Cooperative planning and its utilization in German physical activity promotion: a brief introduction.

INTRODUCTION

The fact that many potentially successful interventions remain stuck in the demonstration stage rather than being widely implemented or scaled up remains a central problem of health promotion (Green and Glasgow, 2006; Milat ; Reis ). For the healthcare setting, it has been found that transferring research results and innovation into practice may take many years (Green, 2014, Hanney ). Interventions are often developed under laboratory conditions rather than with a focus on real-world contexts (Card ; Escoffery ). To alleviate this problem, various approaches have been proposed that build on the active involvement of those who will be applying or taking part in the respective interventions, including participatory approaches (Simonds ; Salsberg ; van den Driessen Mareeuw ), action research (Parkin, 2009), empowerment (Wallerstein, 1992; Tengland, 2012), citizen science (King ) or knowledge co-production (Greenhalgh ; Kothari ).

Against this backdrop, in 2013, the German Ministry of Research and Education launched a call for research consortia in primary prevention and health promotion aimed at reducing the costs for the healthcare system caused by lifestyle and environmental factors, which called for interdisciplinary approaches and the inclusion of setting practitioners (BMBF, 2013). One of the consortia to receive funding between 2015 and 2021 was Capital4Health (www.capital4health.de/en last accessed 14 October 2021), which aimed to promote capabilities for physical activity and active lifestyles across the lifecourse (i.e. pre-school children, school children, young adults in vocational education and older adults). The consortium consisted of five setting-based projects and two cross-cutting projects (theory, networking and evaluation) run by nine German research institutions.

An important feature of Capital4Health was that all of its projects used the same approach to foster participation and co-production in order to develop and implement specific actions to promote physical activity, i.e. Cooperative Planning (from German ‘Kooperative Planung’, Rütten, 1997, Rütten and Gelius, 2014). This approach has been widely used to promote health-enhancing physical activity in Germany over the last three decades. This supplement to Health Promotion International aims to introduce Cooperative Planning to a global audience, showcase its applicability across multiple settings by using examples from Capital4Health and discuss its benefits and challenges from a number of different theoretical and practical perspectives.

COOPERATIVE PLANNING

Origins of the approach

While various planning approaches in health promotion might be labeled as being cooperative, throughout this supplement, the term Cooperative Planning is used to refer to a specific approach originally known by the German term ‘Kooperative Planung’. This approach is well known and broadly used in the context of German health and physical activity promotion but may be less familiar to an international audience. This is likely due in part to the fact that much of the extant literature on the approach, in particular more detailed descriptions, is currently available in German only. Consequently, a short introduction to the approach is warranted.

The origins of Cooperative Planning in Germany (see Rütten, 1997) can be traced back to early planning approaches in urban planning and local decision making in 1970s West Germany, as well as to collaborative methods for planning sport and leisure facilities in Finland (Suomi 1991). In the early 1990s, these strands were combined and adapted to the field of sports facility development in Germany (Rütten, 2001).

The most important scholar for the development of Cooperative Planning has undoubtedly been Alfred Rütten, who was part of the original development team. Rütten et al. further developed the approach for sport facility development (‘integrated planning’, Rütten and Schröder, 2001, also see Wetterich and Klopfer, 2000), and proposed its utilization in the broader field of health and physical activity promotion. He also provided the first comprehensive overview of Cooperative Planning (Rütten, 1997) and a detailed step-by-step manual for practitioners (Rütten, 2012). Finally, he initiated a number of German and international projects built around Cooperative Planning, including Capital4Health, from which this supplement emanated. All in all, more than 20 projects with more than 80 planning processes have been conducted since 1991, plus two long-term academic spin-offs in sport facility development that have included more than 400 planning processes (Sommer ).

Main elements

Cooperative Planning is an approach to participation and knowledge co-production with specific goals in mind, i.e. it is geared at developing and implementing a clearly outlined action plan in a time-efficient manner (Rütten, 2001; Rütten and Gelius, 2014). It is based on a planning group representing relevant population groups, professionals, policymakers, and researchers and comprises three phases: (i) team building and needs assessment, (ii) a series of four to six planning sessions, and (iii) supervised intervention and implementation of actions (Rütten, 1997, 2012).

Phase 1 starts by establishing a coordination leader or team to run the process, organize meetings and monitor progress. Depending on the context, this typically consists of an organization, a coordination tandem or a steering committee. The coordinators collect data relevant to the planning process, e.g. information on existing infrastructures, legal requirements, health behavior data or the needs and wants of involved population groups. They are also tasked with assembling a planning group that involves all relevant local stakeholders, usually policymakers, health promotion practitioners, academic experts and population group representatives. Ideally, the planning group should have between 8 and 20 participants representing the different stakeholder perspectives. Participants may be recruited based on their community’s or organization’s readiness for collaboration (Weiner, 2009) or their identified importance to project success (Rütten and Gelius, 2014).

Phase 2 is the centerpiece of Cooperative Planning. It typically consists of a series of six sessions plus additional workgroup meetings where necessary. For a smooth process and optimal results in a reasonably short amount of time (usually 6–12 months), a number of prerequisites are stipulated. These include a qualified moderator accepted by all participants, agreed-upon communication rules based on respect and equality, an easy-to-reach meeting venue, measures to ensure participation of all actors (e.g. appropriate scheduling, childcare and potentially monetary compensation as appropriate), and regular contact between meetings.

The process involves six standard planning sessions, as follows, with the possibility of adding or merging meetings when required by the context: In session 1, participants get to know each other, agree on the rules of the process, review the data relating to the problem or issue at hand provided by the moderator, set a planning goal, and brainstorm potential actions commensurate with identified outcomes of interest. In session 2, ideas are reviewed and prioritized based on their importance, evidence and feasibility. Sessions 3–5 are reserved for the development of actions, which is usually done in smaller workgroups. For each action, participants stipulate a clear objective, specific timeline, intervention implementation steps and milestones, responsibilities and the required resources. If necessary, individual workgroups can hold additional sessions between regular meetings. In the last session, the planning group discusses and adopts the finalized action plan and prepares for the implementation phase of the project.

Phase 3 is dedicated to the implementation of the action plan to affect change. It is supervised either by the entire planning group, the steering committee or one of the participating organizations (e.g. the city administration or a research institution). Implementation progress is discussed at regular intervals, which may lead to the adaptation of steps and milestones in order to remove barriers to successful implementation (i.e. feedback loops are employed). Participants who emerge as ‘champions’ (Greenhalgh ; O’Loughlin ) of the process during phase 2 may become central to the successful implementation of actions [see, e.g. (Herbert-Maul ; Popp )].

OTHER APPROACHES

From a broader theoretical perspective, the Cooperative Planning approach described here has four key components, which exhibit some important parallels but also some differences when compared to other participatory and co-creation approaches in health promotion. First, Cooperative Planning is a theory-based, systematic and goal-oriented approach to plan and implement health promotion interventions. In this regard, it has clear similarities with intervention mapping (Bartholomew ) and health promotion planning [e.g. the PRECEDE–PROCEED Model (Green and Kreuter, 2005)], which also prescribe step-by-step processes involving situation assessment, intervention planning, implementation and evaluation. Arguably, these approaches put more emphasis on the steps of program development in general, while Cooperative Planning provides more guidance on the practical aspects of involving stakeholders in the planning process.

Second, Cooperative Planning aims at involving all relevant stakeholders in the planning process. In this regard, there are clear links to community-based participatory research [CBPR (Minkler and Wallerstein, 2008)]. While sharing many core ideas with Cooperative Planning (e.g. context sensitivity, co-learning and asset identification), however, CBPR is typically used as a broad conceptual framework rather than as a step-by-step approach to intervention development. Another potential distinction is that CBPR is conceptualized from the perspective of involving community members (although, in practice, the major focus often remains on representative community organizations and actors). Conceptually, Cooperative Planning is mainly concerned with the equal involvement of all stakeholder groups, and in some ways even bears similarities with approaches fostering change in organizations rather than communities [see (Holman )]. The CBPR literature also points to the question of the extent of participation in Cooperative Planning when compared to other approaches on the ‘participation ladder’ (Arnstein, 1969) and to its timing of participation. For example, it involves stakeholders mainly in the development of actions, while approaches such as participatory citizen science (King ) highlight resident and stakeholder participation throughout the collaborative research process, from the identification of relevant community issues through subsequent data collection, interpretation and analysis, followed by collaborative action planning, decision-making and local change.

Third, the Cooperative Planning approach is geared at fostering knowledge co-production between different stakeholder groups, an issue that has been discussed from various angles in the health promotion literature. For instance, research on the ‘nexus’ between policy, practice and research has reflected on ways to blur boundaries and share knowledge between these three domains (de Leeuw ; Jansen ). A related discourse is concerned with interactive knowledge-to-action models that overcome the linear transfer of research into policy and practice (Weiss, 1979; CIHR, 2010). Finally, transdisciplinary research (Bergmann ) deals with the interactions both between different academic disciplines and between research, policy and practice. As the co-production framework of the Capital4Health consortium convincingly demonstrates, Cooperative Planning can be conceptualized from all these co-production perspectives (Rütten ). These approaches also link to the broader systemic discourse on intersectoral health governance and Health in All Policies, which emphasizes the fact that health is mostly produced outside the health sector (de Leeuw, 2017). A broad range of methods has been proposed to increase engagement across policy sectors, knowledge translation and community participation, including institutional re-design, rule setting and formats such as workshops and seminars to improve communication.

Fourth, the Cooperative Planning approach described in this supplement involves the use of progress monitoring and feedback loops. Again, these aspects can be found in both intervention mapping (in the form of an evaluation model to ascertain whether all steps of the process were adequate, Bartholomew ) and in health promotion planning with its focus on assessment and evaluation at various stages and the idea of ‘corrective feedback’ (Crosby and Noar, 2011). Overall, a cornerstone of such approaches is post evaluation to inform subsequent development cycles. By comparison, Cooperative Planning typically extends the evaluation process through emphasizing the ‘concurrent’ evaluation of each step in the process by continuously obtaining the perspectives of all involved stakeholders.

OVERVIEW OF THE SUPPLEMENT

With this supplement, we intend to provide insights into these key features of Cooperative Planning and its application in setting-based physical activity promotion across the lifecourse. Each article points to a number of important theoretical and practical aspects, including process preparation, compatibility with other approaches to foster participation and co-creation, measurement and evaluation, and further conceptual development. At the same time, the articles highlight context-specific adaptations, success factors, challenges and important lessons to be learned for potential future use of the Cooperative Planning approach in different settings.

The supplement begins with five articles focused on the different health promotion settings covered by the Capital4Health consortium. First, Müller and Hassel report on the utilization of Cooperative Planning (Müller and Hassel, 2021) to improve capabilities for physical activity in childcare centers. The authors identify a number of facilitators and barriers to Cooperative Planning processes that may inform future evidence-based good practice guidelines for health and physical activity promotion in this important setting. In addition, their study is a good example of how Cooperative Planning can be combined with other means of fostering participation and implementation—in this case, an online self-assessment application (app) for childcare center staff.

The next two contributions illustrate how Cooperative Planning can be employed in schools, and they also shed light on the possibility of using it at multiple levels of impact. First, Ptack and Strobl show how Cooperative Planning (Ptack and Strobl, 2021) was employed to involve pupils, teachers and school administrators in the development of physical activity promotion programs in four Bavarian secondary schools, and they identify a number of crucial success factors for this setting. In particular, they evaluate the impact of Cooperative Planning on the teaching strategies of participating physical education (PE) teachers. The article by Hapke et al. complements these insights by focusing (Hapke ) on the education of the PE teachers themselves. The authors investigate how a Cooperative Planning process involving university lecturers and specialized teacher trainers can help alter these educators’ belief systems regarding physical activity and health, with a potential impact on the teaching practices of generations of future PE teachers.

The contribution by (Kehl ) focuses on the preparation phase of participatory processes aimed at improving physical activity levels in men over 50 years of age living in rural communities. They report on their experience of conducting a qualitative assessment on community readiness for change concerning physical activity and feeding the results into a Cooperative Planning process that engaged local government officials, community NGO representatives and older men. Their article shows that such community-facing assessments can provide an added value to more traditional individually focused assessments in the physical activity field, and it is also an example of applying Cooperative Planning in a community-based environment and for developing gender-sensitive actions for physical activity promotion.

Popp et al. also address the preparation phase (Popp ) of the Cooperative Planning process in their article focused on vocational training in the field of car mechatronics and nursing in Germany. They suggest that a short period of ‘immersion’ in the setting by academic partners may help improve cooperation between academic and non-academic participants. Such a ‘practice dive’ may help researchers to better familiarize themselves with real-world contexts before conducting projects that involve Cooperative Planning or other approaches to participation and co-production. In addition, their commentary gives an insight into the rather unique setting of vocational training , which combines school-based learning with time spent in real-world working environments.

The next two articles also report on experiences gained from the Capital4Health Consortium, but from a cross-cutting evaluation perspective across the four setting- and population-specific projects. Sauter and Loss continuously monitored (Sauter and Loss, 2021) the meetings in all Capital4Health projects using a standardized protocol based on the concept of capacity building. Their analysis highlights some of the main advantages and challenges of the Cooperative Planning approach and also outlines ways of conducting a comparative analysis of similar participatory interventions across different domains. Meanwhile, the article by Gelius et al. focuses on the overall costs of Cooperative Planning (Gelius ). The authors used a standardized template to estimate the expenses incurred for human resources and material costs in all 144 planning meetings in the Capital4Health consortium. The analysis highlights the stark cost differences of participation between different settings and may also serve as a basis for a full-fledged health economic evaluation of Cooperative Planning, also in relation to other intervention types.

The final two contributions come from projects that were not part of the Capital4Health Consortium but that also employed Cooperative Planning in different contexts of physical activity promotion in Germany. First, Abu-Omar et al. reflect on the experience of the BewegtVersorgt project (Abu-Omar ), which employed an adapted Cooperative Planning approach to involve stakeholders in the development of an exercise referral scheme in the German healthcare system. Their article provides valuable insights into the potential of using Cooperative Planning and similar co-production approaches within the heavily regulated healthcare setting and also shows the strong potential of Cooperative Planning to be adapted to the needs of specific contexts. Finally, Kohler et al. report from the KOMBINE project (Kohler ), which used workshops with practitioners and policymakers to identify key components of successful physical activity promotion in the community setting and to develop a framework for action. During the process, Cooperative Planning was integrated into the framework as a central component, illustrating another way of adapting Cooperative Planning to the needs of specific contexts.

Overall, the articles provide evidence that Cooperative Planning can successfully be applied to a variety of settings across the lifecourse, and that it can contribute to producing both outputs (e.g. new health-promoting teaching strategies) and outcomes (e.g. capacities for health promotion; changes in stakeholders’ health-related beliefs). They also show that a thorough preparation phase (Phase 1), especially a detailed assessment of community and/or organizational readiness, is key to its success. The planning process itself (Phase 2) can be adapted to a broad variety of context variables, and process organizers should make use of these possibilities. In addition, our experience indicates that both the planning and the implementation phase (Phase 3) benefit greatly from the identification of and continued support from key individuals acting as champions of the intervention.

CONCLUSION

Cooperative Planning is a systematic and goal-oriented approach that aims at involving all relevant stakeholders and is built on notions of participation, co-production and iterative feedback processes. As such, it has much in common with other, internationally developed approaches but also offers a unique focus and combination of features (i.e. theory and goal orientation, equal involvement of all relevant stakeholders, knowledge co-production across different domains and ongoing stakeholder feedback).

We believe that it can be used in various health promotion settings and contexts, not only in Germany but also in other countries that allow for similar types of citizen participation and knowledge co-production between governments, professionals and academics. This may encourage health promoters and scholars around the world to take a closer look at the approach and the lessons to be learned from its application, compare it to the concepts currently in use in their own countries, and consider it as an option when searching for appropriate ways of engaging stakeholders in health promotion.

Cooperative Planning can either be used on its own or in combination with other theoretical frameworks (e.g. CBPR) or specific approaches (e.g. community-engaged citizen science). It offers a tool for systematically tackling the complexity of health promotion, helping key stakeholders from policy, practice, community and research to learn collaboratively from the great diversity of perspectives and to realize shared goals in public health.