Local drug prevention - From policy to practice : A qualitative case study of policy makers, outreach social workers and at-risk youths

Abstract

The overall aim of this thesis is devoted to understanding a local drug prevention strategy and its implementation through the eyes of policy makers, outreach social workers and at-risk youths. In Norway, municipalities are responsible for many of the services that are important in promoting healthy lives among children and youths. While there has been an evolution in policies towards addressing the social determinants of health and the intersectoral collaboration required to address those issues, there remains a need to investigate how these policies coincide with the structures in the municipalities. This thesis is inspired by theoretical perspectives from both the fields of health promotion and governance. It relies on findings from a qualitative case study which investigated a local drug prevention strategy and follows how that strategy is implemented throughout the municipal organization of Bergen, Norway. Through interviews with policy makers, advisers and the service providers interacting with youths, the thesis provides powerful insights into the structures of local policy implementation that are at play when designing policies that include many policy sectors. In addition, youths participated in focus groups to discuss how they received the overall drug prevention strategy. The thesis consists of three published articles, with the findings summarized and discussed in a synopsis.

Article 1 draws on the findings from policy makers and advisers in the municipality of Bergen to provide insights into the structures for collaboration and integration with complex public health challenges like drug prevention. The findings reveal that – even though collaboration was crucial – there was limited actual integration for drug prevention. The policy makers experience diverging perceptions of ownership of drug prevention as a policy field, while the advisers experience a lack of mandate for collaboration. These findings indicate that the structures within the municipal organization are siloed and that integrating boundary-spanning policies is challenging.

Article 2 combines the perspectives of policy makers and practitioners in a local outreach prevention service, to investigate the local structures for drug prevention. The findings reveal a drug prevention strategy which, aims to create good living conditions and promote protective factors for the youths, all in line with a health-promoting perspective. Although the drug prevention strategy is impeded by the siloed organization of the municipality, the outreach service describes an ability to create collaborations. The findings highlight the structures surrounding street-level bureaucrats and their ability in the vertical structure of the municipality to “overcome” structural constraints to provide at-risk youths with the services they need.

Article 3 provides insight into how the overall drug prevention strategy is received through the eyes of at-risk youth. The findings are complemented with data from the outreach social workers to broaden the analysis. The findings show that the youths experience the services of the municipality as fragmented and rely on the outreach service to navigate a complex bureaucracy. The outreach service also has a resource approach, which is contrasted to other services’ more deficit-oriented approach. These findings support the notion that the outreach service acts as a safety net for youths who fall between the cracks of the system and demonstrates the need for empowerment-oriented approaches aimed at at-risk youths.

Based on the findings in the three articles, I have identified elements in the horizontal and vertical structures in the municipality which limit and promote integration in complex public health policies. While there is limited collaboration across policy areas to address the social determinants of health, the outreach social workers in the vertical structures can counter fragmentation and act as a safety net for the youths. The outreach service demonstrates empowering practices and places the needs of the youths at the centre of their collaborations with other services. The thesis reaffirms the need for policy sectors in the horizontal structures to address the social determinants of health. Without a reorientation of policies, the strategies will continue with selected and indicated strategies to address at-risk youths and consequently not move upstream to promote health. The thesis also advocates for awareness of the structures needed to translate policies into practice on a local level.