), the public health authority then began its first small-scale, low-threshold and more participatory health promotion measures in 2001 in the Lenzsiedlung of the Hamburg borough of Eimsbüttel.This is a high-rise housing estate with 3000 residents in social housing.It is worth highlighting that the proportion of children and adolescents, migrants, single parents and recipients of social security is well above the Hamburg average ( [6], p. 50ff).
The measures were developed to target young families in particular.Since the public health authority had no human resources and only very few material resources for health promotion measures according to the establishment plan, it needed to acquire cooperation partners and to develop additional financial resources for this project.
In October 2003, the public health authority invited in institutions from the areas of social affairs, child and family support, education and health care who were working in or on behalf of the Lenzsiedlung.It suggested setting up a round table to develop health promotion measures or to increase their effectiveness by cooperating and networking.The presence of a permanent practice partner on location in the form of the neighbourhood association 'Lenzsiedlung e. V. -Association for Children, Youth and Community' [7] was highly beneficial.
In November 2003, the Institute of Medical Sociology (IMS) at the University Medical Center Hamburg-Eppendorf and the public health authority Eimsbüttel agreed to collaborate on a research project into health promotion through the formation of structures to develop capacities in the Lenzsiedlung.In 2004, for the IMS' funding application to the Federal Ministry of Education and Research, the public health authority developed a detailed 'Preliminary Action Concept' for a planned project called the 'Lenzgesund Prevention Programme -Networked Early Support Measures for Pregnancy, Birth and the First Years of Life' [8].
Once the research project had been approved, preliminary action and research concepts were presented to the round table in January 2005, and the participants were invited to jointly implement and further develop the prevention programme, which met with a positive response.
Even though Lenzgesund only had access to material resources in the middle fourdigit range in addition to a grant to finance a family midwifery offer and to provide eight working hours per week for planning and organisation, it was nevertheless an ambitious project for the borough at the time, which increased its importance and the 'health promotion' task's organisational embedding in the authority.
The regular feedback the research group presented to the round table strengthened the latter's function and cohesion and promoted the role documentation, evaluation and quality development played as part of the practical work.

Main features of the Lenzgesund prevention programme
The method chosen in the Lenzsiedlung can be characterised as a participationoriented 'bottom-up' approach to neighbourhood-related health promotion and is characterised by the following design elements: health promotion is primarily designed within a residential area by parties who are already active there and is primarily aimed at the area's residents.Offers from external providers, for example prevention courses, in individual cases also those partially subsidised by health insurance companies or advisory services, are brought into the neighbourhood.The offers are made visible to all residents via internal communication channels within the neighbourhood.In the same way, the providers receive feedback relatively quickly for the offers' needs-based further development and expansion.Communication and cooperation form the core of neighbourhood-focused health promotion.To this end, the 'permanent' presence of a contact person as well as of a coordinator and a cooperation and coordination committee are important.
The prevention programme's overriding aim was to promote health and to strengthen the social opportunities available to the Lenzsiedlung's residents.The development of community capacities played a crucial role (see below for their definition and measurement).
The preliminary action plan presented by the public health authority ( [9], p. 71ff) defined the following 9 or 11 fields of action in which the abovementioned goals should be pursued: For each field of action goals, target groups, the initial situation, offers, opportunities to create structures, possible cooperation partners as well as success parameters and measurement methods were presented.Despite this detailed formulation, the preliminary action plan was not understood as an agenda that had to be implemented 1:1 but was rather intended as a 'powerful impact' that should give potential cooperation partners a decisive impetus for action.

Implementation and further development of Lenzgesund
The health promotion measures' development in the Lenzsiedlung, the timing of which did not entirely overlap that of the prevention programme, can be broken down into four major phases that had different 'development tasks' , which we will briefly outline below.

2001-2003 Gaining a foothold in the neighbourhood
The phase was characterised by the planning, implementation and evaluation of initial offers and the establishment of local communication.
One of the offers was an external consultation hour for the borough's advisory service for mothers, which was, however, discontinued after 2 years due to a lack of response.With 16 events in 2 years, the 'Health talks for women by women' were strongly geared to the needs of migrant women both in terms of content and methods used.These were very well received.From autumn 2002 onwards, it became possible to employ a family midwife in the Lenzsiedlung who not only provided noticeable support for the neighbourhood's young families but was also considered by other institutions as an important addition to their own offers and who thereby prepared the basis for cooperation.This development ultimately led to the establishment of a 'Health Round Table ' in the autumn of 2003.

2004-2010 Growth through cooperation
The topic of this phase was the development of a cooperative working structure and linked to it the offer's quantitative and qualitative strengthening.
The round table, which included youth welfare institutions, day-care centres, schools, the borough's administration and borough politicians as well as GP surgeries, pharmacies and other health care providers, initially dealt with collegial advice on current offers and the initiation of smaller projects such as a (multilingual) orientation guide on how to access health care services.
At the beginning of the cooperation, the start of the prevention programme and its scientific supervision in 2005 created new, activating impulses.In the months and years that followed, various parties/institutions developed further health promotion offers for the neighbourhood, including the 'baby driver's license' (a series of seminars for parents-to-be), a back training programme, the violence-prevention exercise programme Fit & Peaceful, the psychomotoric exercise programme, the 'health scout' (a contact centre that mediates between residents and the neighbourhood's official authorities), thematic speaking courses and the Zahn-Lenz dental-health campaign ( [6], p. 182ff).
The round table met three times a year.In addition to reports from practical settings, specialist inputs and feedback from the accompanying research, at longer intervals it also reflected on the quality of its own way of operating and, if needed, adapted the programme to the changing situations in the neighbourhood.Starting in autumn 2009, the Lenzsiedlung association increasingly organised its own offers such as nutrition and exercise courses, swimming courses for female migrants and information events about, for example, breast cancer prevention and mental health.
Participants from previous events actively enquired about other offers, for example swimming courses or application-oriented language courses and became involved in organising them.Other residents began to develop their own offers such as dance classes for girls or boxing training for various target groups and have been managing these successfully for years.

onwards Stabilisation
In mid-2012, the Eimsbüttel district office, two local housing associations and the Lenzsiedlung association prepared an agreement to secure the continuation and further development of important offers for the period after the prevention programme and neighbourhood's development would end.This included annual funds provided by the two housing companies in the low five-digit range, and the district office provided supporting work capacities as well as a disposition fund amounting to € 4000 per annum.This agreement was concluded in early 2013.
At this point in time, as declared at the beginning of its involvement in the neighbourhood, the public health authority had withdrawn from its role as initiator, moderator and organiser but at the same time pledged further support for health promotion measures.Some of the tasks previously performed by the round table, which was also dissolved in mid-2012, were integrated into two other local bodies.
When the formal prevention programme ended in mid-2012, health promotion in the Lenzsiedlung was at a quantitatively and qualitatively impressive stage of development.Various aspects of the situation which had been achieved by then indicated that the essential 'achievements' of 8 years of structured neighbourhood-related health promotion would continue to exist beyond 2012, and constructive further development seemed possible [6].
The following sections of this report investigate the extent to which the expectations for the sustainable embedding of the health promotion measures have been realised.Section 5 provides an overview of the three research phases or projects.Sections 6 and 7 focus on the two most important evaluation approaches which were used to present and assess the ongoing developments following the prevention programme's final phase in 2012 up to the end of 2016.Finally, Section 8 briefly discusses the current situation and perspectives.

The research projects at a glance
In November 2003, about 2 years after the first as yet unsystematic activities were carried out in the Lenzsiedlung by the Eimsbüttel public health authority, initial contact was made with the Institute of Medical Sociology at the University Medical Center Hamburg-Eppendorf.In 2004, these led to the research group's first application for funding from the Federal Ministry of Education and Research and to the application's approval.In early 2005, formal research began.

Research project 1: Developing evaluation methods in a participatory manner
The first project's primary aim (2005)(2006)(2007)(2008) was to develop and test methods for evaluating small-scale neighbourhood-related health promotion measures.The tests and feedback also contributed to the further development of the practical activities.
The project's initial, innovative thematic core was the development of a survey instrument: Structure formation or capacity development ('Capacity Building') as an intermediate success parameter was to be designed, operationalised and tested.While the concept had been received and accepted in Germany, it was being not applied and used for scientific work.
A secondary, thematic core of the research project focused on indicators for smallscale health reporting.However, we will not be dealing with this topic further in this article [6].
In detail, the Institute of Medical Sociology's activities during the first project from 2005 to 2008 were as follows: • A survey of the municipal capacities available in the Lenzsiedlung at the following times 2002 (retrospectively), 2005 and 2008; • Conducting of a resident survey on health offers and needs (February/March 2006); • Neighbourhood-specific evaluation of the results of physical school entrance examinations and school dental examinations in the first-and fourth-year primary school children; • Preparation of two 'neighbourhood diagnoses' , i.e. small-scale health reports (October 2006 and October 2007); • Accompanying research on individual interventions; • Creation of the overview 'Who is who in Lenzgesund?' (October 2007).
Based on this successful cooperation, it was possible to achieve the approval of the second project and a continuation of the joint work.

Research project 2: Generate knowledge and practical aids
The rare possibility of the long-term evaluation of a socio-spatial prevention programme in a disadvantaged neighbourhood was to be exploited in the second project (2009-2012) by continuing with the evaluations.In addition to the evaluation, a second focal point was to test the transfer of both the practical approaches and methods of evaluation and quality development.
A so-called health team was formed as a participatory planning and steering committee for the evaluation procedures and innovative interventions, which alongside the Institute of Medical Sociology also included the Lenzsiedlung association, the Rauhe Haus Eimsbüttel and the public health authority as the programme's sponsors and organisers [6].

The focus: The KEQ [capacity development in the neighbourhood] instrument
The research group's focus was on the surveys about the development of community capacities in the neighbourhood supported by the KEQ instrument, the results of which were presented and discussed at the round table [8].
The KEQ was developed on the basis of international preliminary work [10] and was explicitly introduced by Walter and Schwartz in 2003 as a benefit dimension and target parameter for prevention and health promotion measures ( [11], p. 206).More detailed information on this has been published elsewhere [12,13].
The score of the instrument can range from 1 to 5 points.When the score goes up, we have improvements on the respective dimension, when it goes down, this shows a decline in achievements.The reliability of the five subscales of KEQ was checked using Cronbach's alpha and Spearman-Brown's split-half coefficient.The internal consistency ranges from 0.82 to 0.94 and is without exception satisfactory [12].
The KEQ questionnaire as well as supporting information and materials for carrying out, evaluating and documenting future surveys is freely accessible on the Institute of Medical Sociology's website [14] as well as on other Internet platforms [15].

Research project 3: Sustainability checks
The long-term evaluation was aimed primarily at the aspects of quality development and stabilisation and covered the years 2014-2017 [16].
In terms of content, the process of stabilising offers for neighbourhood-related health promotion following the end of the prevention programme in the summer of 2012 should be presented and checked using various evaluation approaches (for the approaches not presented here, see [17]).
The focus was still on the method we developed for assessing the 'capacity development in the neighbourhood (KEQ )' , which we intended to make even more practice-friendly in design.Another focus was the testing of an audit procedure, which was supposed to complement the various internal evaluation views by providing an outside view.Reports about these two evaluation approaches follow below.

Evaluation of the capacity development in the neighbourhood (KEQ )
The KEQ instrument has been presented in detail elsewhere [12] and was last presented in an improved and abridged version [18].It allowed us to compare the previous results from 2011 against two points in time after the programme had expired (2015 and 2017).
The results for the five capacity development dimensions observed in the Lenzsiedlung neighbourhood (KEQ ) have been summarised in an overview network diagram (see Figure 1).Average point values per dimension are shown for the years 2011 (t3), 2015 (t4) and 2017 (t5), that is for the final phase and the stabilisation phase of the Lenzgesund prevention programme that took place after the summer of 2012.
As a result, the continued positive KEQ assessments in the fifth survey (t5) should be emphasised.This applies equally to all dimensions, whereby compared with the third survey (t3), after a short-term decline, improvements were again observed in the 'health promotion' dimension in particular (mean: 3.6 at t5 compared with 3.2 at t4).This confirms that the capacity development process continued during the stabilisation phase.Despite the expiry of the official Lenzgesund prevention programme in 2012, a lot is obviously still going well and seems to be sustainable [18].

External evaluation via an audit
The KEQ instrument's aim is to allow for a quantitative survey of the community capacities.To do this, a significant number of people are usually needed who are both familiar with the community and who have the broadest possible general knowledge of the neighbourhood or district which extends beyond their respective specialised tasks.These respondents, however, represent an inside view of the outcome evaluation; in many cases they are also parties who are active in the neighbourhood at the same time.This leads to possible accusations that the local experts are too involved in the health promotion activities to give neutral answers, or, to put it even more blatantly: that the respondents would in fact be carrying out a self-evaluation and therefore evaluate the situation too positively.
To verify this, we organised a systematic review by five external experts and compared their assessments with the results of the local experts.Our procedure was closely based on an audit or the overlapping procedure of a peer review as it is practised in the medical field [19].
Table 1 summarises the document-based assessments of the first audit, i.e. the auditors' assessments for the years 2013/14 and relates them to the mean values from the KEQ survey of February 2015, which was also based on assessments for the years 2014/15.The auditors were of course unaware of the results of the KEQ survey.On average the auditors' assessments were more positive for all five dimensions.With a positive deviation of +0.1 to +0.9, they were, in some cases, significantly higher than the assessments of the local parties (column on the right of the table).This is particularly apparent for the dimensions 'Available resources' and 'Health promotion'.The individual statements made by the auditors (A1-A5) show that their assessments were not homogeneous, rather in some cases they do clearly differ, which is explored and discussed in more detail elsewhere [16,20].In general, the comparison shows that the external auditors working based on the documents provided from the accompanying research made more positive assessments than those we received from the parties involved in the neighbourhood using KEQ.We explained this mainly by the fact that the parties' high expectations are often disappointed during the course of everyday experience, and they accordingly rate their successes low.
Despite our reluctance to generalise too quickly, we can say that for evaluations it is not always true that self-evaluations always result in the assessments being too positive; as in our case, the opposite can also be true, namely there can be an insufficient appreciation of one's own achievements [20].

Conclusion and outlook
Our cooperation with the parties of the Lensziedlung could just as easily be called practice-oriented evaluation research or evaluative practice-oriented research.It was always about a 'hybrid' , namely the implementation of a 'model' programme in a disadvantaged neighbourhood on the one hand and the development of model evaluation approaches on the other.The integration of scientific and practical evidence production approaches was a guiding principle for the entire cooperation process (since 2004), that is for the joint efforts of practical application and research in the Lenzsiedlung.We are convinced that the work put into the Lenzsiedlung was and is sustainable.
In addition to the positive results of the evaluations, we can also rejoice in concrete decisions in recent times: on the basis of the Prevention Act in Germany and its implementation in Hamburg, it has been decided that municipal or neighbourhood-related health promotion should be financed and implemented jointly by the public health authorities and social insurance institutions.The first of these cooperation projects in Hamburg is entitled: 'Local Networking Centre for Health Promotion: Healthy in Eimsbüttel' and since August 2018 has been managing health promotion measures in two further neighbourhoods [21] (Eidelstedt and Schnelsen-Süd) based on the trials conducted in the Lenzsiedlung.However, the experiences gained from the programme will also continue to bear fruit beyond Hamburg: since June 2018, 'Lenzgesund' has been presented as an inspiring example for the development of integrated municipal health strategies on the service pages of the nationwide Internet portal 'Partner Process Health for All' [22].The programme is furthermore held up as a model of good practice in the second large practice portal for equal health opportunities [23].

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Birth preparation • Pregnancy and parenthood of minors • Support after birth and during the first year of life Health action competence/Health literacy

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Lenzgesund': A Long-Term Community Health Promotion Programme in a Deprived… DOI: http://dx.doi.org/10.5772/intechopen.1019132010-2012 Increased embedding Increasingly, health promotion measures were incorporated into the offer profile of the local facilities and into the residents' range of expectations and even actions.

Table 1 .
External and self-assessments up to t4 (2015) in comparison (individual assessments and mean values).