Does the socioeconomic positioned neighbourhood matter? Norwegian adolescents' perceptions of barriers and facilitators for physical activity.

BACKGROUND AND AIMS: A higher proportion of adolescents from lower socioeconomic position families tend to be less physically active than their counterparts from higher socioeconomic position families. More research is needed to understand the causes of these differences, particularly the influence of the neighbourhood environment. This qualitative study aims to explore how adolescents and their parents from higher and lower socioeconomic neighbourhoods perceive the social, organisational and physical environment influencing adolescents' physical activity behaviours. METHOD: We conducted six semi-structured focus groups with 35 13-14-year-olds and eight interviews with some of their parents. The interviewees were recruited from one higher and two lower socioeconomic neighbourhoods in Oslo, Norway. Theme-based coding was used for analysis, and the results discussed in light of an ecological framework. RESULTS: The results indicate that factors like social norms in a neighbourhood could shape adolescents' physical activity behaviour, and a social norm of an active lifestyle seemed to be an essential facilitator in the higher socioeconomic neighbourhood. Higher availability of physical activity and high parental engagement seemed to facilitate higher physical activity in this neighbourhood. In the lower socioeconomic neighbourhoods, the availability of local organised physical activity and volunteer engagement from parents varied. Programmes from the municipality and volunteer organisations seemed to influence and be essential for adolescents' physical activity behaviour in these neighbourhoods. CONCLUSIONS: The results illustrate the complexity of behaviour and environment interaction, and a limitation in explaining the phenomenon by focusing primarily on the individual level rather than an ecological perspective.

Nordic responses to covid-19 from a health promotion perspective.

On 30 January 2020, the disease covid-19 was declared by the World Health Organization to be an international threat to human health and on 11 March 2020, the outbreak was declared a pandemic. The aim of this study was to analyse policy strategies developed by the five Nordic countries during the first 3 months of the pandemic from a health promotion perspective in order to identify Nordic responses to the crisis. Although the Nordic countries have a long tradition of co-operation as well as similar social welfare policies and legislation, each country developed their own strategies towards the crisis. The strategies identified were analysed from a health promotion perspective emanating from five principles: intersectorality, sustainability, equity, empowerment and a lifecourse perspective. Denmark, Finland and Norway had lockdowns to varying degrees, whereas Sweden and Iceland had no lockdowns. Iceland implemented a test and tracking strategy from the very beginning. All countries based their recommendations and restrictions on appeals to solidarity and trust in institutions and fellow citizens. The analysis showed that the strategies in all countries could be related to health promotion principles with some differences between the countries especially regarding equity and sustainability. The Nordic governments took responsibility for protecting their citizens by developing policy strategies based on restrictions and recommendations congruent with the principles of health promotion. The findings also identified issues that will pose challenges for future pandemic strategies.

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.

Are universal measures sufficient in reducing child poverty in the Nordic countries? An analysis of policies and political commitments.

BACKGROUND: The five Nordic countries (Denmark, Finland, Iceland, Norway and Sweden) have long traditions of social welfare policies that have eradicated poverty as part of their goals. The purpose of this study was to increase our understanding of why child poverty is still significant in the Nordic countries despite existing strategies. METHODS: A qualitative analysis of Nordic government documents and reports between 2007 and 2019 was carried out to track changes in public health priorities and political measures and to determine the similarities and differences between the five countries. RESULTS: In all countries, most of the measures were universal, such as benefits during pregnancy, paid parental leave before and after the child was born, paid parental leave related to children's sickness, child allowances, day care, free health care for children and support for disabled children. National policies aimed to reduce social inequalities and child poverty exist in all five countries, but unaffordable housing, unequal disposable family income distribution and unequal income distribution at local municipality levels seem to be obstacles to reaching national policy goals. CONCLUSIONS: Despite comprehensive universal measures to eradicate child poverty, inequalities are significant and increasing in some of the Nordic countries. This might be due to a lack of proportional universalism, where universal measures are in place in all Nordic countries, but with a lack of scale and intensity proportional to the children and families at risk. The significance of eliminating social inequalities needs to be emphasised at the local level.

Perceptions of the social and physical environment of adolescents' dietary behaviour in neighbourhoods of different socioeconomic position.

A higher proportion of adolescents from families in a lower socioeconomic position (SEP) tends to have more unhealthy dietary behaviours, and overweight and obesity, than their counterparts in higher SEPs. More research is needed to understand the causes of these differences, in particular the influence of the neighbourhood environment, which has been explored less. The presented qualitative study explores how adolescents and their parents from higher and lower SEP neighbourhoods perceive the social and physical environment influencing adolescents' dietary behaviours. We conducted 6 semi-structured focus groups with 35 13-14 year olds and 8 interviews with some of their parents. The interviewees were recruited from one higher and two lower SEP neighbourhoods in Oslo, Norway. Theme-based inductive coding was used for analysis, and the results discussed in light of an ecological framework. The results indicate that all the adolescents experience several barriers to healthy dietary behaviours. For adolescents in the lower SEP neighbourhood, one or both parents desired their cultural cuisine served at home, whereas the adolescents wanted and often consumed western dishes. Fast-food restaurants or hanging out at the mall was perceived as the preferred social arena, often due to lack of involvement in either leisure-time physical activities or youth clubs as a safe, engaging option. The adolescents in the higher SEP neighbourhood perceived social norms which accentuated healthy dietary choices. When more possibilities for activities were present and the adolescents expressed being highly engaged in leisure-time physical activity, this also seemed to facilitate healthier dietary behaviours. These findings indicate how several factors simultaneously can influence dietary behaviour. Use of a multi-layered approach when exploring the environmental influences could increase knowledge about tackling social inequalities in dietary behaviours among adolescents.

29 recommendations to combat social inequalities in health. The Norwegian Council on Social Inequalities in Health.

All political parties in Norway agree that social inequalities in health comprise a public health problem and should be reduced. Against this background, the Council on Social Inequalities in Health has taken action to provide specific advice to reduce social health differences. Our recommendations focus on the entire social gradient rather than just poverty and the socially disadvantaged. By proposing action on the social determinants of health such as affordable child-care, education, living environments and income structures, we aim to facilitate a possible re-orientation of policy away from redistribution to universalism. The striking challenges of the causes of health differences are complex, and the 29 recommendations to combat social inequality of health demand cross sectorial actions. The recommendations are listed thematically and have not been prioritized. Some are fundamental and require pronounced changes across sectors, whereas others are minor and sector-specific.

Collaboration for drug prevention: Is it possible in a "siloed" governmental structure?

PURPOSE: Norwegian municipalities report that drug misuse is the most important public health challenge. The municipalities play a unique role in drug prevention aimed at youth, since young people rely on several services in their daily lives that are organized by different municipal departments. However, the municipal structure is described as siloed, and the policy areas as differentiated. This situation has led to a need for integration between different policy sectors to prevent drug use and promote health. The following study explores how policymakers describe the structures for integration within local government in practice with regard to drug prevention aimed at youth, contributing to the ongoing debate on collaboration and integration in response to public health challenges. METHODS: A single case study design was used to investigate the accounts of policymakers from different municipal departments in a Norwegian municipality following Axelsson and Axelsson's conceptual scheme of integration. FINDINGS: Collaboration between departments was viewed as important to successfully address drug prevention; however, the policymakers recognized problems with integration. The participants described confusion regarding ownership between the departments and a perceived lack of a mandate for collaboration. CONCLUSIONS: The findings and discussion illustrate that integration of drug prevention in a siloed structure relies on departments appreciating their respective roles in drug prevention and advisers experiencing a mandate to manage the siloes that exist in the organization. By gaining a better understanding of the siloed structures, we can provide valuable information needed to navigate them.

Public health terminology: Hindrance to a Health in All Policies approach?

AIM: National public health policies in Norway are based on a Health in All Policies (HiAP) approach. At the local level, this means that public health, as a cross-sectional responsibility, should be implemented in all municipal sectors by integrating public health policies in municipal planning and management systems. The paper investigates these local processes, focusing on the use of public health terminology and how this terminology is translated from national to local contexts. We ask whether the terms 'public health' and 'public health work' are suitable when implementing an HiAP approach. METHODS: A qualitative case study based on analyses of interviews and planning documents was performed in three Norwegian municipalities. RESULTS: The results present dilemmas associated with using public health terminology when implementing an HiAP approach. On the one hand, the terms are experienced as wide, complex, advanced and unnecessary. On the other hand, the terms are experienced as important for a systematic approach towards understanding public health ideology and cross-sectional responsibility. One municipality used alternative terminology. CONCLUSIONS: This paper promotes debate about the appropriateness of using the terms 'public health' and 'public health work' at the local level. It suggests that adaptation is suitable and necessary, unless it compromises knowledge, responsibility and a systematic approach. This study concludes that the use of terminology is a central factor when implementing the Norwegian Public Health Act at the local level.

Economic poverty among children and adolescents in the Nordic countries.

AIMS: This study aimed to identify applied definitions and measurements of economic poverty and to explore the proportions and characteristics of children and adolescents living in economic poverty in Denmark, Finland, Iceland, Norway and Sweden during the last decade and to compare various statistics between the Nordic countries. METHODS: Official data from central national authorities on statistics, national reports and European Union Statistics of income and living conditions data were collected and analysed during 2015-2016. RESULTS: The proportion of Nordic children living in economic poverty in 2014 ranged from 9.4% in Norway to 18.5% in Sweden. Compared with the European Union average, from 2004 to 2014 Nordic families with dependent children experienced fewer difficulties in making their money last, even though Icelandic families reported considerable difficulties. The characteristics of children living in economic poverty proved to be similar in the five countries and were related to their parents' level of education and employment, single-parent households and - in Denmark, Norway and Sweden - to immigrant background. In Finland, poverty among children was linked in particular to low income in employed households. CONCLUSIONS: This study showed that economic poverty among Nordic families with dependent children has increased during the latest decade, but it also showed that poverty rates are not necessarily connected to families' ability to make their money last. Therefore additional studies are needed to explore existing policies and political commitments in the Nordic countries to compensate families with dependent children living in poverty.

Capacity to reduce inequities in health in Norwegian municipalities.

AIMS: One of the goals of the Norwegian Public Health Act is to reduce health inequities. The act mandates the implementation of policies and measures with municipalities and county municipalities to accomplish this goal. The article explores the prerequisites for municipal capacity to reduce health inequities and how the capacity is built and sustained. METHODS: The paper is a literature study of articles and reports using data from two surveys on the implementation of public health policies sent to all Norwegian municipalities: the first, a few months before the implementation of the Public Health Act in 2012; the second in 2014. RESULTS: Six dimensions are included in the capacity concept. Leadership and governance refers to the regulating tool of laws that frame the local implementation of public health policies. Municipalities implement inter-sectoral working groups and public health coordinators to coordinate their public health policies and measures. Financing of public health is fragmented. Possibilities for municipalities to enter into partnerships with county municipalities are not equally distributed. Owing to the organisational structures, municipalities largely define public health as health policy. Workforce and competence refers to the employment of public health coordinators, and knowledge development refers to the mandated production of health overviews in municipalities. CONCLUSIONS: The capacity to reduce health inequities varies among municipalities. However, if municipalities build on the prerequisites they control, establishing inter-sectoral working groups and employing public health coordinators in authoritative positions, national governance instruments and regional resources may sustain their capacity.

Promoting health by addressing living conditions in Norwegian municipalities.

Worldwide, inequalities in health are increasing, even in well-developed welfare states such as Norway, which in 2012, saw a new public health act take effect that enshrined equity in health as national policy and devolved to municipalities' responsibility to act on the social determinants of health. The act deems governance structures and "Health in All Policies" approaches as important steering mechanisms for local health promotion. The aim of this study is to investigate whether Norway's municipalities address living conditions - economic circumstances, housing, employment and educational factors - in local health promotion, and what factors are associated with doing so. All Norway's municipalities (n= 428) were included in this cross-sectional study, and both register and survey data were used and were subjected to descriptive and bi- and multivariate regression analyses. Eighty-two percent of the municipalities reported that they were capable of reducing inequalities in health. Forty percent of the municipalities defined living conditions as a main challenge in their local public health promotion, while 48% cited it as a main health promotion priority. Our study shows that defining living conditions as a main challenge is positively associated with size of municipality, and also its assessment of its own capability in reducing inequalities in health. The latter factor was also associated with actually prioritizing living conditions in health promotion, as was having established cross-sectorial working groups or inter-municipal collaboration related to local health promotion. This study underlines the importance of inter-sectoral collaboration to promote health and well-being.

Health in All Policies: A cross-sectional study of the public health coordinators' role in Norwegian municipalities.

AIMS: The public health coordinator (PHC) is a municipal-government position in Norway whose role is to organise and oversee municipal policies and functions to support national public health goals. This cross-sectional study investigates conditions associated with use of PHCs by Norwegian municipalities in the period immediately before the new Public Health Act came into effect in 2012, decentralising responsibility for citizen health to the municipal level. This study provides descriptive baseline data regarding Norwegian municipalities' use of PHCs in this time - a marker for municipal engagement with inter-sectorial collaboration - before this policy was nationally mandated, and explores whether municipal characteristics such as structure, socio-economic status and extent of Health in All Policies (HiAP) implementation were associated factors. METHODS: All Norway's municipalities (N=428) were included. We combined Norwegian register data with survey data. Descriptive analyses and bi- and multivariate logistic regression analyses were performed. RESULTS: A total of 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 office. Our study indicates 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) are significantly associated with Norwegian municipalities having a PHC. CONCLUSIONS: This study suggests that the municipality's implementation of HiAP, as well as lower socio-economic indicators, is associated with the use of PHCs in Norway, but not factors related to municipal structure.

Are equity aspects communicated in Nordic public health documents?

AIMS: To explore if the term equity was applied and how measures for addressing social inequalities in health and reducing inequity were communicated in selected Nordic documents concerning public health. METHODS: Documents from Denmark, Finland, Norway, and Sweden were collected and analysed by Nordic authors. Data included material from websites of ministries and authorities responsible for public health issues, with primary focus on steering documents, action programmes, and reports from 2001 until spring 2013. RESULTS: Most strategies applied in Danish, Finnish, and Swedish documents focused on the population in general but paid special attention to vulnerable groups. The latest Danish and Finnish documents communicate a clearer commitment to address social inequalities in health. They emphasise the social gradient and the need to address the social determinants in order to improve the position of disadvantaged groups. Norwegian authorities have paid increasing attention to inequity/social inequalities in health and initiated a new law in 2012 which aims to address the social gradient in a more clear way than seen elsewhere in the Nordic countries. CONCLUSIONS: In the Nordic countries, redistribution by means of universal welfare policies is historically viewed as a vital mechanism to improve the situation of vulnerable groups and level the social gradient. To establish the concept of equity as a strong concern and a core value within health promotion, it is important to be aware how policies can contribute to enable reduction of social health differences.

Family policy and inequalities in health in different welfare states.

This article focuses on differences in health and welfare outcomes for families with children in three European countries, discussed in relation to national policies for child and family welfare. Data consist of policy documents and cross-national surveys. The document analysis was based on policy documents that described government policies. The statistical analyses utilize data from the European Social Survey. For the analyses in this article, a sub-sample of child families was selected from the countries Slovenia, Sweden, and the United Kingdom. Data showed that England's policy has mainly addressed socially disadvantaged groups and areas. Sweden and Slovenia are mainly developing universal policies. The United Kingdom has high scores for subjective general health, but a steep income gradient in the population. Parents in England experience the highest level of at-risk-of-poverty. Sweden generally scores well on health outcomes and on level of at-risk-of-poverty, and the gradient in self-rated general health is the mildest. Slovenia has the weakest economy, but low levels of inequality and low child at-risk-for-poverty scores. The Slovenian example suggests that not only the level of economic wealth, but also its distribution in the population, has bearings on health and life satisfaction, not least on the health of children.

The concept of ''equity'' in health-promotion articles by Nordic authors - a matter of some confusion and misconception.

AIMS: This paper focuses on equity in health, one of the key principles of the Ottawa Charter. It aims at analysing and discussing how the concept was defined, applied, and integrated in health-promotion articles by authors with a Nordic affiliation. METHODS: Abstracts were first identified by the search word ''health promotion'' as a key word. The search was limited to 1986-2008 and abstracts written in English by authors with a Nordic affiliation. Abstracts/articles for the present study were subsequently selected from these abstracts using the search word ''equity'' and analysed by quantitative and qualitative content analysis. FINDINGS: A majority of the 18 articles in the study did not include any proper definition of the term ''equity in health''. Most articles dealt with health in general or ''Health for All'' aspects and did not focus on specific strategies for vulnerable individuals or groups. The theoretical papers had a clear focus on equity aspects even though the concept of equity was sometimes included in an implicit way. In contrast, most papers reporting empirical studies did not specifically target equity aspects. Instead, the analysis gave the impression that many authors used the term ''equity'' synonymously with ''equality in health''. CONCLUSIONS: The findings may indicate that the concept of ''equity in health'' has been attenuated or even forgotten by Nordic health-promotion researchers and needs to be re-established as a strong concern within health promotion.

Different welfare states--different policies? An analysis of the substance of national health promotion policies in three European countries.

This study examines healthy public policy development in three European countries representing different welfare regimes: England representing the liberal model; Norway, the social democratic model; and the Netherlands, the corporatist model. National policy documents were used for the analysis. In England and Norway, health promotion has a prominent place and there is a political focus on the broader determinants of health. However, while the Norwegian policies have an explicit focus on the social gradient, the English policies have a much clearer focus on disadvantaged groups and geographic areas. In the Netherlands, the main focus is on disease prevention and risk behaviors. In the Netherlands and England there is a strong focus on the free will of the population in changing unhealthy lifestyles. By analyzing the different policies in the light of Esping-Andersen's typology of welfare state regimes, it is possible to better understand the differences among the countries. While all types of regimes seem willing to develop targeted measures, the social democratic regime seems the most willing to also develop structural measures addressing the wider social determinants of health.

Local drug prevention strategies through the eyes of policy makers and outreach social workers in Norway.

More than half of the municipalities in Norway report drug misuse as the most important public health challenge. Following a whole-of-government tradition, the ambition is to achieve horizontal and vertical coordination between different policy areas to address complex problems, such as youth drug use, and avoid fragmented services. This study aims to offer new perspectives on how governmental structures shape local drug prevention. By including the perspective of both local policy makers and outreach social workers, we can come closer to understanding how local drug prevention transforms policy into practice. The study will thus explore how policy makers and outreach social workers describe the local drug prevention strategy and how the outreach social workers implement it in practice. An instrumental case study of one Norwegian municipality was used to investigate the structures for drug prevention in detail. Data were gathered through 14 interviews with public officials from the relevant policy areas and outreach social workers from a drug prevention outreach service. The data were analysed using a thematic framework analysis. This study demonstrated that the policy makers' and outreach social workers' descriptions of drug prevention highlighted the creation of good living conditions and promotion of protective factors surrounding at-risk youths. This perspective may offer a broader approach to drug policy, which includes many policy areas. While collaboration was regarded as paramount, the policy makers described a "siloed" organisation that made it difficult to collaborate. The outreach social workers, however, indicated that they were able to navigate the "siloed" structures. We discuss the structural conditions surrounding outreach social workers that shape the implementation of policies, such as the resource perspective. The discussion shows that outreach social workers may act as a safety net for a potentially fragmented municipal structure for drug prevention.

Norwegian public health policy: revitalization of the social democratic welfare state?

Norway is part of the so-called social democratic welfare state model, which is characterized by its emphasis on solidarity and redistribution among social groups. The concepts of upstream and downstream policy measures may be useful to characterize different approaches to public health policies: upstream measures would be structural measures, in line with the social democratic welfare state model, while downstream measures would be more targeted at individuals or groups at some sort of risk. The aim of this article is to analyze national policies in Norway and how these may be characterized in terms of upstream and downstream factors. Health promotion and public health policies have been high on the Norwegian political agenda for two decades. However, the national policy emphasis has shifted between strategies aimed at individuals and structural strategies--that is, between downstream and upstream measures. Until 2003, policies included mainly downstream measures, but since then a policy shift has taken place and current policy includes an emphasis on upstream measures. This policy was strengthened after a left-wing coalition came into government in 2005. It may be argued that the present policy represents a revitalization of universal and structural measures, in line with the social democratic welfare state model.