Identification of starting points to promote health and wellbeing at the community level – a qualitative study

Definition of the term community

The meaning of the term “community” varies across research disciplines [14]. We understand “community” in both geographical and social terms in which residents of a politically organized entity share concerns and responsibilities for issues of common importance such as health promotion and disease prevention [14].

Definition of the term setting

In line with the definition used by the World Health Organization (WHO), we considered a “setting” a “place […] in which people engage in daily activities in which environmental, organizational and personal factors interact to affect health and wellbeing” [15].

Participants

In preparation for the OYA project, the following structures were established to plan and implement health promotion interventions in the community: a steering committee, a scientific sounding board, and a community sounding board. The steering committee consists of the principal investigator (JEF), the mayor of the community, the coordination office (project administration from the community site and project administration from the Mannheim Institute of Public Health [CS, MA]). The scientific sounding board is represented by researchers from various disciplines that provide the steering committee with evidence-based information on different topics related to community health. The community sounding board is comprised of a rotating membership of residents that represent different community “settings” (e.g., child care, elder care, businesses, non-profit organizations, village councils, and local government). These community sounding board members represent the interests of the residents because they either belong to a special population group (e.g., elderly), were representatives of facilities or organizations (e.g., churches, schools, sports clubs), or were elected by the community members to a post (e.g., village councils). As community sounding board members represent the views of the community members from various settings, they served as the key informants for the current qualitative assessment. In line with the CBPR approach, key informants (e.g., from community sounding boards) can assist the researchers in identifying priorities and enable better access to community residents. According to McKenna, et al. [11] another advantage of using members of a community sounding board as key informants is that they will be directly involved in the planning of health promotion interventions later on in the project. Besides being a member of the community sounding board, no further inclusion and exclusion criteria were specified to take part in an interview.

Recruitment for the qualitative interviews began in August 2016 using a mail invitation sent by the steering committee in which general information about the project was provided. Follow up contact with each individual on the community sounding board was made by phone call or email one week after the initial invitation. Those who could not be reached after three attempts were considered non-responders. We contacted a total of 37 community sounding board members with 30 agreeing to participate (response rate: 81.1%). As concurrent theme analysis (described below) suggested theme saturation following interviews with this sample, we chose not to expand recruitment to individuals outside the community sounding board. As further confirmation of theme saturation, however, as mentioned before, we invited all members of the community to a participatory workshop to hear their views on the topic “Increasing health and wellbeing within the community”.

Semi-structured interview guide

Potentially relevant topics related to health and wellbeing in the target community were identified during a two-day workshop that took place at the target community before the official start of the OYA project. The workshop was attended by the steering committee, the scientific sounding board and various members of our research institute. The aim of the workshop was to get to know the target community and its main characteristics. The workshop included district inspections by foot, visits to various settings (e.g., kindergartens, schools, nursing homes for elderly, and companies) and summary reports about the observations made in the community. Based on the results of the workshop three of the authors (CG, JEF, KH) developed the semi-structured interview guide with open-ended questions to explore the following three main topics in the interviews: resources that were already present in the community and facilitated the promotion of health and wellbeing; existing barriers that currently worked against health and wellbeing; and needs and challenges that should be addressed to promote health and wellbeing in the community (Additional file 1). To assure interview questions did not lead the interviewee in a pre-defined direction and to gain comprehensive information, we developed both broad and detailed interview questions. To assure that we do not miss any relevant theme, a final question probed other issues/topics potentially relevant to promoting health and well-being in the community that had not been raised during the interview. Feedback from all authors was provided and incorporated into the interview guide. In line with the CBPR approach the interview guide was also discussed with and approved for use by the steering committee at the community site.

Interview procedure

As an initial step, two interviews were conducted by two of the authors (CG, CS) to pretest the applicability of the interview guide. As only minor changes in the word order of two interview questions were made and no differences in interview style were observed, we included data from both test interviews in our analysis.

Separate face-to-face interviews with each interviewee were conducted in German from August to November 2016 by three of the authors (CG, CS, MA). All interviews were conducted in private settings in the absence of others. The majority (n = 27; 90%) took place in person and on-site in the community with three interviews conducted by phone at the interviewees’ request. At the beginning of each interview, interviewees were encouraged to respond from the perspective of the population group or setting that they represented. To reduce social desirability bias, interviewees were assured prior to the interview that there were no right or wrong answers. Interviewees were advised that their participation was voluntary, written informed consent was obtained in each case and no compensation was provided.

Data management and analysis

All interviews were audiotaped (Olympus-DS-2500) and transcribed verbatim by an external transcription service. Each transcription was checked for accuracy and anonymized by the research team. Transcripts averaged 22 pages (min. 10; max: 38) in length.

Transcripts were loaded into MAXQDA 12.3 (VERBI Software GmbH, Berlin), a qualitative data analysis software package that assisted in interview coding and analysis. Structuring qualitative content analysis suggested by Kuckartz [16] was used to analyse the data. In a first step, all authors developed an initial coding scheme based on the topics addressed in the semi-structured interview guide including the following main categories: “Existing resources”, “Existing barriers”, “Needs and challenges”, and “Further topics”. The applicability of the initial coding scheme was tested by all team members coding two interviews independently. In a second step, the resulting coding scheme was applied to all interviews and was continually refined through identification of inductive (sub)codes that emerged out of the interview material during the coding process. Any new codes were discussed and adopted during regular team meetings only if all coders agreed. In a third step all interviews were coded again by applying the final coding scheme. In a final step all coded interviews were assessed for emerging themes and subthemes presented in the result section.

For quality assurance in data coding, we used several strategies. Interview transcripts were assigned to five coders (CB, JH-K, LS, MA, MS) who worked in pairs. Each pair independently coded a set of two to three interviews and then compared coding assignments. Differences in coding assignments were discussed until consensus was achieved. The composition of coding pairs was changed after two to three interviews to reduce the possibility of introducing a systematic bias.

The notes that were derived from the participatory workshop with community residents were transferred into MAXQDA and analysed applying the same methods used for analysing the qualitative interviews.

Main findings

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 [17]: 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 [18–20].

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 [21–23]. 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 [24–26] and a better quality of life in parents and family members [27–29].

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 [30]. 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”) [31].

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 [32]. For example, offering flexible working hours might facilitate social engagement among employees. Puska [30] 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 [30]. 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 [33] 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 [11]. 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) [33]. 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 [11]. 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) [33] 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 [36]. 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 [30].

Limitations

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.