The new healthin the village

A participation project fostering resilience in rural areas

www.pfalzklinikum.de© iStock.com/alvarez

www.resilienz-pfalz.de

Dear Reader,

Pfalzklinikum is a service provider for mental health in the Rhineland-Palatinate in SouthwestGermany with over 2,000 employees in 14 locations. Its work encompasses approximately 1.4million people in the Palatinate, focusing on community-based, child and adolescent, generalpsychiatry and neurology services.

As mental health is its daily mission, Pfalzklinikum focuses on more than helping peoplebecoming mentally healthy again. Rather, maintaining and fostering mental health is theoverall objective of the organisation and its declared duty – not only for its patients and clients,but also for its employees and the people living in the Palatinate.

By founding the initiative “The Palatinate makes itself/you strong – ways to resilience”together with different project partners, Pfalzklinikum pursues the idea of salutogenesis inmental health. The key is resilience - the ability to advance by personal crises instead ofbreaking from them, to be able to cope well with changes and the ups and downs of life.

The interdisciplinary group of project partners consists of sociologists, anthropologists,economists, pedagogues, psychiatrists, psychologists and communication scientists. In orderto change the people’s attitude towards mental health – a mostly pathogenetic one – into asalutognetic one, the initiative follows a new approach of social communication, based on theoutcomes of their own scientific research. Together the experts focus on a systemic approach:looking at different social levels such as the individual, families, enterprises and communities.

The following eBook introduces one of our projects concentrating on the community aspect:“Resilience in rural areas through participation”. Project leader Prof. Dr. Cordula Borbe invitesyou to get to know the idea of how resilience in communities can be fostered and which stepsthe process takes in order to get the public thinking about mental health.

Introduction

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Cordula Borbe is professor for social work at the Nordhausen University of Applied Sciencesin Thuringia. Her research focus lies on the exploration of social space, mental health careand resilience. Together with Prof. Dr. Markus Steffens she is leading the research project"Healthy in the Donnersberg district - resilience in rural areas through participation".

Markus Steffens is head physician at Klinik Hohemark in Oberursel and teaches at theMainz Catholic University of Applied Sciences in the fields resilience and prevention as wellas risk and protective factors for mental health. Another project partner is the researchteam around Prof. Dr. Brigitte Anderl-Doliwa of Mainz Catholic University of AppliedSciences. She is also senior nurse at Pfalzklinikum's clinic in Kaiserslautern. The researchproject is supported by Pfalzklinikum, the municipality of Rockenhausen and the healthinsurance company AOK Rheinland-Pfalz/Saarland.

Contact: borbe@hs-nordhausen.de www.hs-nordhausen.de

Resilience in rural areas is currently atopical subject looked at and analyzedfrom very different points of view (forexample Henkel 2016; Renker 2018). Thissubject arouses particular interest when aprocess of active civic participation isinitiated to identify local resilience factors.The present article aims at informingabout such a process in the Donnersbergdistrict (Palatinate) and invites you toencourage participation processes in ruralareas which simultaneously raise theawareness for health factors and promotethem.

[…] “resilience is the ability of a systemto absorb shock and carry onperforming the function that it wasdesigned to do. Resilience thinking […]anticipates change and understandsthat major shocks are inevitable in aworld that is facing huge challenges[…] and social unrest. Resilience is notabout predicting what shocks we willface, or when they will occur, but it isabout ensuring that we are preparedfor them when they do”. (Bugler 2018)

Accordingly, the topic of resilience mainlyinvolves the anticipation of impendingchanges in the social environmentperceived as uncertainties due tounexpected events in a world havingbecome insecure (Bonß 2015, p. 5). In ruralareas these are especially uncertaintiesconcerning old-age provision, vacanciesbecause of rural exodus due to migrationinto urban spaces and so causedinfrastructure losses (Henkel 2015, p. 125).From resilience research, however, it is

known that people have a kind ofprotective shield rendering them resistantand relatively crisis-proof. The core ofresilience is the unshaken belief in theability to shape one’s own life (Welter-Enderlin/Hildenbrand 2012). The termresilience (from the Latin resilire, ‘bounce’‘rebound’) means “tonicity, resistivity andelasticity”. As a positive guiding principle,resilience names strengths but alsohazards. The concept of resilience createsthe connection between crisis awarenessand a potential for solution options(Wustmann 2004). Health literacy isunderstood as the ability to inform oneselfabout the prevention of diseases and thepromotion of health in every-day life, toform a view and to make decisionsmaintaining or improving the quality of life.For this not only individual skills arerequired but also encounter, networkingand participation possibilities admittingpeople into local scopes of creativity andcreating connections to technical qualityand availability of information andproviders (Jordan/Töppich 2015).

Pantucek gives fundamental thoughts todifferences between urban spaces andperipheral rural areas. He stresses that thechallenges of socio-physical work areidentical for both areas while the pre-requisites can differ nevertheless: e.g. theproximity of the decision-makers, small-scale structured civil society/societies, pooraccessibility of specialized services and soon as examples for rural areas. Pantucekthinks that the art of socio-physicalworking in rural areas is to make use of thenarrowness of the community and at thesame time be in a position to go beyond itsborders (Pantucek 2009).

Resilience in rural areasthrough participation

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This explorative study in the Donnersbergdistrict (Palatinate) was commissioned byPfalzklinikum and is carried out by theNordhausen University of Applied Sciencesand the Mainz Catholic University ofApplied Sciences using a mixed-methodapproach. It comprises quantitative aswell as qualitative elements. Following adetailed literature analysis and a socialenvironment analysis (Spatzek/Wolf-Ostermann 2016) students and project teammembers started to familiarize themselveswith the municipalities of Rockenhausen inthe Donnersberg district in April 2018 bymeans of 16 social environment inspectionsplus accompanying qualitative interviews.The social environment inspection is anobservation method to collect impressionsand perceptions in a certain region/socialenvironment. It is a technical inspection ofan area aiming at perceiving the socio-ecological qualities of places with all one’ssenses. Social environment inspections areclassified as qualitative research methods.The procedures are based on inquiry andparticipatory observation and havedeveloped from the dynamics of youthwork and their epistemological interest toacquire “social environment knowledge”(Böhnisch/Münchmeier 1990).

The methodical procedure is applied forthe evaluation:

Discovering the neigh bourhood

The interviews carried out with citizens ofthe municipalities of Rockenhausen andthe city of Rockenhausen are transcribedand evaluated by means of a qualitativecontent analysis with the help of theprofessional MAXQDA software. Thefollowing results are essential:

l clubs are identified as important drivingforces for the community and for health – however, they are said to beendangered due to a shortage of youngpeople

l a functional health concept is dominating

l the fear of a medical emergency isgreater than the fear of the impendingloss of the regional acute care hospital

l nature is graded as an important resource

l property is considered highly importantand positive (sedentarism)

l villages of the municipality are describedas very heterogeneous

l differing views and needs of the youngand the old are identified and

l differing views and needs of old andnew residents are mentioned severaltimes.

Following the social environment inspectionsthe first two citizens’ fora on the subject of“resilience in the Donnersberg district” tookplace in the Donnersberg district in Juneand July 2018. In case of most citizenspresent their professional activity and theirrole as citizens overlap thematically. So, itis possible to appreciate diverse expertcontributions from different perspectives.

Key concern in the public fora is to jointlywork out which resilient and health-promoting structures in rural areas are

Evaluation of the social environment inspections by means of observation sheets

Evaluation of the interviews by meansof qualitative content analysis

Students/project team membersNordhausen and Mainz Universities of Applied Sciences

Transcription of the interviews

Interviews based on key questions

Social environment inspections

1: Methodical procedure (own depiction)

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identifiable. Together with local values andmoral concepts social environment relatedidentity is essential for resilient structuresin rural areas. In resilient structures theoriginal state prior to a crisis (such as the demographic change for example) isthe starting point for change becauseresilience describes a transformationprocess taking up existing structures andtransferring them into resistant and thusfuture-oriented forms. The term resiliencemust be understood rather in the contextof innovation than in the context ofreaction. The dynamic shaping of possibletransformation processes stands for thepower of self-renewal of a region. This mayimply a slight change of the concept ofsociety (Newman 2009).

As the format for the citizens’ fora, a kind ofworld café is chosen with the participantsspreading around four tables. Each of thefour table groups deals with one specificquestion:

1. What is the region’s strength? What areyou proud of?

2. What can you do/do you want to doconcretely to strengthen the resistivity ofyour region? What is feasible in reality?

3. What health factors do you identify forthe Donnersberg district?

4. What must be done so that you feel (still)more at ease in your region?

These questions encourage the citizens to participate actively. Regarding the

participation possibilities as citizensparticularly the second activating questionreaches stage 2 of Maria Lüttringhaus’sparticipation model (cf. Lüttringhaus 2000,pp. 66-68) (fig 2 above).

Catching ideas for development

It is easy for the citizens to look at thingsfrom a positive perspective, for examplewhen asked: “What are you particularlyproud of?” In this context above all the keywords climate/nature, literacy, majoremployers of the region, well accessibleswimming pool, residing companies andgood interrelations were mentioned.

However, when an active citizens’ partic -ipation in terms of a binding commitmentis required, professional conversationtechniques and moderation are needed(Lüttringhaus/Streich 2004). As a resultmany ideas are gathered here, too:integration of the youth, collection ofsignatures, initiation of citizens’ initiatives,use of platforms such as change.org, lettersto the editors, projects, demonstrationsand so on are cautiously mentioned aspossibilities.

The question concerning the health factorsin the Donnersberg district is answered as follows: respectful interaction of thepeople living there, contact with animals,quietness, the landscape and the cyclepaths are just a part of the diverse replieswhich promote health from the citizens’point of view.

Improvements of the overall well-being are

Information

Low intensity

Voice Co-decision Self-organisation

High intensity

2: Participation stages Rahel El-Maawi (2013) according to Lüttringhaus 2000

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seen especially in medical care, but also inpartially missing (community) actions,poorly developed broadband supply andtoo many vacant shops and apartments.

It is striking that the factors appreciated asthe region’s strengths are exactly the samefactors that are considered wholesome.Apparently, many aspects of healthalready exist in the Donnersberg districtand the citizens are aware of it and feelproud. It becomes clear, however, whichsteps must to be taken in future tostrengthen resilience in rural areas.

During the second citizens’ forum a “redthread” in the form of a key ring isdistributed accompanying the topic ofresilience sustainably and making it visible.The identified main topics of the firstCitizens’ forum are introduced and theguests are asked to rate the topicsimportant to them by means of a pointsystem. In doing so, participation stage 3 isreached, the citizens take part byprioritization and thus actively influencethe topics to be covered.

In this way, a clear topical preference isidentified. The guests of that evening optfor the following topics:

l Mobility

l Stay healthy

l Young people

l Digitisation.

Following an exchange of ideas about theexpectations and targets of the evening,two work groups are formed.

The selected topics comprise a wide rangeof dimension-specific aspects. Particularlythe dimensions “social issues” and “health”as well as the dimension “human beings”are focused on and looked at in theirinteractions.

Mobility and staying healthy:

Fast this work group agrees that health isfundamentally influenced by social contacts.There is a lively discussion on the issue ofoffering centers for encounter, especially suchfocusing on multi-generational encounters.

Communal jam making of young and oldpeople is agreed upon as a participationproject to be tackled.

Young people and digitization:

After an agreement on the regrettable factthat village schools and village shops asareas of encounter die out it becomes clearthat it is necessary to create new encounterpossibilities and especially possibilities forthe integration of the young as thoseincreasingly drop away in the villages. Acommon target is to motivate and winadolescents and young people to helpdeveloping the village life and an ownidentity with the village.

Successful participation is shown especiallythrough the project called “Spatial villagedevelopment and village coach for playing”during its initial phase. It is noted that moreallies are still needed to enhance andexpand the project. In response, a citizenhas offered to hold computer classes and/orcreate a website to announce the project.Phone numbers and addresses have beenexchanged and a foundation for futurepartnerships is laid.

Participation as a base is not new and noinvention of our times. However, with thehealthcare system, the administration andpolitics facing ever more complex challengesthe current importance of participation isgrowing rapidly. For good reason, becauseit is an investment into the quality ofdemocracy, yields manifold benefits andincreases the feel-good factor in the socialenvironment (cf. Senate Administration forUrban Development and EnvironmentBerlin 2012, p. 14).

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Of interest for the degree of participationis Roger Hart’s illustration from the 90s(Roger 1992) used in the debate about anappropriate participation of young peoplein political decision-making processes. The‘ladder of participation’ he developed forUNESCO in the 70s distinguishes thedegree of participation by means of stageswhich were modified and updated byGaby Straßburger and Judith Rieger in2014 (see Fig 3 above).

According to this depiction visiting a citizens’forum to participate in decisions in thesocial environment is already a possibility(stage 4) (Straßburger/Rieger 2014, p. 232).In case of an active participation incitizens’ fora, participation in decision-making and the exercise of freedom ofpersonal responsibility are assumed (pointsystem) and thus participation in all itsfacets. The exercise of civic freedom ofdecision (stage 6 of the stage model) canbe found with all guests of the citizens’fora: The participation shows that thecitizens actively use their right to expresstheir opinion and to take an active part.

Civic initiatives (stage 7) have not been

observed thus far: Citizens organize and realize their plans autonomously.Here probably further meetings andnetworking are required for which twomore citizens’ fora in autumn 2018 willprovide suitable opportunities. As a logicconsequence of the current results thepresentation and implementation of akind of “swap meet” is planned for thethird citizens’ forum: According to themotto “swap yourself healthy” the citizenswill be able to plan together whichservices can be swapped between youngand old people while providing room for(new) encounters. To ensure success,cooperation with the city of Rockenhausenis needed and letters are written to thetwo regional deaneries requesting theirhelp in promoting the citizens’ fora. Thisshould yeild good results as invitationsissued by the church as “players of theneighborhood” have been successful(Bestmann 2012).

It is the citizens serving the common goodthat are the source of power in rural areas(Henkel 2015, p. 328). The citizens’ self-organization offers the opportunity offuture potential for communal resilience.

Make contributions as provided for in the procedure

Give one’s view in the run-up of decisions

Inform oneself

Exercise civic freedom of decision

Use freedom of personal responsibility

Participate in decisions

Seek living world expertise

Ask for opinions

Provide information

Transfer decision-making power

STAGES OF PARTICIPATION STAGES OF PARTICIPATION

PRELIMINARY STAGES OF PARTICIPATION PRELIMINARY STAGES OF PARTICIPATION

Partially delegate decision-making competence

Admit co-determination

Civic personal initiatives

Participation from an institutional-professional perspective

Participation fromthe citizen’s perspective

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3: Straßburger, Rieger (ed.) (2014): Partizipation kompakt – Für Studium, Lehre und Praxis sozialer Berufe, p. 232

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