In this paper, network analytical methods were used to give an overview of the three model regions involved in the project ‘Familie+’. Their structural and process characteristics as well as the interconnectedness of the actors within each network were outlined. The networks were mainly characterized by their different sizes as well as different distribution of network partners in terms of their subject matter and structure. Network partners who are in contact interact with each other mostly on a quarterly basis and in the context of informal collaboration. Social networks are particularly important in terms of supporting partnerships and collaborations within a research process (35).
If the three networks are placed in the context of their structure for community health promotion, the following characteristics can be identified. Although network#2 for community health promotion is still in its early stages, it is intriguing to note that it has both the highest network density but also the lowest degree centrality. In contrast, network#3, with its already very developed structure for community health promotion, has the lowest network density and, similar to network#2, one-third greater degree centrality than network#3. High degree centrality can have both benefits and drawbacks, as a small number of stakeholders connect many other institutions that would otherwise not be connected. This can have a positive impact on the effective dissemination of information and strengthen networking with other institutions through these key stakeholders, but at the same time, communication depends on these gatekeepers and could represent bottlenecks with regard to the transfer of information (36). In network#2 and network#3, one institution each from the subject area health has the greatest betweenness-centrality and represents an important communication interface. Betweenness centrality is an indicator of an actor's influence in a network and provides information about the extent of its control potential. Actors with high betweenness centrality serve as a strong link between other network partners through their strategic network placement and serve, for example, as mediators of information (26, 31). In network#1, on the other hand, the most central actors are a social and educational institution and an actor in the field of nutrition. In this region, however, there is a greater number of stakeholders dealing with the subject area health on a superordinate level compared to the other two regions, which in turn could explain the lower centrality of these institutions. When analyzing networks as a whole, adjusting for network size is important because the larger the network, the less dense it becomes and the higher the degree of centralization (17). Especially with regard to the high degree centrality in #network1 and #network3, the very short average path length in all three networks represents an optimal condition for the implementation of community health promotion projects, as most relevant institutions seem to be quickly accessible, which facilitates information exchange and communication.
Network analysis served as a suitable tool for making existing network structures visible in the ‘Familie+’ project in the three model regions involved. Although the networks are still in their initial stages and do not yet have any influence on the project, it is important to survey and analyze the already existing structures. The socio-ecological approach, which includes a multi-setting as well as participatory design and underpins the community-based obesity prevention project ‘Familie+’, is broad, therefore the present study focused on the analysis of stakeholders from different network levels and their interaction. Interactions were captured similarly to already existing studies measured by type and extent of contact, but further research is needed to examine community networks in a more interpretative analysis that surveys barriers and contributions to communication, rules of communication as well as dimensions and quality of interaction (27, 35). Nevertheless, a foundation could be created at the beginning of the project simply by pointing out previously known and unknown actors and fields of work, on which the respective municipalities can build and expand their networks. A specific exchange between the stakeholders can initiate an intensive engagement with the topic of health promotion of primary school children, common goals, development opportunities and ideas in further project phases. A project guide on the topic of strategic design of municipal prevention and health promotion indicates that network analyses as part of the assessment of the current situation in the early phase of municipal health promotion projects lead into the sustainable processing of the respective topics and needs for action (37).
Based on the results of the network analysis and the observation that the urban model region with its very distinctive structure for community health promotion already has a well-connected network and a health facilitator, it would be desirable to initiate further expansion and strengthening of the network at the health policy level in the other model regions by providing necessary ressources. To achieve systematic networking of the health-related network levels, additional health facilitators can be deployed whose main task is to link the primary and tertiary levels. This approach has already been successfully implemented in a Brazilian family health program (14) and could also be used within ‘Familie+’ to strengthen networking and information exchange between the health policy level and primary schools including children and their families. In addition, sufficient resources must be made available to strengthen the network so that other network and cooperation partners can be involved in a participatory manner. For further planning and a successful course of the ‘Familie+’ project, it would be valuable to identify potential organizational collaborations in order to maintain and strengthen partnerships and to identify any gaps in the network. To date, there is no evidence that the use of a network analysis provides intelligent targeting of key relationships and collaborations (38). A comparison of the networks of the three model regions over the course of the intervention would be useful to identify different multipliers that could be beneficial for knowledge transfer to the target groups.
This study also has some potential limitations in the context of preparing and conducting the network analysis. The network definition was based on the subjective results of the individual expert interviews within the respective municipalities, therefore there may be institutions that were forgotten or otherwise excluded. The institutional contacts selected to conduct the network analysis were those that appeared to have the best knowledge of the day-to-day operations of their institutions. Still, the information provided by some respondents could be limited and inconsistent due to institutional changes (including the Corona pandemic), job changes, and changes in roles and responsibilities. Another problem in conducting the survey-based network analysis was the non-participation of potentially relevant network partners in all three municipalities due to inaccessibility by email or phone and lack of time on the part of stakeholders. The study is a subjective survey, implying that the results are under the influence of social desirability. At the municipal level, it should again be noted that the networks have different prerequisites due to their location (urban versus rural) as well as different levels of prior experience in municipal health promotion. The hierarchical position as well as the objectives of the experts and individual stakeholders are decisive for the contribution of resources that have a beneficial effect on the project 'Familie+' as well as on community health promotion in the model regions. Nevertheless, the study had a strength with its sufficiently high response rate, as the incomplete data sets appeared to be representative of those involved in the overall project. The inclusion of adjusted control variables as well as the identification of communication-related confounders would be advisable, as the interpretation of the results is influenced by different network sizes as well as structural characteristics or unusual events.