Health Promotion -Key Integrated Urban District Development Topic

The concentration of disadvantaged households - unemployed, welfare recipients, migrants, single parents, large families - in urban districts with special development needs is associated with a concentration of poverty in these areas. In Germany as in other countries poverty is correlated with a considerably higher health risk. (1). For instance, mortality is 2.6 times as high among the unemployed as among workers (cf. Trabert 2002: 137). Rates of illness are also substantially higher for individuals with low socioeconomic status than for people who earn more (cf. Rosenbrock/Geene 2000). One reason is the increase in health hazards as a result of social disadvantage in connection with a decrease in personal, financial and social resources to overcome these risks (cf. e.g. Babitsch 2000: 130 ff.). Predominantly middle-class-oriented preventive medicine services and health promotion rarely benefit these population segments (cf. Grahlen/van Os-Fingsberg 2000: 90). Frequently unwholesome patterns of behaviour - smoking, alcohol and drug abuse, poor eating habits, lack of exercise - aggravate the situation (vgl. Babitsch 2000: 131).

The health of migrants is especially jeopardized by their own migration or that of relatives, (2), ignorance of existing preventive and care services, language barriers and cultural disorientation. However, so far only sparse data is available on their health status. (3): For example, the mortality of foreign infants is 29 percent higher than among Germans, and the risk of suffering a work-related accident is slightly higher, if sex and occupation variables are held constant (cf. cf. Commissioner for Refugees, Migration and Integration (ed.) (2000: 160). A 1997 district health report complied for the Nuremberg-Gostenhof district, where foreigners make up more than 40 percent of the population (cf. (cf. Nuremberg Health Department (ed. (1997))) concludes that the dental condition of foreign children in the district is inferior to that of the overall juvenile population. The dentation of 63 percent of the children of foreign origin aged three to six required treatment. Only 40 percent of German children needed such care.

Since the Ottawa Charter of the World Health Organization (WHO) of 1986 and the related 1989 founding of the German Healthy City Network (cf. Stender in this issue; http://www.Gesunde-Staedte-Netzwerk.de/) the connection between poverty and health is attracting more and more attention. Evidence for this trend is provided by the annual nationwide Poverty and Health congress, which has taken place in Berlin since 1995 (cf. article in this issue). In recent years the link between health promotion and social development of urban districts has gained more and more weight in the congress agenda. In 2001 and 2002 a separate congress section was devoted to Socially Integrative City and Health. These events made it clear that social development of urban districts is an important element of integrated health promotion policy and that wellness and health promotion are prerequisites for combating discrimination of residents of urban districts with special needs.

Probleme in den Programmgebieten (Befragung)

Focus on health: so far virtually neglected in programme implementation

In a survey conduced by the German Institute of Urban Affairs (Difu) in pilot districts as part of Difu's programme support contract, respondents in only 8.1 percent of the districts cited health problems. The field of health was therefore one of the least-mentioned issues. One cause of the low score may be the lack of attention given to health in traditional urban renewal. (4). Another reason might be that due to their urban planning background most respondents tended to attribute environmentally influenced (5) Ghealth problems - such as noxious noise - to environmental pollution and living-space shortcomings. (6). An objective estimate of health problems in the districts would be considerably higher.

This claim is borne out by experience in the 16 Socially Integrative City pilot districts. In 14, onsite programme support teams report health problems in the neighbourhood. They focus on health problems in children and adolescents such as overweight, poor posture, respiratory disease, tooth decay, allergies and motor and speech development disorders. (7). The symptoms of neglect of children's health may, as in the Hamburg-Altona - Lurup pilot district, extend to deprivation. "Talks with the staff in schools, childcare and youth facilities repeatedly revealed that many children are famished - particularly after the weekend" (Breckner et al. 2002: 41). In the Berlin-Kreuzberg - Kottbusser Tor pilot district this problem is even more conspicuous: "Hungry people are no rarity," neighbourhood managers report. Apart from homeless adults, more and more children of all nationalities can be seen scrounging for carelessly discarded edible waste" (Beer/Musch 2002: 46). Moreover, about one third of the pilot areas are reported to face drastic drug and addiction problems.

Besides these socially determined health hazards, more than half of the pilot districts named environmental health risks, primarily heavy traffic impact, including noise, toxic fumes and elevated accident rates. Particularly neighbourhoods with prewar housing suffer from a shortage of quality parks and open spaces, leading to an unfavourable microclimate and lack of recreation sites as well as playgrounds and areas for children and teenagers to safely romp and unwind. Unlike in the U.S., few investigations are available in Germany to demonstrate the extent to which these environmental health hazards result from uneven distribution of environmental problems among socially differentiated residential areas (df. Maschewsky 2002: 38 f.).

28.8 percent of the Difu survey respondents say that health-related measures and projects are being conducted in their districts. Even if these figures are unexpectedly high compared with the low number of problem references, health still ranks last among the fields of action associated with integrated urban district development. The relevance of this sphere of activity is heavily influenced by the involvement of health authorities in implementation. Wherever municipal health officials participated in elaborating the integrated action plan (in 43 of 187 districts), inclusion of health-oriented measures increases to about 60 percent of the zones.

The cross-sectional character of the health policy area also means that measures in other fields frequently have a bearing on health. A series of measures in the areas of environment, transport and neighbourhood amenities and public space also are helping to reduce environmental health risks. Many athletic programmes play a significant role in promoting health. Likewise, employment measures have a positive effect on health since they entail improvement in workers' financial situations and boost residents' self-esteem (cf. e.g. Junge-Reyer 2000: 32).

However, it seems reasonable to assume that these indirect health benefits from other areas of action are often not intentional but rather incidental gains that the players had originally overlooked. This assumption is substantiated by the fact that only 2.3 percent of respondents consider health-related measures to be particularly important. This outcome reflects the low priority given to the topic of health by programme developers in the municipalities, who tend to concentrate on architecture and urban planning.

District-related strategies for preventative medicine and health promotion

Health projects and measures focus on prophylactic and health promotion services - evidence is found in the pilot district experiences and examples from the Socially Integrative City database (cf. sozialestadt.de/ praxisdatenbank/) (9). Emphasis on residents' living space and daily routines is typical. This district-based approach corresponds to the implementation of disease prevention and health promotion with the WHO "setting approach" adopted in 1986 (cf. Göpel 2002: 16). Settings are defined as facets of life with their specific social and organizational structures, e.g. school, company, district, neighbourhood, in which people tend to congregate and develop lifestyles that influence their health. District-applied disease prevention and health promotion in programme districts is devoted to developing easily accessible services for hard-to-reach target groups and is intended to improve health system cooperation through networking.

Development of low-threshold services for particular target groups

Easily accessible, targeted disease prevention and health promotion measures are being developed in the light of the experience that traditional services are oriented primarily toward the middle classes and rarely reach high-risk groups in medically adverse social situations. Recently developed provisions therefore focus on living conditions that are major determinants of health and on individual and group resources of the targeted subpopulations. It has proved advantageous to localize the measures - in accordance with the setting approach - in sites and facilities in the district with which the target groups are familiar. Such venues include schools, childcare centres, clubs, and even mosques and other social and religious institutions.

• Services for children and adolescents

Young people are an important target group for these services, first, because their health is frequently already impaired; second, because this group has a bounty of wellness which should be maintained and harnessed as a resource. Youth work mainstays include onsite projects serving nutritious meals and making youngsters aware of the relationship between wholesome food and good health, exercise programmes and violence and addiction prevention measures. (10)

The Best Way to a Child's Minds Is Through Its Stomach, a Wuppertal-Osterbaum project Photo: Kindercanteen workers

In Bremen-Schwachhausen a joint initiative drafted a plan to provide meals in schools. It was organized by a local school, the municipal education and research department, the city's department of labour, health, women's, youth and social services; and Quirl, a women's self-help group. The school cafeteria cooks and serves its students balanced meals. Quirl hires and trains unemployed women to work in the cafeteria. The objective of PriceWorthy Nutrition in the urban district of Lüneburg-Kaltenmoor, launched by the Lower Saxony Ministry of Food, Agriculture and Forestry, is to improve eating habits of people in the district and of the nutrition of the girls and boys in its school system. Project participants helped develop the following services and activities: lunch for the student body, breakfast for residents, seminars on nutrition, publication of a cookbook and catering events with "quality refreshments". A project designated The Best Way to a Child's Mind is Through Its Stomach gave primary school pupils and students in the lower grades of secondary schools, six- to 12-year-olds, in the Wuppertal-Osterbaum district cooked hot lunches in a kindercanteen at a nearby community centre. They also obtain help with their homework and have unstructured play time. The health centre in Gelsenkirchen-Bismarck/Schalke-Nord is heavily involved in projects for young people. Courses range from AIDS awareness to antiviolence training. A two-year preschool health promotion pilot project is testing new exercise approaches in nursery schools. erprobt.

• Services for women

Other measures target women in the district and give them an opportunity to familiarize themselves with health promotion possibilities and obtain counselling. (11). The main idea is to motivate women to do something for their own health, to practise "wellness" (e.g. correct eating and good grooming) every day and to avail themselves of medical aid more discerningly. Many activities are also intended to sensitize women, as mothers, for health promotion and to convince them of its importance for the wellbeing of their children. Another basic theme of these programmes is encouraging and supporting self-help in the district. The projects are designed to make it easier for women to meet other women in the area and arrange mutual assistance. They encourage them to show initiative and take responsibility for solving their own problems.

Examples of women-oriented health projects include the Lurup Frauenoase in Hamburg-Altona and the Mother-Child Exercise and More Group in Recklinghausen-Hochlarmark. "The Lurup women-only oasis hosts diverse project, topic and interest groups of various sizes. They are coordinated by female volunteers." (Breckner et al. 2002: 45). One of the Lurup projects is a Sunday brunch served in the rooms of a clubhouse. After the meal together, two specially trained employees take charge of the children and put them through a psychomotor exercise routine. The women and mothers use this "child-free time" to gain information and advice on health promotion opportunities. They receive briefings and individual guidance from local female experts and staff of the Hamburg Women's Health Centre. The Mother-Child Exercise and More Group, sponsored by the Socially Integrative City district office and the municipality, has attracted 15 mothers, who play, sing and do crafts with their toddlers. Leaders pay special attention to the linguistic development of the children, two thirds of whom are immigrants' offspring. Continual physical education offerings are geared to help them pick up German. The motto is Learning by Exercising. The sports club and the adult education centre augment this programme with lecture series on such subjects as Healthy Eating and Exercise for Toddlers and Preschoolers. The Bismarck Health Centre in Gelsenkirchen runs a similar scheme.

Women-only programmes often target migrants. (12). This group frequently has huge gaps in its knowledge of health issues, existing disease prevention measures and medical care programmes because deficient German and their socially and culturally shaped understanding of a woman's role prevent them from gaining full exposure and access to what is available. This target group has proven receptive to information in members' native tongues, easy-access courses, informal discussion groups and, above all, house calls as well as immediate intervention when health problems arise in their families.

Bayouma-Haus, Boxhagener Platz, Berlin-Friedrichshain, hosts a health project aimed mainly at migrant women. The intercultural encounter centre offers lectures on disease prevention and health awareness, literature on health topics in various languages, targeted preventative measures in cooperation with the borough health authorities, multiplier events for health and welfare experts and talks for alien families at the adult education centre.

• Networking in urban district health promotion

The goal in establishing networks for district health promotion (13) is erecting cooperative neighbourhood health improvement alliances supported jointly by health officials and onsite health promoters. Possible partners include the health department, nongovernmental health and community agencies, self-help groups, physicians, pharmacists, health insurers, sports clubs and schools and childcare institutions. Experience shows that the initiation of such networks often offers the first chance to get acquainted, to exchange differing views and ideas on health promotion and to prompt various joint activities in the district.

	Bismarck Health Centre in Gelsenkirchen Videostill: Daylight Berlin

Several players in Hamburg-Heimfeld-Nord have banded together in the Arbeitskreis Gesundes Heimfeld and adopted the motto Healthy Heimfeld. Once a month representatives of health agencies, childcare centres, schools, a child protection centre, youth club, women's association, parish charities and the Socially Integrative City district office meet to debate current issues, adopt common priorities and organize district-oriented activities to incite the population to do something about its health on its own initiative. Parents and children are the main target groups. A survey of residents resulted in a focus on nutrition, exercise and education. To address these issues, Arbeitskreis Gesundes Heimfeld organized information events, a Women's Exercise Week and health-related booths at the district's annual fair.

Boosting health promotion as a Socially Integrative City prong

Although it is a key component of integrated urban district development, health promotion has thus far taken a back seat in Socially Integrative City implementation, although some programme districts have already demonstrated promising approaches for district-oriented health promotion. It therefore appears necessary to intensify activity in this field as a part of integrated district development. Promotion of good health and prevention of poor health are major factors in offsetting underprivilege in specially challenged neighbourhoods. One way of giving health issues more airing in district Integrated City player networks is involving all locally active health officials and promoters more intensively in integrated district development to attain interaction of all programme levels - municipal, intermediate and neighbourhood. It is a boon when neighbourhood management, the key tool in implementing the Socially Integrative City programme, integrates health promotion in its operations and helps establish, consolidate and steer networking and cooperation schemes to coordinate relevant government, intermediate and neighbourhood agencies.

Notes

(1) Cf. e.g. Ministry of Health and Social Security (ed.)(2001); Rosenbrock/Geene (2000: 10 ff.); Mielck (2000); Knopf et al. (1999: 169 ff.).

(2) "Migration normally involves separations, massive anxiety about the future, legal uncertainties and, in the case of refugees, often traumatic experiences and difficult social conditions in Germany." (HHamburg Health Promotion Task Force (ed.) [2002: Editorial]).

(3) Statistics on morbidity and claims for health services by migrants are still sketchy since neither representative investigations with explicit statements on their health situation exist, nor do these population segments feature separately in general studies on health conditions. Cf. Commissioner for Refugees, Migration and Integration (ed.) (2000: 159).

(4) For example, a Hamburg-Eppendorf University Medical Centre Medical Sociology Institute research project on Health Promotion, Citizen Involvement and Urban Development examines whether and to what extent health issues play a role in the Osterkirchenviertel renewal district in Hamburg-Altona. The study indicated that an overtly expressed health reference is almost entirely lacking. Cf. Alf Trojan et al. (1998: 23 f.).

(5) Differentiation between socially and environmentally determined health hazards is a component of a socioeconomic health model. This model is the theoretical foundation of the 1986 World Health Organization (WHO) Ottawa Charter guiding principles of health promotion. Cf. Alf Trojan et al. (1998: 15).

(6) The study cited in Note 4 also stated that traffic and environmental stress were mentioned in discussion on the investigated rehabilitation procedure but with no reference to health. Cf. Trojan und andere (1998: 23 ff.).

(7) A general discussion of the health status of disadvantaged young people is found in Hock/Holz/Simmedinger (2000); Borough of Berlin-Mitte Department of Health and Social Services (ed.) (2001: 34 ff); Federal Radiation Protection Office (ed.) (undated).

(8) Interaction between policy areas is not treated by this survey, which had virtually no interdisciplinary component. The cross-sectional orientation of individual sectors often only became progressively clear in the course of programme implementation.

(9) While prophylaxis is designed for targeted prevention of diseases and health impairment by reducing stress and risks, health promotion is aimed at bolstering health resources and opportunities. This refers both to individuals and to all levels of society. Cf. Walter et al. (2001: 23).

(10) Cf. e.g. the following projects in the Socially Integrative City project database : Eating in Schools (Bremen, Bremen-Schwachhausen/Vahr, Schwachhausen), Restructuring of Cafeteria Operation at Mümmelmannsberg Education Centre (Hamburg, Hamburg-Mitte, Mümmelmannsberg, (PriceWorthy Nutrition (Lower Saxony, Lüneburg, Kaltenmoor), Bismarck Health Centre (North Rhine-Westphalia, Gelsenkirchen, Bismarck/Schalke-Nord), "We Don't Fancy Violence - Social Measures to Prevent Violence in the Immediate Social Setting (Bavaria, Regensburg, Humboldtstraße); The Best Way Is Through Its Stomach - Kindercanteen (North Rhine-Westphalia, Wuppertal, Osterbaum).

(11) Cf. e.g. the following projects in the Socially Integrative City project database : Lurup Frauenoase (Hamburg, Hamburg-Altona, Lurup), Bismarck Health Centre (North Rhine-Westphalia, Gelsenkirchen, Bismarck/Schalke-Nord), Mother-Child Exercise and More (North Rhine-Westphalia, Recklinghausen, Hochlarmark), Guardian Angels Club - Health and Social Support for Expectant Mothers and Young Families in the District) (Schleswig-Holstein, Flensburg-Neustadt).

(12) Cf. e.g. the following projects in the Socially Integrative City project database : Health project in the Bayouma-Haus Intercultural Encounter Centre (Berlin, Berlin-Friedrichshain/Kreuzberg, Boxhagener Platz), Bismarck Health Centre (North Rhine-Westphalia, Gelsenkirchen, Bismarck/Schalke-Nord).

(13) Cf. e.g. Stappert/Leßmann (2000: 40 ff.) and the following project in the Socially Integrative City database : Healthy Heimfeld - Network for Neighbourhood Health Promotion (Hamburg, Hamburg-Harburg, Heimfeld-Nord).

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