Addressing the social determinants of health at the local level: Opportunities and challenges

The Role of Chief Medical officers in making Public Health Overview Documents in Norwegian Municipalities. A qualitative Study

AIMS

To investigate how Chief Medical Officers experience their role in the municipalities´ work with making the public health overview documents, demanded by the Norwegian Public Health Act from 2012.

METHODS

A qualitative study with semi-structured focus group interviews with 21 Chief Medical Officers from 20 different municipalities in Norway. The interviews were conducted in 2017. The data were analyzed thematically.

RESULTS

The Chief Medical Officers were mainly positive to participating in making public health overview documents. They took on roles as leaders of the work, medical advisors, data collectors towards local GPs and listening post to other sectors. Organizational factors like too small positions and a lack of tradition to involve the CMO in public health work were experienced as barriers to their involvement. The collaboration with the public health coordinators was said to be rewarding, and the intersectoral process involved employees from other sectors in a new way in public health. Although there were some positive experiences, several CMOs considered the use and impact of the public health overview document as limited.

CONCLUSION

There was a large variation in the amount and the type of involvement the Chief Medical Officers had in making the public health overview documents in Norwegian municipalities. More research is needed to understand if this has any consequences for the quality of public health work in the municipalities and whether it is a sign of a changing role of the Chief Medical Officers.

County-Level Socio-Environmental Factors Associated With Stroke Mortality in the United States: A Cross-Sectional Study

We used machine learning methods to explore sociodemographic and environmental determinants of health (SEDH) associated with county-level stroke mortality in the USA. We conducted a cross-sectional analysis of individuals aged ≥15 years who died from all stroke subtypes between 2016 and 2020. We analyzed 54 county-level SEDH possibly associated with age-adjusted stroke mortality rates/100,000 people. Classification and Regression Tree (CART) was used to identify specific county-level clusters associated with stroke mortality. Variable importance was assessed using Random Forest analysis. A total of 501,391 decedents from 2397 counties were included. CART identified 10 clusters, with 77.5% relative increase in stroke mortality rates across the spectrum (28.5 vs 50.7 per 100,000 persons). CART identified 8 SEDH to guide the classification of the county clusters. Including, annual Median Household Income ($), live births with Low Birthweight (%), current adult Smokers (%), adults reporting Severe Housing Problems (%), adequate Access to Exercise (%), adults reporting Physical Inactivity (%), adults with diagnosed Diabetes (%), and adults reporting Excessive Drinking (%). In conclusion, SEDH exposures have a complex relationship with stroke. Machine learning approaches can help deconstruct this relationship and demonstrate associations that allow improved understanding of the socio-environmental drivers of stroke and development of targeted interventions.

Intersectoral Partnerships Between Local Governments and Health Organisations in High-Income Contexts: A Scoping Review

BACKGROUND

Local governments are the closest level of government to the communities they serve. Traditionally providing roads, rates and garbage services, they are also responsible for policy and regulation, particularly land use planning and community facilities and services that have direct and indirect impacts on (equitable) health and well-being. Partnerships between health agencies and local government are therefore an attractive proposition to progress actions that positively impact community health and well-being. Yet, the factors underpinning these partnerships across different contexts are underdeveloped, as mechanisms to improve population health and well-being.

METHODS

A scoping review was conducted to gain insight into the concepts, theories, sources, and knowledge gaps that shape partnerships between health and local governments. The search strategy followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines and was informed by a critical realist approach that identifies necessary, contingent and contextual factors in the literature. MEDLINE, Scopus, Web of Science, and ProQuest Central databases were searched for studies published between January 2005 and July 2021.

RESULTS

The search yielded 3472 studies, after deleting duplicates and initial title and abstract screening, 188 papers underwent full text review. Twenty-nine papers were included in the review. Key themes shaping partnerships included funding and resources; partnership qualities; governance and policy; and evaluation and measures of success. The functional, organisational and individual aspects of these themes are explored and presented in a framework.

CONCLUSION

Given that local government are the closest level of government to community, this paper provides a sophisticated roadmap that can underpin partnerships between local government and health agencies aiming to influence population health outcomes. By identifying key themes across contexts, we provide a framework that may assist in designing and evaluating evidence-informed health and local government partnerships.

Strategies for knowledge exchange for action to address place-based determinants of health inequalities: an umbrella review

BACKGROUND

Place-based health inequalities persist despite decades of academics and other stakeholders generating ideas and evidence on how to reduce them. This may in part reflect a failure in effective knowledge exchange (KE). We aim to understand what KE strategies are effective in supporting actions on place-based determinants and the barriers and facilitators to this KE.

METHODS

An umbrella review was undertaken to identify relevant KE strategies. Systematic reviews were identified by searching academic databases (Medline, Embase, Scopus, Web of Science) and handsearching. Synthesis involved charting and thematic analysis.

RESULTS

Fourteen systematic reviews were included comprising 105 unique, relevant studies. Four approaches to KE were identified: improving access to knowledge, collaborative approaches, participatory models and KE as part of advocacy. While barriers and facilitators were reported, KE approaches were rarely evaluated for their effectiveness.

CONCLUSIONS

Based on these four approaches, our review produced a framework, which may support planning of future KE strategies. The findings also suggest the importance of attending to political context, including the ways in which this may impede a more upstream place-based focus in favour of behavioural interventions and the extent that researchers are willing to engage with politicized agendas.

Factors of the policy process influencing Health in All Policies in local government: A scoping review

Objectives

This review aimed to identify factors in the policymaking environment that influence a Health in all Policies approach in local government, how these vary across different municipal contexts, and the extent that theories of the policy process are applied.

Methods

A scoping review was conducted to include sources published in English, between 2001 and 2021 in three databases, and assessed for inclusion by two blind reviewers.

Results

Sixty-four sources were included. Sixteen factors of the policy process were identified, expanding on previously reported literature to include understanding and framing of health, use of evidence, policy priority, and influence of political ideology. Eleven sources applied or referred to theories of the policy process and few reported findings based on different local government contexts.

Conclusion

There are a range of factors influencing a Health in All Policies approach in local government, although a limited understanding of how these differ across contexts. A theory-informed lens contributed to identifying a breadth of factors, although lack of explicit application of theories of the policy process in studies makes it difficult to ascertain meaningful synthesis of the interconnectedness of these factors.

Local Welfare Systems and Health Inequalities: The Effects of Institutional Overlapping and Local Variations

A growing research agenda shows the importance of local welfare systems in understanding socio-spatial inequalities in health. Welfare services provided by local governments overlap with those provided by other levels of government. Thus, differences in the provision of welfare services between municipalities could explain differences in residents' health, moderating the magnitude of health inequalities if local governments deploy actions capable of positively influencing the social determinants of health. This article attempts to analyse this idea in the Spanish case, exploring the influence of local policies according to the orientation of municipal spending on three indicators of the population's health status: self-perceived health, healthy practices and activity limitations due to health problems. A multilevel cross-sectional study was designed using information from two waves of the 2006-2007 and 2011-2012 National Health Survey for the population aged 15 years and older (N = 31,378) residing in Spanish municipalities of 20,000 inhabitants or over (N = 373). The results show that the magnitude of inequalities in self-perceived health, in the adoption of healthy practices and in daily activity limitations by social class are smaller as municipalities" spending was oriented towards policy areas considered as redistributive. Therefore, the proposed institutional overlap thesis could help understand the role of subnational governments on the magnitude of health inequalities, as well as in comparative analysis between countries with institutional systems in which local governments have a greater or lesser capacity to provide welfare services.

Norwegian policies to reduce social inequalities in health: Developments from 1987 to 2021

Reducing social inequalities in health has been an important aim in the development of the Nordic welfare states. This Commentary presents the development of Norwegian policies in this area from 1987 to 2021. Social inequalities entered the political agenda in Norway in the 1980s, but were mostly defined as a problem for selected marginalised groups. The World Health Organization project led by Michael Marmot was an inspiration for Norwegian policy-makers and the concept of the social gradient was introduced. From 2005, levelling the social gradient in health became a central strategy in Norwegian policy-making and culminated in the Public Health Act 2012. This Act focuses on the structural determinants of health and the municipalities have a central role in its implementation. However, the municipalities are mostly responsible for services providing downstream measures and have little control over social determinants such as tax or labour market policies. The Public Health Act is important because it institutionalises social inequalities as a policy field within public health. Not only the municipalities, but all administrative levels have to contribute to meet the aim of reducing the social gradient.

Rainbows over the world's public health: determinants of health models in the past, present, and future

The need to visualise the complexity of the determinants of population health and their interactions inspired the development of the rainbow model. In this commentary we chronicle how variations of this model have emerged, including the initial models of Haglund and Svanström (1982), Dahlgren and Whitehead (1991), and the Östgöta model (2014), and we illustrate how these models have been influential in both public health and beyond. All these models have strong Nordic connections and are thus an important Nordic contribution to public health. Further, these models have underpinned and facilitated other examples of Nordic leadership in public health, including practical efforts to address health inequalities and design new health policy approaches.

Apart from documenting the emergence of rainbow models and their wide range of contemporary uses, we examine a range of criticisms levelled at these models – including limitations in methodological development and in scope. We propose the time is ripe for an updated generic determinants of health model, one that elucidates and preserves the core value in older models, while recognising the developments that have occurred over the past decades in our understanding of the determinants of health. We conclude with an example of a generic model that fulfills the general purposes of a determinants of health model while maintaining the necessary scope for further adjustments to be made in the future, as well as adjustments to location or context-specific purposes, in education, research, health promotion and beyond.

A study of socio-economic inequalities in self-reported oral and general health in South-East Norway

This study assesses the association between socioeconomic determinants and self-reported health using data from a regional Norwegian health survey. We included 9,068 participants ≥ 25 years. Survey data were linked to registry data on education and income. Self-reported oral and general health were separately assessed and categorized into ‘good’/‘poor’. Exposures were educational level, personal income, and economic security. Prevalence ratios (PR) were computed to assess the associations between socioeconomic determinants and self-reported health using Poisson regression models. Participants with low education or income had poorer oral and general health than those with more education or higher income. Comparing the highest and lowest education levels, adjusted PRs for poor oral and general health were 1.27 (95%CI, 1.11–1.46) and 1.43 (95%CI, 1.29–1.59), respectively. Correspondingly, PRs for lowest income quintiles compared to highest quintile were 1.34 (95%CI, 1.17–1.55) and 2.10 (95%CI, 1.82–2.43). Low economic security was also significantly associated with poor oral and general health. There were socioeconomic gradients and positive linear trends between levels of education and income in relation to both outcomes (P-linear trends < 0.001). We found statistical evidence of effect modification by gender on the association between education and oral and general health, and by age group between income and oral health.

Theory-based capacity building intervention for intersectoral action for health at local governments: An exploratory pilot study

Aim

To design, implement and evaluate a nurse‐led capacity building intervention (PromoGOB) for intersectoral action for health at local governments.

Design

The programme was based on theories of the policy process and organizational change and facilitated by a nurse developing a health broker role. A complex intervention perspective was adopted in carrying out the study. The intervention was evaluated using a mixed method embedded design.

Methods

Quantitative component relied on a specific questionnaire. This tool, designed and piloted ad hoc, measured the capacity in terms of knowledge, awareness, resources, skills, and commitment, both at sectoral and government levels. For the qualitative component, semi‐structured interviews were conducted. These explored the perceived capacity and feasibility and acceptability issues. The programme was initiated at the end of October 2019, and it lasted a total of 5 weeks. Nineteen individuals representing various sectors at a local government in northern Spain participated in the study. The data analysis was concluded by the end of March 2020.

Findings

PromoGOB positively influenced participants' capacity for addressing health promotion. Awareness component, intersectoral work and the nurse as health broker were essential in the programme. The necessity of political participation was identified as an issue to be prioritized in future studies.

Conclusion

This study highlights the relevance of capacity building at local governments and the role that nurses can play in it. Further work should be undertaken to continue developing Health in All Policies approach at local level.

Impact

This study offers a starting point for nurses to get involved in the policy process of health promotion, performing a specific role as health brokers, building capacity at local governments for addressing social determinants of health, and delving into theories and concepts of the Health in All Policies field.

Local public health projectification in practice: a qualitative study of facilitators and barriers to a public health plan implementation

AIMS

To identify factors perceived by local government employees to affect the implementation of a municipal public health plan.

METHODS

Qualitative individual interviews (n=13) were carried out. Participants were sampled from three districts in Oslo municipality, Norway, and asked about their experiences with an ongoing implementation of the Oslo Public Health Plan (2017-2020). The conceptual framework of public sector projectification - a growing reliance on project organisation of policies - informed the study. The consolidated framework for implementation research was used to aid data coding and subsequent thematic analysis.

RESULTS

Implementation facilitators included factors perceived to support flexibility, including plan adaptability to the local setting, and factors perceived to enable structure and control during the implementation process, such as the articulation of specific goals and a shared understanding of public health work. Barriers were mainly related to complex aspects of the plan, such as the need to involve multiple stakeholders and levels of governance, and to tensions between the time-limited implementation process and the permanent organisational structures.

CONCLUSIONS

This study has demonstrated how research-based methods can be used for the evaluation of a local community implementation process. It has identified implementation determinants using a predetermined taxonomy of operationally defined factors that are likely to influence implementation. However, while implementing a time-limited public health plan can be seen as 'taking action' in relation to multidimensional and complex problems, further research is needed to investigate whether plan implementation has a long-term impact on the surrounding organisation and, eventually, on public health outcomes.

‘Health in All Policies’ and the Urge for Coordination: The Work of Public Health Coordinators and Their Impact and Influence in Local Public Health Policies: A Cross-Sectional Study

Building heavily on the Health in All Policies (HiAP) approach, Norway implemented the Public Health Act in 2012 to reduce social inequalities in health. Local public health coordinators (PHCs) at municipal levels were seen as tools to provide local intersectoral public health work. In this study, we examine factors related to intersectoral agency and if intersectoral work is understood as relevant to securing social justice in local policy outcomes. A national web-based survey in 2019 of all Norwegian PHCs (n = 428) was conducted with a response rate of 60%. Data were analysed through multiple linear regression, hierarchical regression modelling and structural equation modelling. Neither factors relating to community contexts nor individual characteristics were associated with intersectoral agency. Organisational factors, especially position size, being organised at the top level and having a job description, were significantly associated with perceptions of intersectoral agency. PHCs seeing themselves as intersectoral agents also found themselves able to affect annual budgets and policy outcomes. We conclude that municipal PHC positions can be important HiAP tools in local public health policies. However, organisational factors affect how PHCs perceive their influence and role in the municipal organisation and thereby their possibilities to influence local policymaking through intersectoral agency.

Utilizing public health core competencies to share data effectively with community organizations to promote health equity

OBJECTIVES

This article utilizes an adapted model for research transfer to highlight the important role of Local Public Health Agencies (LPHAs) to share data more effectively with local community organizations to advance health equity.

METHODS

A literature review related to public health data sharing with local community partners was conducted using Medline, Embase, and CINAHL databases and grey literature sources with 12 articles included for analysis. Six LPHAs distributed an online survey to 405 local community organizations to define their current data uses and needs. Survey and literature review findings informed a one-day deliberative dialogue event with 19 participants who brought multiple perspectives together on the barriers and potential solutions for data sharing.

RESULTS

Results are discussed utilizing the three stages of data sharing: awareness, communication, and collaboration. Awareness of the barriers and needs of community partners related to data, and the public health core competency of assessment and analysis is the first stage. More effective is the second stage, where LPHAs proactively communicate to understand and meet the needs of community partners. Data sharing is the most effective when LPHAs use the third stage of collaboration to work with community partners to mutually benefit from data sharing.

CONCLUSION

When LPHAs utilize their core competencies of assessment and analysis, communication, and collaboration to share data with community partners, they are able to share data more effectively. This allows community partners to modify programs to better serve priority populations and improve population health.

Population Health Inequalities Across and Within European Metropolitan Areas through the Lens of the EURO-HEALTHY Population Health Index

The different geographical contexts seen in European metropolitan areas are reflected in the uneven distribution of health risk factors for the population. Accumulating evidence on multiple health determinants point to the importance of individual, social, economic, physical and built environment features, which can be shaped by the local authorities. The complexity of measuring health, which at the same time underscores the level of intra-urban inequalities, calls for integrated and multidimensional approaches. The aim of this study is to analyse inequalities in health determinants and health outcomes across and within nine metropolitan areas: Athens, Barcelona, Berlin-Brandenburg, Brussels, Lisbon, London, Prague, Stockholm and Turin. We use the EURO-HEALTHY Population Health Index (PHI), a tool that measures health in two components: Health Determinants and Health Outcomes. The application of this tool revealed important inequalities between metropolitan areas: Better scores were found in Northern cities when compared with their Southern and Eastern counterparts in both components. The analysis of geographical patterns within metropolitan areas showed that there are intra-urban inequalities, and, in most cities, they appear to form spatial clusters. Identifying which urban areas are measurably worse off, in either Health Determinants or Health Outcomes, or both, provides a basis for redirecting local action and for ongoing comparisons with other metropolitan areas.