We conducted a comprehensive assessment among key informants to uncover needs, challenges, barriers and existing resources that might help identify community endorsed starting points for efforts to promote health and wellbeing in the community and should be considered in the planning and implementation of such initiatives. The themes that emerged were not directly related to either health or community wellbeing and appeared to center on what one might consider more “upstream” determinants of health and wellbeing : natural resources and built environment, access to services, and social cohesion including the subthemes social engagement and volunteerism, sense of community, and shared identity. That health and wellbeing were not identified as specific priorities by key informants suggests that these should not be presented as the primary focus of a community-wide initiative, but rather be incorporated as secondary goals in future programming.
Possible starting points
Given that interviewees consistently endorsed the importance of natural resources, it might be useful building on these resources in future efforts to increase health and wellbeing. For example, modernizing existing walking paths in local forests or building new ones were suggested as one possibility to foster physical activity among community members – a common health promotion goal. Furthermore, better leveraging local forests as recreational resources may also improve physical and mental health, as previous research has shown associations of the natural environment (e.g., parks and green spaces) on both health outcomes [18,19,20].
Building on specific, well-functioning resources identified by interviewees (e.g., services for children and the elderly) also appears to be a strategy that would work in the target community. Enhancing the quality of care provided in institutions like day care facilities, schools and also nursing homes (e.g., extending hours of operation or increasing the caregiver/child- or the nursing staff/resident-ratio) was endorsed as an effort that might translate into better wellbeing and quality of life in children and the elderly and has also been found in former research [21,22,23]. In addition, such improvements were thought to reduce the burden on caregivers, nursing staff, parents, and family members caring for dependent relatives resulting, in turn, in greater job satisfaction in caregivers [24,25,26] and a better quality of life in parents and family members [27,28,29].
Future programs could also benefit from volunteerism and social engagement, as these were consistently mentioned as central resources in the community. A useful strategy prior to implementing programs to increase health and wellbeing might be to leverage these resources by involving already engaged community members or to build partnerships with existing social or sports organizations . This approach has the benefit of capitalizing on the knowledge and expertise in what works well in planning and implementing any new undertaking in their community. Involvement by community residents may also prove valuable in reducing reluctance among other community members in participating in newly developed programs (e.g., the “snowball effect”) .
However, as interviewees identified the challenge of sustaining social engagement over time, developing strategies to accomplish this goal and increase the attractiveness of volunteerism in the community seem necessary. Local employers, for example, could contribute to the sustainability of social engagement and volunteerism by encouraging employees to engage socially outside their paid work . For example, offering flexible working hours might facilitate social engagement among employees. Puska  also suggested including various organizations from different sectors and settings into the project as a useful strategy to successfully implement health promotion programs at the community level. In addition, he emphasized that it was important to establish such collaborations as “win-win situations” for both sides, the community and the organizations . In addition, key informants stated that receiving more support from the local government was important for motivating volunteers and for ensuring the existence of clubs in the future. However, it seemed that besides a suggestion for waiving utility costs, community members shared few concrete ideas about the shape such support strategies might take.
Interviewees commonly identified the centralization of and access to services as a fundamental barrier in the community. Penchansky and Thomas  identify five dimensions of access that should be carefully considered in program planning: availability, accessibility, accommodation, affordability, and acceptability. While the availability of services (e.g., the volume and type of existing services such as medical care, grocery shopping, or cultural activities) was commonly endorsed as a valuable resource in the city center, improving the accessibility of these services for residents living in the suburbs was identified as a need. An initiative that included on demand shuttle services to the city center might represent an appropriate initial response, for example. Indeed, some interviewees suggested that such a shuttle service could improve quality of life among various community members that have to rely on public transport to get to the city center (e.g., children, adolescents, and the elderly). Extending transportation networks to ensure greater accessibility of locations where leisure-time activities take place were thought to address two emergent themes: an opportunity for equal use of existing resources like woodland parks to a larger segment of the community who might otherwise lack direct access to a natural resource and a boon for enhancing quality of life. In a former CBPR study missing transportation networks were also suggested interviewees as a barrier to participate in physical activity or to buy healthy food . Developing informal transportation networks in the form of community car pooling and modifying the built environment to ensure accessibility for the elderly or disabled represents additional strategies endorsed by interviewees as potential starting points.
Offering services occasionally in the suburbs outside the city center represents a third strategy identified by interviewees that might address both limited accessibility and accommodation - the extent to which services are organized to accept and act on input from users, including the perceived appropriateness of aspects of these services (e.g., hours of operation) . Implementing programs that incorporate this strategy might be quite effective in promoting health. A systematic review documents, for example, that offering mobile markets, conducting weekly farmer’s markets, or installing fruit and vegetable stands in the suburbs increases access to and consumption of fresher, more nutritious foods [34, 35]. In line with previous research key informants emphasized that affordability should also be considered when planning future programs . For example, offering such programs at no or low costs, were suggested as a way to enable community members on a limited budget to participate in future programs. Although views on a fifth dimension of access, the acceptability of services (e.g., user attitudes on provider characteristics and provider attitudes on user characteristics)  were varied, creating greater acceptability of services to better reach specific, often underserved age groups such as adolescents and senior citizens in this community might represent a future focus.
Beyond questions of access to services within their community, many interviewees voiced concerns regarding decreased social contact and the relative absence of gathering places for fostering cross-generational and cross-cultural social exchange. These concerns might be addressed in health promotion initiatives. Previous work suggests, for example, that the activity of planning and establishing such a gathering place could, by itself, serve to enhance a sense of community and foster a shared identity, and may also increase health and wellbeing of community members . For the success of such a project, outreach and active engagement by members throughout the community and their involvement in the planning and implementation processes appears essential .
Although this study uncovered several emerging themes salient to members of the target community with potentially broader implications elsewhere, a few limitations should be acknowledged. First, we restricted interviews to members of the community sounding board. While these individuals came from or officially represented a variety of different community settings, their views on resources, existing opportunities or barriers might have been unique or failed to reflect the potentially broader views of community members. To ensure a breadth of views, we obtained and analyzed data from members of the general public attending our participatory workshop on increasing health and well-being in the community. Second, as we did not conduct a formal process of member checking, our interpretations may have differed in important ways from the perspective of our interviewees. We observed, however, a high degree of consistency in the themes and subthemes emerging from key informant interviews, suggesting theme saturation and further confirmation of this by data from community attendees at the participatory workshop. We therefore consider our data to be useful in identifying potential starting points and key issues for consideration in planning and implementing a community-based participatory research initiative. Third, we focused on resources, barriers, challenges, and needs in a single community. Although the relative importance of these emerging themes might vary or the presence of other more pressing issues may exist in other settings, we feel that the overarching value of the strategy we used is that it can be widely applied in diverse settings to identify starting points that are salient to community members and that can shape efforts to promote health or other objectives in more locally meaningful and therefore effective and sustainable ways. Importantly, this approach benefits from the CBPR tradition in which insights and priorities are derived from members of the target community that might have been otherwise overlooked.