Health promotion has pledged to tackle inequities in health within and between societies.1 There is common agreement among public health practitioners that setting based health promotion actions, fostering participation and empowerment can result in sustained efforts and thus reduce inequities in health.2 However, especially for disadvantaged population subgroups, initiating participation in and empowerment through health promotion actions has been described as difficult.3

The “BIG project” uses a participatory and collaborative approach to promote physical activity, as a key behavioural determinant of health, among disadvantaged women in three different settings: a residential area, a work site and a sports club.i The key characteristics of the women taking part in the project include: low income or social welfare, low educational attainment, unemployed or in a blue collar occupation, single parent or from an ethnic minority. Many of these women stem from Turkey or Russia; German disadvantaged women often have low educational attainment and are single parents. The overall goal of BIG is to increase physical activity among this group, supporting the women to overcome the social, environmental and economic factors known to inhibit physical activity. The project was stimulated by national health survey data indicating that women from these groups have high prevalences of sedentary lifestyles compared with other groups, and also have high prevalences of conditions related to inactivity such as being obese. Increasing physical activity among this group is considered to result in improved physical, social and mental health, as well as improving community connectedness and generating supportive environments.4 As such, the concept of physical activity employed in the BIG project goes beyond the traditional physical activity concept. The project resulted, among other things, in the foundation of low-fee exercise classes featuring child care, women-only indoor pool hours, swimming classes for women only, project offices to organise exercise classes run by these women and different marketing activities. The project evaluation considered the reach of project activities, potential changes in health behaviour, potential health benefits, as well as the potential social and economic impact of the project implementation.

Preliminary findings from the project’s evaluation highlight differences in the success of this approach in each of the different settings. This paper explores these differences and describes features of a set of “social catalysts” which seem to be crucial for a successful implementation of the project.

THEORETICAL FRAMEWORK: IMPORTANT FACTORS FOR HEALTH PROMOTION IMPLEMENTATION

The BIG project follows a structural model of health promotion implementation which integrates different intervention levels related to structures of lifestyle and policy making (Fig. 1).5 Within this model, health promotion implementation is determined by structures of both lifestyle (eg life conduct as well as the living conditions of a target group) and structures of policy making (eg policy makers and their policy environment). Taking the complexity of lifestyle and policy-making structures into account, successful health promotion implementation requires a multiplicity of intervention levels (eg at the individual, social and infrastructural level).

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Figure 1 Structure of health promotion implementation; modified model following Rütten.5

To exemplify the model, options and barriers for the implementation of women-only indoor pool hours are discussed along these different intervention levels. For example, Muslim women might be keen to go swimming but for cultural reasons will not use a public swimming pool that is open for both sexes (individual intervention level, life conduct). Individual policy makers might be interested in supporting Muslim women’s swimming by implementing women-only hours in the public swimming pool but cannot do so for political reasons (individual intervention level, policy making). Muslim women may have well-established social networks, increasing the likelihood that many of them would use women-only pool hours if the news is spread within their community (social intervention level, living conditions). A policy decision on women-only hours could be more likely if policy networks and interest groups (eg on women’s rights or integration of migrants) would advocate it (social intervention level, policy environment). Women-only swimming hours within a public swimming pool close to their living area may increase Muslim women’s participation in swimming (infrastructural intervention level, living conditions), but the public agency managing the pool may be restricted by certain regulations and therefore could refuse to provide this service (infrastructural intervention level, policy making).

To assess the relevant policy-making structures for the implementation of the project, BIG used an instrument based on a theoretical model for policy analysis in health promotion. This instrument has already been tested in an international study and assesses policy rationales along the dimensions of institutional goals, obligations, resources and opportunities.6 7 Using this instrument, qualitative interviews were conducted with policy makers at the national, regional (state) and local level in order to explore policy options for project implementation.

To assess the relevant structures of lifestyle (life conduct, social relationships, living conditions), the BIG project used a theoretical framework for conducting qualitative interviews with disadvantaged women.5 Additionally, focus group discussions with women and experts were conducted in order to explore assets for project development and implementation related to the lifestyle structure of the target group.

ASSETS FOR HEALTH AND DEVELOPMENT AS IMPORTANT FACTORS OF HEALTH PROMOTION IMPLEMENTATION

Over the last two decades, WHO has developed various approaches to foster the implementation of the original concepts and principles of health promotion. For example, the investment for health and development (IHD) approach and the Verona initiative explored pragmatic ways of positioning health issues in different policy sectors by fostering public participation and intersectoral collaboration.8

Most recently, work carried out by WHO has recognised that assets-based approaches to health promotion are crucial to support the promotion of population health and to reduce health inequalities.9 Asset models, in this instance, tend to accentuate positive capability to identify problems and activate solutions that promote the self-esteem of individuals and communities, leading to less reliance on professional services. In this context, health assets can be defined “as any factor (or resource), which enhances the ability of individuals, communities and populations to maintain and sustain health and well-being. These assets can operate at the level of the individual, family or community as protective (and/or promoting) factors to buffer against life’s stresses”.10

The present research project is one of the first case studies that uses the concept of health assets in designing, implementing and evaluating a health promotion intervention. Within the BIG project, the concept of health assets was adapted to an “assets for physical activity” concept. As such, assets for physical activity were defined as factors or resources that would enhance the ability of individuals, communities and populations to begin, maintain and sustain adequate levels of physical activity. As with the broader concept of health assets, assets for physical activity are thought to operate at the individual, family and community level.

Owing to the complexity of the structural model outlined above (Fig. 1), assets for physical activity were specified as potentially being individuals (eg exercise instructors as role models or policy makers supporting BIG as part of their professional work), social groups and organisations (eg supportive social networks or voluntary organisations and public agencies adopting exercise classes) or infrastructures (eg exercise facilities or public services providing child care).

METHODS AND RESULTS OF ASSETS ASSESSMENT

In order to collect information on potential assets for physical activity, the following methodology was applied. First, two focus groups were conducted in each setting. One focus group was organised for women in the settings and one for local experts. The aim of the focus group meetings was the identification of assets for physical activity (individuals, social groups or organisations, infrastructures) in the settings. In order to identify potential assets, participants of the focus groups brainstormed in small groups about assets on the different levels (individuals, social groups and organisations, infrastructures) and then charted all assets identified. Second, participants in all focus groups were invited to a workshop. In the workshop, participants in the focus groups reported on and discussed identified assets. Third, at the end of the workshop, all participants visualised overlapping assets identified by the different focus groups and brainstormed about potential interventions to promote physical activity among women. In the next step, these assets were used in the development of interventions for the promotion of physical activity among women in a cooperative planning process. For this purpose, a planning group of experts and women was established in each setting. These groups met six times to decide on and implement interventions to promote physical activity. Identified assets were presented to the groups at the first meeting, and the importance of their utilisation was reiterated throughout the planning process.

A number of potential assets for physical activity were generated through the focus groups and the workshop. At the individual level, 63 persons were nominated as being potentially helpful in supporting the work of the project. The workshop resulted in nine persons who were referred to by both focus groups. Among these were local government staff, exercise instructors, ministers of local churches and citizens. Organisations referred to as potential assets included sport clubs, volunteer organisations, different local government departments and commercial organisations. Experts named 43 organisations as assets; women named 27 organisations. The workshop identified, for example, a gym, a local church, the operator of the public indoor pool, two sport clubs and the local office of recreational and cultural affairs as overlapping assets. On the infrastructural level, 27 (experts) and 53 (women) assets were identified. Infrastructural assets nominated ranged from parks and recreational facilities to community rooms, unused grounds in the neighbourhood and the exercise facilities of schools and sport clubs. The workshop identified, for example, the facilities of sport clubs, the gym of a primary school, rooms in the local mosque and parks in the area as overlapping assets.

In order to evaluate the use of assets and their impact on the development of interventions, the utilisation of assets in the planning group was charted. The aim of the evaluation was to generate hypotheses about the impact of the identified assets for physical activity on developing interventions. Overall, the evaluation of the use of assets yielded that some, but not all, assets for physical activity were employed in the process of planning and implementing interventions.

At the individual level, some of the most powerful supporters of the cooperative planning process were identified through the mapping of assets. These included one well-respected woman from the migrant community and local government staff who were particularly supportive during the implementation of the project. Through the well-respected migrant woman, other women were reached to participate in project implementation. At the organisational level, some of the nominated volunteer organisations turned out to be assets for the implementation of project work. For example, the support of the local office of recreational and cultural affairs was crucial for the establishment of a project office in the residential area. However, mapping the potential assets did not always yield support, for example one of the nominated (labour) sport clubs rejected several invitations to be engaged in the project, and thus did not function as an asset at all. Also, it became apparent in the later stages of project work that some powerful supporters of the project implementation had never been nominated as assets. For example, the local adult education centre (folk university) was contacted at one point in the search for an instructor of the women-only swimming classes and is now one of the responsible bodies of BIG exercise classes, but had not been nominated either by experts or by women as an asset for the project.

The evaluation of the utilisation of assets and observations of the processes of project implementation raised a number of issues that, in our view, are important for health promotion in general, and the utilisation of assets-based approaches for health promotion implementation in particular. One focal evaluation question in this regard is which and why certain types of assets function as catalysts in health promotion project implementation and others do not, and whether determinants of success for these catalysts might be described? Answering these questions has the potential for strengthening the implementation of health promotion action by maximising the available assets in local communities.

Based on our observations, empowered individuals, informal networks, mediating social institutions and organisational structures might function as particularly important assets for the implementation of health promotion actions. We refer to these assets as social catalysts.

EMPOWERED INDIVIDUALS AS SOCIAL CATALYSTS IN HEALTH PROMOTION

In two of the three BIG settings (residential area, sports club), disadvantaged women acted as social catalysts, leading to the involvement of other disadvantaged women in the implementation of BIG. For example, in the residential area, a Muslim woman who participated in a qualitative interview at the start of the project assumed the role of coplanner and coworker in BIG and, at the same time, successfully invited many other Muslims to participate in both project development and activities offered by the project (ie different programmes and opportunities for physical activity). In a qualitative interview, she indicated to us that she had always felt comfortable in taking the lead among Muslim women, but had been very reluctant to do so in the presence of Germans. She reported that, through engagement in BIG, she feels now more comfortable speaking in the presence of Germans. Another native-born German from the residential area has had a similar career and function within the BIG project. In this case, small grants from a local civic trust and the Bavarian Ministry of Health allowed the BIG planning group to employ her part time as project coordinator for the residential area, where she now runs her own project office. One of her main tasks is to use her new job to develop what she already does, ie to act as a social catalyst for the participation and collaboration of other disadvantaged women in BIG activities.

It is, in our opinion, a positive outcome of project participation that these women are acting as social catalysts in BIG. However, there seem to be characteristics of these women that enable them to function in such a way. In our observation, they share the characteristics of the group of disadvantaged women (such as low income, unemployment or difficult migration background), while at the same time showing strengths in areas such as communication or other social skills. These characteristics seem to enable these women to function as respected community members whose opinion is heard.

INFORMAL NETWORKS AS SOCIAL CATALYSTS IN HEALTH PROMOTION

In two of the three settings of BIG (again in the residential area and the sports club), informal social networks were especially helpful in initiating and sustaining women’s participation and collaboration in project implementation. The evaluation indicated that Muslim women were over-represented in both BIG project development and activities. In our opinion, the ease in reaching Muslim women for participation in BIG may be related to their complex system of social relationships. Muslim women seem to have large social networks (with other Muslim women) that they use to exchange information and recruit social support. After key persons in these informal social networks had taken part in the project, many of their acquaintances readily joined in.

Similarly, informal social networks functioned as social catalysts for the involvement of a group of women who are immigrants from Russia in the health promotion activities offered by the sports club. In this case, it was also one key person (an empowered individual) from the group and an already established informal social network among the immigrants from Russia that proved to be crucial assets for the involvement of the whole group.

In comparison, disadvantaged native-born German women were more difficult to reach for health promotion activities. As the general marketing of the project (eg flyers, newspaper articles on project activities) was geared towards attracting all groups of women equally, these difficulties in reaching German women might result from the fact that they seemed to be rather isolated. We observed that German women usually joined and left the planning group meetings alone, while Muslim women would almost always join and leave in groups.

Especially in the sports club, difficulties were encountered in engaging German women in project activities. Just recently, through one woman working for a voluntary association helping single parent mothers, a small group of women was recruited to participate in exercise classes at the sports club.

MEDIATING SOCIAL INSTITUTIONS AS SOCIAL CATALYSTS IN HEALTH PROMOTION

In the phase of project implementation, BIG had to deal with a number of voluntary associations such as sports clubs, church communities or cultural (Muslim) clubs. These voluntary organisations represent what have been called “mediating structures”, ie social institutions mediating between private and public life.11

Using the example of the sports clubs, our observations of the role of sports clubs as a social catalyst for participation in health promotion action are twofold. On the one hand, the sports club that represented one of the BIG settings was successful in initiating the involvement of a group of immigrants from Russia into the activities of BIG. In this case, sport associations of the state of Bavaria and at the national level were helpful in mediating public funds (from the German Ministry of the Interior) to the local level. On the other hand, this sports club was only partly successful in initiating participation and collaboration from other groups of disadvantaged women. In particular, it reached only very few women in the neighbourhood in which the sports club is situated. Neither empowered individuals nor informal social networks in this potentially large group of participants residing in this neighbourhood could be identified. This seems to indicate that mediating social institutions such as voluntary organisations can potentially function as a social catalyst for health promotion implementation if they receive support from empowered individuals and informal networks.

However, it was also observed that other voluntary organisations (eg another sports club) rejected cooperation with BIG. Besides outside support from empowered individuals and informal networks, internal commitments (goals and obligations) are, based on our observations, crucial determinants for the utilisation of volunteer organisations for project implementation. For example, the aforementioned labour sports club, while potentially having access to disadvantaged women, might have rejected cooperating with BIG because of goals geared towards competitive sports rather then health promotion among women. Such goals were indicated by a local newspaper interview with the president of the sports club and one woman who had been formerly affiliated with the sports club who participated in one of the planning groups.

ORGANISATIONAL STRUCTURES

The three settings of the BIG project show quite different cultures, policies and organisational structures:

• the work site setting is the most formalised setting characterised by decisive organisational structures such as clearly defined tasks and roles, strict hierarchies of decision making, etc.

• the sports club also represents a formally organised setting but, due to the special characteristics of such associations, eg voluntary work and participatory procedures of decision making, it is more sensitive to personal needs and the private life of its members

• the residential area, although several formal organisations (companies, sports clubs etc.) are situated here, is not formally organised.

According to different organisational structures, participation and collaboration of the target group in BIG activities varied greatly. Disadvantaged women were most engaged in the residential area both as partners and coworkers in project development and implementation and as participants of the programmes offered by the project. From our point of view, such engagement might be explained by (1) empowered individuals who were able to (2) recruit informal networks to join the planning and implementation process (3) that was supported by public and non-governmental organisations.

As outlined above, some voluntary organisations were successful in engaging disadvantaged women in BIG activities. Taking their organisational structures into consideration, this might be explained by features of this structure that seemed to foster participation (organisation is based on voluntary work) and participatory decision making. In contrast, women in the work site setting showed the least engagement as coworkers and as participants, eg of programmes for physical activity offered by BIG, compared with the other two settings. This might be explained by a prevailing culture of professional management in this setting that defined health promotion action as a provision of services to clients (employees) rather than being a collaborative task.

DISCUSSION

This research note is based on preliminary analysis and observations of potential key assets for implementation of health promotion action through participation and collaboration. Of course, a more systematic evaluation with a detailed outline of the theory and methods applied in this research is necessary to confirm the early findings presented here. Nevertheless, observations and data already collected on the process of implementing BIG might already be of interest for policy makers, public health professionals or other stakeholders in health promotion. As indicated, empowered individuals and informal social networks seem to have been crucial for reaching disadvantaged groups for the implementation of health promotion action. At the organisational level, volunteer organisations with commitments towards these groups and organisational structures have been seen as crucial for the implementation of health promotion actions.

Asking what social catalysts might be of primary importance for health promotion projects, our recommendation would be to focus on all of them, not least because they seem to interact. For example, the organisational structure of the residential area was least formalised but covered many organisational opportunities (eg social services, infrastructures, professionals and volunteers). In particular, it provided enough room for implementing the BIG policy on citizen participation and interorganisational development. This organisational structure proved to be a social catalyst for the early engagement of empowered individuals in project development. These women then acted as social catalysts to involve other disadvantaged women in BIG activities. In this context, a well-established informal social network of the Muslim women in this residential area turned out to be an important social catalyst for the exceptionally good participation and collaboration of this group. Although the different voluntary organisations within this residential area have not yet developed their full potential as social catalysts (because not all of them have commitments towards disadvantaged women), the BIG example of the sport club setting shows what added value they may provide if such commitment could be generated.

In general, questions on (1) the initialisation of participation and collaboration, (2) the implementation of health promotion programmes or policies and (3) the sustainability of such implementation efforts have received increased attention in recent years.

• For example, existing competences, value orientations that favour health and external opportunities have been described as determinants for the participation of voluntary organisations in health promotion action.12 Also, the establishment of good communication channels and perceptions of equal partnerships among the different stakeholders have been identified as fostering participation.13

• Concerning programme implementation, equal partnerships between researchers and groups to be reached for health promotion action, and the integration of intervention and evaluation research have been described as factors fostering project implementation.14

• Regarding sustainability, Baum et al.15 identified, among other health-related values, leadership, community involvement and scientific support as crucial for sustaining health promotion actions.

Beyond this body of work, we believe that our attempt to describe catalysts for generating participation and collaboration (via empowered individuals and informal networks) and project implementation (via mediating institutions and favourable organisational structures) might be useful in fostering the implementation and sustainability of health promotion action using assets-based approaches. As our model describes factors related to the individual (structures of lifestyle) and policy level (structures of policy making), and describes factors related to participation and implementation, it might represent a starting point for the development of a conceptual framework that could be used to identify and use key health assets for the development of effective health promotion action.

Beyond its potential implication for health promotion action, this note might also stimulate further research on social catalysts in health promotion. We suggest the following three directions:

• Future research might focus on further assessment of social catalysts in health promotion action. For example, are there, beyond these four types of social catalysts, other social catalysts for health promotion implementation? And do these types function in similar ways in other health promotion contexts (eg related to other target groups and settings)?

• Future research could investigate potential strategies and measures for developing social catalysts in health promotion action. For example, can social catalysts be fostered or are they either existing or non-existing? And what would be the right way to nurture them and when do we run the risk of diminishing their potential?

• Future research could develop appropriate methods for the evaluation of the effectiveness of social catalysts in generating participation and collaboration in health promotion activities. For example, how to explore the variety of social inputs and social processes in health promotion action that could be relevant for the analysis of social catalysts? How to measure immediate outcomes as well as the long-term impact of social catalysts? How to integrate different evaluation dimensions such as the impact of social catalysts on health development but also on social development, educational development, city development and economic development?