"Helse i alt kommunen gjør?..." : -en undersøkelse av samvariasjoner mellom kommunale faktorer og norske kommuners bruk av folkehelsekoordinator, fokus på levekår og prioritering av fordelingshensyn blant sosioøkonomiske grupper.

Abstract

In 2012, a new public health act took effect in Norway, highlighting the importance of health equity and the use of “health in all policies” (HiAP) approach to reduce social inequalities in health. The act passed the main responsibility for health promotion to the municipalities, and expected this level to act on the social determinants of health. The aim of this thesis was to investigate health promotion at local level in Norway, and examine how Norwegian municipalities address social inequalities in health. The main objectives were threefold: 1) to examine the use of public health coordinators (PHC) and the associations between having employed a PHC and municipal characteristics; 2) to examine municipal awareness of living conditions to address social inequalities in health; and 3) to examine municipal prioritization of fair distribution of socioeconomic resources among social groups, and its association with changes in HiAP- tools, such as health overviews and employment of PHCs.

For this study, registry data were combined with data from two questionnaire studies distributed to all Norwegian municipalities (N= 428) in 2011 and 2014. All data used in the study were collected and analyzed at a municipal level. Of the thesis’ three substudies, sub-study 1 and 2 made use of a cross-sectional design using data from respectively 2011 and 2014. Sub-study 3 combined data from both 2011 and 2014 in a longitudinal design where change in municipal use of HiAP-tools were explored. Data were analyzed by use of univariate, bivariate and multivariate statistics.

The first sub study found that 76% of Norwegian municipalities employed a PHC in the period just before 2012. Of the PHCs employed, 22% were employed full time and 28% were located within the staff of the chief executive officer. Based on the results from multiple logistic regression analyses, this study showed that partnership for health promotion with county councils (OR= 7.78), development of a health overview (OR= 3.53), collaboration with non-government sectors (OR= 2.85) and low socio-economic status (OR= 0.46) were all significantly associated with Norwegian municipalities having a PHC.

The second sub-study found that 40% of Norwegian municipalities defined living conditions as a main challenge in their local health promotion efforts, while 48% cited it as a main health promotion priority. The study showed that defining living conditions as a main challenge were positively associated with the size of the municipality (OR=1.60), and the municipality’s assessment of its own capability in reducing inequalities in health (OR= 4.66). The latter factor was also positively associated with prioritizing living conditions in health promotion (OR= 3.89). Municipalities having established cross-sectorial working groups (OR= 3.01) or intermunicipal collaboration (OR= 2.23) were also associated with prioritizing living conditions in health promotion at local level.

The last sub-study investigated changes in municipal use of HiAP- tools, and whether such changes were associated with municipal prioritization of fair distribution among social groups. Thirty-eight percent of the municipalities reported that they prioritized fair distribution among social groups when making political decisions, while 70% prioritized fair distribution in their local health promotion initiatives. Results from multiple logistic regression analyses showed that municipalities that developed health overviews after the act was implemented were more likely to prioritize fair distribution in political decision-making (OR= 2.54) compared to municipalities that had not developed such overviews. However, municipalities that employed PHCs after the implementation of the public health act had a lower likelihood of prioritizing fair distribution in local health promotion initiatives (OR= 0.22) compared to municipalities without a PHC.

Taking the results from all the three sub-studies into account, this thesis suggests that the use of local health promotion addressing social inequalities in health are carried out in various degrees in the Norwegian municipalities. Nevertheless, when inequalities are addressed, it is done through advanced forms of integration where both vertical and horizontal structures apply. Finally, the results indicate that the PHC's role in addressing social inequalities in health seems to be unclear. Overall, it seems that the local level in Norway still has a way to go to accommodate the main principles of the Norwegian public health act to address social inequalities in health.