Clinical Sports Medicine

Health Promotion – A Vision and Task for the Next 10 Years

Gesundheitsförderung – eine Vision und Aufgabe für die nächsten 10 Jahre

In Germany there is an urgent need for general prevention and health promotion. If Germany is compared to other Western European countries, it becomes clear that, while life expectancy in Germany has increased over the last 30 years, Germany still remains at the bottom of the ranking among all Western European countries (5).

Germany was also one of the last countries to implement national strategy and implementation plans for physical activity as demanded by the World Health Organization (WHO) (10).

Current Status

Exercise promotion takes a prominent place in health promotion, since this supports the health of people of all ages in a wide variety of ways. The prevalence of physical inactivity is high in the German population (3) and most people do not achieve the minimum 150 minutes per week recommended by WHO exercise guidelines (3).

While there are several initiatives and campaigns in Germany for prevention and exercise Promotion (2), many of these have not been evaluated, are not widely available, or are totally unknown to the broad public. In order to support and realize measures of exercise promotion, the role, understanding and importance of prevention must be clearly changed.

Germany needs a discussion in society in which prevention, health promotion and provisions (especially exercise promotion) must be brought into the public focus and support given to citizens in the implementation and spread. In this, primary prevention and also secondary and tertiary prevention are essential.

Chances are offered in the fact that the German population is aging and becoming more diverse. Media use and (with it) sedentary behavior are continuously on the rise. The medial possibilities for reaching practically all levels of the population are constantly increasing. It is easier now than ever to place topics in the medial agenda, making them accessible to people’s awareness. Additional measures are needed in order for this topic to become established and have a positive influence on lifestyles.

A Look to the Future

But what, exactly, should health-promoting lifestyles in Germany be like in the (near) future? Prevention and health promotion must be accessible and part of everyday life for all citizens. For this, it is important to establish best-practice examples and to implement them everywhere (2).  Concepts reflecting practice must be worked out, realized and established with the participation of many people. Prevention must be anchored in everyday life and reach the citizens directly: only programs and concepts which are known can be applied, and only what is applied can be crowned with success. Health promotion must become concrete. This includes the concept "Exercise is medicine" from the USA, in which (family) doctors integrate the question of the patient’s regular physical activity, respond to the answer and prescribe exercise.

Many determinants of health or illness can be actively modulated, but it requires an extensive approach, since many determinants influence each other. For this reason, any prevention and health promotion must be considered a complex, society-based construct which must act at several levels at once to achieve a population-wide effect. Multi-level interventions, in which political-structural measures are combined with consultation and information offers, publicity and the coordination of measures on site appear especially to promise success (9).

Since the groundwork for health and exercise behavior is laid at a young age and difficult to change later, healthy growth via cooperation of various settings or socialization authorities requires particular support. Worldwide, more than 80% of 11 to 17-year-olds are not sufficiently active (4), in Germany this even holds for 88% of the girls and 80% of the Boys (4). Exercise promotion must therefore be integrated into everyday life right from the start and anchored in various settings. Starting with the first U-examinations, parents must be informed of the importance of exercise for child development and the concept of health promotion begun in the nursery and continued in kindergarten and elementary schools. Often demanded and established, for example in the USA, where it is considered a means of combatting inactivity in children, daily sport sessions should be viewed with caution. Studies in Germany have shown that children do not exercise in the moderate to intensive range demanded by WHO for more than 8.5 minutes per hour of school sport (6). The active transport to school, on the other hand, can have health-promoting aspects (7).

For this, communities must make physical exercise possible by transportation measures, such as expansion of cycle paths and provision of uncomplicated, inexpensive bicycle rental Systems. Healthy and safe exercise in everyday life must be realized by appropriate shaping of the environment. Health-promoting conditions for living and working must be achieved by cooperation between various political and social areas for all levels of the population in order to provide for health equality between genders and socioeconomic groups, independent of age and origin.

Since this is one of the doctors’ tasks, medical studies must depart from the almost exclusively curative-directed contents and vastly expand the preventive approach to better get across the importance and chances for the patients. Doctors must regularly continue their education in this respect and - as required in the Prevention Law (8) – stay informed of the regional possibilities for health promotion. This is the only way to be in a position to offer patients appropriate and well-founded individual prevention within the current resources, and to be able to provide them with tools or contact addresses.Health insurance companies must offer regular prevention and health-checks starting at a young age and in cooperation with the communities create living conditions which are health-promoting and attractive. At the moment, the public health insurance companies spent only about 3% of their budget for prevention (1). Low-price, medial support systems must be developed, applied and maintained to provide and sustain alternative behaviors to strengthen public health competence on a lasting Basis.

Importance of Evidence-Based Measures

This all makes it clear that extensive health promotion can arise only from the interaction of many different measures and regulations. Initial re-thinking is already there, but implementation is still coupled with great challenges and creating all of the necessary basics requires networking of all sociopolitical offices. Experiments are still being made in many areas and goals are only slowly defined. This requires courageous decisions from politicians with active citizen participation to attain effectiveness of the new modern political concepts of health promotion in the population. The WHO demands ascribing the necessary political priorities and resources to make implementation of goals feasible at all. If, in addition, greater chances for health equality are to be attained, target-group-specific design of preventive offers is necessary which strives for broad dialogue with those affected.

In addition, intensive scientific direction and involvement are needed: prevention can only be effective, feasible, individually appropriate and sustainable if these factors are first evaluated in the form of extensive studies and programs. Thus, evidence-basing must be assigned a high value in the social and scientific context. Changes which will survive in future are only possible by means of financing, performance and support of evaluated, controlled, evidence-based measures which are meaningful and which are worthwhile for the health of future generations.


  1. BÖDEKER W, MOEBUS S. Ausgaben der gesetzlichenKrankenversicherung für Gesundheitsförderung und Prävention2012-2017: Positive Effekte durch das Präventionsgesetz?Gesundheitswesen. 2019 [Epub ahead of print].
  2. FÜZÉKI E, BANZER W. Bewegungsförderung aktuell – Glas halb volloder halb leer? Dtsch Z Sportmed. 2019;70:263-264.
  3. GUTHOLD R, STEVENS GA, RILEY LM, BULL FC. Worldwide trends ininsufficient physical activity from 2001 to 2016: a pooled analysisof 358 population-based surveys with 1·9 million participants.Lancet Glob Health. 2018; 6: e1077-e1086.
  4. GUTHOLD R, STEVENS GA, RILEY LM, BULL FC. Global trends ininsufficient physical activity among adolescents: a pooledanalysis of 298 population-based surveys with 1.6 millionparticipants. Lancet Child Adolesc Health. 2020; 4: 23-35.
  5. INSTITUTE FOR HEALTH METRICS AND EVALUATION (IHME). Findingsfrom the Global Burden of Disease Study 2017. Seattle, WA:IHME, 2018.
  6. KOBEL S, KETTNER S, ERKELENZ N, KESZTYÜS D, STEINACKER JM. Effectsof physical education on objectively determined physical activityin primary school children – which proportioning is best? JTeach Phys Educ. 2015;34:537-547.
  7. KOBEL S, WARTHA O, STEINACKER JM. Correlates of active transportto school in German primary school children. Dtsch Z Sportmed.2019;70:67-74.
  8. PRÄVENTIONSGESETZ – PRÄVG. Gesetz zur Stärkung derGesundheitsförderung und der Prävention. Bundesgesetzblatt.2015; 31: 1368-1379. Bundesanzeiger Verlag, Köln.
  9. WORLD HEALTH ORGANISATION. Interventions on diet and physicalactivity: what works: summary report. WHO: Geneva, 2009.
  10. WORLD HEALTH ORGANISATION. ACTIVE: a technical package forincreasing physical activity. WHO: Geneva, 2018.
Dr. Susanne Kobel
Projektgruppe „Komm mit in das gesunde
Boot“, Sektion Sport- und Rehabilitationsmedizin,
Universitätsklinikum Ulm
Frauensteige 6 – Haus 58/33, 89075 Ulm