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15.10.2020 - Ausgabe: 5/2020

Implementation of the National Recommendations on Physical Activity and the Promotion of Physical Activity in Practice: Experiences from six model municipalities testing the so-called KOMBINE concept

By Lea Dippon, Natalie Helsper, Simone Kohler, PD Dr. habil. Karim Abu-Omar, Prof. Dr. Klaus Pfeifer, Dr. Jana Semrau (all Friedrich-Alexander-Universität
Erlangen-Nürnberg), Prof. Dr. Dr. h.c. Alfred Rütten

© Michael Zwicker

National Recommendations on Physical Activity and the Promotion of Physical Activity for Germany (German abbreviation NEBB) were first developed and disseminated in 2016. They are considered approaches to population-based physical activity promotion and thus recommend community-based multi-component approaches as well as policy and environment-related measures. In addition, the Prevention Act, which came into force in 2016, and the services according to §20a SGB V have strengthened the role of Lebenswelt Kommune (municipal living environment) in the health promotion of socially disadvantaged people. Therefore, the project KOMBINE (German abbreviation for municipal promotion of physical activity to implement the national recommendations) pursues the exemplary development, testing and evaluation of a concept for implementing the National Recommendations into the municipal context. The focus is on the development of sustainable structures for the promotion of physical activity in the municipality which are practical, demand-oriented and scientifically sound. Promoting physical activity at local level can contribute to reducing health inequalities, since this approach is directed at the entire population, while at the same time finding access routes to people with social disadvantages without exposing them to stigmatisation. The project will last two and a half years and is divided into three successive phases based on an activation and participation approach. The aim of this article is to give a brief overview of the three project phases and the current state of the development of measures.


Overview of the three project phases

In phase 1, an action model for the sustainable structural development of municipal physical activity promotion was developed by taking into account access routes to people with social disadvantages. In cooperation with municipal representatives, national decision-makers and scientists, relevant needs, success factors as well as obstacles to municipal physical activity promotion were identified. Then, on the basis of the responses collected, nine key factors for a successful implementation in the municipal context were identified: political support; integration of existing structures; cooperation and cross-sector collaboration; participation; communication; skills and qualification; strategic planning and methodological approach; resources/infrastructure - financial, personnel, time; appropriate offers. The key components were then integrated into the action model. 

Since the beginning of phase two in April 2019, the action model has been tested in three districts (Bad Kissingen, Schmalkalden-Meiningen, Segeberg), two large cities (Marburg, Solingen) and one metropolis (Stuttgart). Based on the experiences of the different players from politics, science and practice, demand-oriented and context-specific measures can be developed in the framework of a cooperative planning process. 

In order to prepare for a nationwide implementation of the NEBB, in Phase 3 both municipalities which are already participating as well as other interested municipalities will be involved. In addition, the experience gained in the six model municipalities to test the action model will form the basis for the preparation of a manual which should provide interested municipalities with detailed instructions on how to promote physical activity on the basis of the so-called KOMBINE approach.

In all three phases, evaluations of the KOMBINE model municipalities are carried out both during the trial phase and as a follow-up assessment. 


Current status of the development of measures

Parallel to the preparatory phase and stocktaking in phase 2 of KOMBINE, cooperative planning groups were formed in all six model municipalities. At the beginning of the cooperative planning stage, ideas from all parties involved were collected followed by the prioritisation of ideas for the promotion of physical activity on-site. In the next step, concrete measures were derived from the prioritised ideas and elaborated in topic/community-specific working groups. The measures are oriented towards the four dimensions of municipal physical activity promotion (physical activity behaviour, infrastructure to promote physical activity, citizen participation, overall policy to promote physical activity) while at the same time taking into account health equity. In the following, exemplary measures are presented which have been developed in the model municipalities in the above-mentioned dimensions of physical activity promotion. 

In each of the three participating administrative districts, three municipal working groups and one administrative working group were formed in the course of the cooperative planning meetings.  At the district level, the examples given for the overall policy of physical activity promotion include a political decision for an additional school sports lesson or the creation of regional "movement pilots" to counteract the shortage of exercise leaders and also to create fitness opportunities for people with social disadvantages.  Measures for an infrastructure that promotes physical activity include the planning and promotion of senior-friendly hiking trails with the participation of target groups and the creation of exercise areas in the living environment.  In the area of physical activity behaviour, too, a number of cross-community offers are planned, such as rollator training, the so-called "Waldbaden im Landkreis" (forest-bathing in the district), a KOMBINE mobile for going to freely accessible exercise offers and the establishment of a network for sustainable promotion of physical activity. As a further measure of civic participation, a local process is to be installed in which access routes to physical activity will be developed together with socially disadvantaged people. 

The working groups at local authority level have developed measures in the four dimensions of physical activity promotion by paying special attention to health equity in accordance with the needs of the respective municipality. One measure that can be assigned to the two dimensions of physical activity behaviour and civic participation is the planning of regular physical activity events to offer people receiving state transfer payments access to physical activity opportunities in the municipality. With the help of "door openers" (i.e. people who have access to people with social disadvantages), families with social disadvantages should thus be reached directly in order to involve them in the project from the moment of planning up to its implementation. Other municipalities address senior citizens and work on measures in the areas of infrastructure promoting physical activity ( e.g .hiking trail with benches as resting places), physical activity behaviour ( e.g .revitalising senior citizens' sport, walking groups) and public relations. One municipality is planning to establish swimming courses in an open all-day school in a district with a high proportion of socially disadvantaged people. The long-term aim is to extend the swimming courses to other population groups such as women in difficult life situations. A further measure to promote physical activity is to register the existing exercise and sports offers and promote them through public relations work. 

Thematic working groups have been set up in the two cities and the metropolis. In one city, for example, the working group on "Physical Activity Offerings, Organisation, Information & Public Relations" deals with the acquisition of a so-called fitness bus in the area of physical activity behaviour. The bus is meant to help encourage citizens in the various districts to get exercise by providing the relevant fitness material as well as shuttle services for people with social disadvantages to give them access to exercise facilities. Another priority is the creation of low-threshold, multilingual and culturally sensitive fitness opportunities. In addition, people with social disadvantages are to be specifically addressed and offered both qualification and further training opportunities. Public places (e.g. schoolyards, sports facilities) should be made available in order to create an infrastructure which is conducive to physical activity. Civic participation is pursued by qualifying civic-minded people as movement pilots. The working group "Infrastructure, Networks & Cooperation" with its focus on movement conducive infrastructure works on the development of a multi-generational playground. Three other working groups focus on the needs of target groups (children and women, senior citizens, transfer recipients). The focus is on measures to promote physical activity behaviour, e.g. low-threshold access for senior citizens to existing offers such as sports in the park, multi-generational sports festivals, development of a health week and the training of people with social disadvantages as examiners for (the acquisition of) sports badges. In the dimension of civic participation, the working group on "Communication, barriers, participation" addresses above all better communication and increasing participation by children and young people with social disadvantages. Another working group mainly focuses on creating the lacking structures in terms of an overall strategy of physical activity promotion.


Description of measures

In the following section specific examples of measures that have been developed or partly implemented in one rural municipality and two urban model municipalities are described. 


♦  Hiking trails with benches:

Despite the restrictions during the COVID-19 pandemic, this measure has already been implemented in a rural municipality. In the course of one morning, around 30 volunteers set up 23 benches, financed by the municipality, along paths and forest edges. Now care citizens hiking on the three new circular footpaths also offered the opportunity of having a rest. This physical activity infrastructure provides low-threshold access for people with different health conditions. In addition, signs will be put up on the benches to provide detailed information about fitness opportunities. The maintenance of the benches is guaranteed by a bench sponsorship, to which some volunteers have committed themselves. In addition to families, also some senior citizens from the village have taken on sponsorships. Furthermore it is planned to set up of an information board with a hiking map as well as an official inauguration, probably including an organised rally. 


♦ Multi-generational playground:

For this measure, a concept for the development of a multi-generational movement place is to be worked out, which can be implemented in different districts with the participation of citizens while at the same time enabling the transfer of individual elements to other locations. The offer should address all generations and family forms, be appropriately designed for all weather conditions and freely accessible to kindergartens and school classes. Furthermore, the possibility of networking and mobility to the multi-generational playground and the urban districts should be ensured. Through the participation of people with social disadvantages, a process of appropriation is aimed at, people should be able to identify with it - "It's mine". An assessment of needs of people with social disadvantages is to be carried out including surveys, interviews and discussions with social institutions. In addition, three to four moderated information events are planned to develop the concept with the participation of associations, social institutions and people with social disadvantages by involving them in the implementation of the measures. The construction of the multi-generational playground is being financed from municipal funds. 


♦ Overall strategy:

As part of the cooperative planning process, a broad cross-sector network for the promotion of physical activity taking into account equal health opportunities was created for the first time in the municipality. "What does it take the municipality to ensure that all citizens, regardless of their situation in life, can get enough exercise?" serves as the common question of this cross-sector group. In the large plenary session of the Cooperative Planning Group, the participants initially focused their ideas on a district with a high proportion of people with social disadvantages. The current focus is strongly on how to create model access routes for people with social disadvantages in the pilot district. However, the implementation of individual steps, which considers the expertise of local actors, is still pending. In the event of successful implementation of measures, the knowledge gained is to be transferred to a course of action and, after consultation with the cooperative planning group, to the city as a whole.


Summary and outlook

The implementation of the Prevention Act and the scientifically based National Recommendations on Physical Activity and the Promotion of Physical Activity in municipal practice is a central challenge. Through the involvement of players from practice, politics and science in phase 1 of KOMBINE, a common vision for the implementation of municipal promotion of physical activity with a focus on socially disadvantaged people was developed. The realisation in the form of an action model, which takes into account the experiences of the aforementioned players, promotes a successful interactive transfer of scientific findings into municipal practice.

Phase 2 of KOMBINE focuses on testing the jointly developed action model in six model municipalities. In all the model municipalities it has been possible to establish a cooperative planning group with cross-sectoral and interdisciplinary members. By taking into account local experiences of the municipal players and recording the municipal-specific input factors, the basis for a context-specific and demand-oriented development of measures was thus established. A look at the current status of the development of measures shows that in each of the model municipalities measures for all dimensions of physical activity promotion have been developed by taking into account access routes to people with social disadvantages. The implementation of these measures will represent a promising milestone in the development of structures promoting physical activity in the municipalities, both locally and with regard to the implementation of the National Recommendations on Physical Activity and the Promotion of Physical Activity.  

However, the experience of phase 2 of KOMBINE in the six model municipalities also indicates that political support, an essential key component, varies in the different model municipalities. For example, the involvement of political decision-makers in the process, as one aspect of political support, varies in the different model municipalities. To actually reach this target group, their participation in the phase when further measures are developed is a central element. And despite the intensive participation approach in KOMBINE, the direct involvement of people with social disadvantages in the cooperative planning group in the model municipalities represents a further challenge. In addition, the COVID-19 pandemic required some adjustments, as several meetings and the implementation of various measures had to be postponed. At the same time, in some municipalities the restrictions and the associated increased demand for outdoor exercise could be used as an opportunity to offer free access to exercise in open spaces. In the meantime, however, new dates for the planning meetings have been organised and the implementation of further measures which should help to anchor sustainable structures that promote health and physical activity, particularly of people with social disadvantages, is already in progress. 



The KOMBINE project is funded by the Federal Centre for Health Education on behalf of and with funds from the statutory health insurance fund according to § 20a SGB V within the framework of the GKV Alliance for Health (www.gkv-buendnis.de).



We would like to thank all parties involved in Phase 1 of KOMBINE as well as the six model municipalities of Bad Kissingen, Schmalkalden-Meiningen, Segeberg, Marburg, Solingen and Stuttgart for their intensive support and cooperative collaboration throughout the process. 


[1] Rütten, A., & Pfeifer, K. (2016). Nationale Empfehlungen für Bewegung und Bewegungsförderung (p. 129). Erlangen-Nürnberg: FAU.

[2] Pfeifer, K., & Rütten, A. (2017). Nationale Empfehlungen für Bewegung und Bewegungsförderung. Das Gesundheitswesen, 79(S 01), S2-S3.

[3] GKV-Spitzenverband (2018). Leitfaden Prävention – Handlungsfelder und Kriterien nach § 20 Abs. 2 SGB V. Zugriff am 25.08.2020 unter https://www.gkv-spitzenverband.de/media/dokumente/presse/publikationen/Leitfaden_Pravention_2018_barrierefrei.pdf

[4] Semrau, J., Helsper, N., Janz, L., Kohler, S., Abu-Omar, K., Pfeifer, K., & Rütten, A. (2019). KOMBINE–Kommunale Bewegungsförderung zur Implementierung der Nationalen Empfehlungen. B&G Bewegungstherapie und Gesundheitssport, 35(03), 169-170.

[5] Kohler, S., Semrau, J., Janz, L., Helsper, N., Abu-Omar, K., Pfeifer, K., & Rütten, A. (2019). Von Erfolgsfaktoren, Hindernissen und Bedarfen zu Schlüsselkomponenten der kommunalen Bewegungsförderung bei Menschen mit sozialer Benachteiligung: Bericht von einem Workshop. B&G Bewegungstherapie und Gesundheitssport, 35(05), 265-272.

[6] Rütten, A. (1997). Kooperative Planung und Gesundheits-förderung Ein Implementationsansatz. Zeitschrift für Gesundheitswissenschaften= Journal of public health, 5(3), 257-272.

[7] PartNet Netzwerk Partizipative Gesundheitsforschung. Partizipative Gesundheitsforschung – eine Definition (2018). Im Internet: https://www.partnetgesundheit. de/index.php/pgf-definition. Stand: 15.05.2019

[8] Helsper, N., Kohler, Simone, Semrau, Jana, Dippon, L., Abu-Omar, K., Pfeifer, K., & Rütten, A. (2020). KOMBINE – Kommunale Bewegungsförderung KOMBINE - Kommunale Bewegungsförderung zur Implementierung der Nationalen Empfehlungen. In Landesvereinigung für Gesundheit und Akademie für Sozialmedizin Niedersachsen e.V. (Ed.), impu!se der Gesundheitsförderung. Blühende Landschaft oder Irrgarten? 5 Jahre Präventionsgesetz (No. 106, p. 22).

[9] Rütten, A., & Gelius, P. (2011). The interplay of structure and agency in health promotion: integrating a concept of structural change and the policy dimension into a multi-level model and applying it to health promotion principles and practice. Social Science & Medicine, 73(7), 953-959.



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