Perseverance, partnerships and passion: ingredients for successful local government policy to promote healthy and sustainable diets.

BACKGROUND: Local government authorities are well-placed to invest in evidence-based food policies that promote a population-wide shift to healthy and sustainable diets. This study describes the contextual factors that facilitated or impeded policy-making related to healthy and sustainable diets within a 'best-performing' local government in Victoria, Australia. METHODS: Guided by the Consolidated Framework for Implementation Research (CFIR), data from semi-structured interviews with individuals involved in developing the City of Greater Bendigo's Food System Strategy were analysed using the seven-stage Framework Method. RESULTS: Semi-structured interviews (n = 24) were conducted with City of Greater Bendigo employees (n = 15) and key stakeholders working for local organisations (n = 6) or at a state or national level (n = 3). Interviewees mostly held positions of leadership (n = 20) and represented diverse areas of focus from health (n = 7), food systems (n = 4) and planning and public policy (n = 3). Data analysis revealed 12 cross-cutting themes; eight facilitating factors and four impeding factors. Facilitating factors included perseverance, community engagement, supportive state policy, effective leadership, a global platform and networks, partnerships, workforce capacity and passion, and the use of scientific evidence. Impeding factors included access to secure, ongoing financial resources, prohibitive state and federal policy, COVID-related disruptions to community engagement and competing stakeholder interests. Overall, this study suggests that the City of Greater Bendigo's success in developing an evidence-based local food system policy is built upon (i) a holistic worldview that embraces systems-thinking and credible frameworks, (ii) a sustained commitment and investment throughout the inner-setting over time, and (iii) the ability to establish and nurture meaningful partnerships with community groups, neighbouring local government areas and state-level stakeholders, built upon values of reciprocity and respect. CONCLUSIONS: Despite insufficient resourcing and prohibitive policy at higher levels of government, this 'best performing' local government in Victoria, Australia developed an evidence-based food system policy by employing highly skilled and passionate employees, embracing a holistic worldview towards planetary health and harnessing global networks. Local government authorities aspiring to develop integrated food policy should nurture a workforce culture of taking bold evidence-informed policy action, invest in mechanisms to enable long-standing partnerships with community stakeholders and be prepared to endure a 'slow-burn' approach.

Medical Treatment of Criminals in Premodern China Based on Qing Era Local Archives: Focusing on the Case of Ba County in the late 18th Century.

This study aimed to confirm what kind of medical treatment was given to criminals by the local governments in Qing China and the role of the government doctors in charge of the criminals' medical care. Using local administrative and historical materials, I explore the procedures and methods of medical treatment and explain the treatment processes for criminals. The findings demonstrate that, although different from modern ideals, in premodern China under the emperor's rule, there were provisions for ailing criminals to receive medical treatment. In the Qing era, the execution of actual punishments worked as a keynote of judicial policy, and the number of criminals managed by local government offices was larger than before. The government doctors took charge of the criminals' medical treatment, but it seems that their position in the Qing era was not popular due to low salaries and psychological resistance to treating guilty criminals. Moreover, the government doctors dispatched to treat criminals were required to play an additional role. They had to testify that there were no other causes of death other than disease, which demonstrates that the government doctor played a role in determining whether the death was a crime. However, their treatment practices for criminals demonstrate the use of traditional medicine from the Tang and Song era onwards. There are two reasons for this. First, unlike the private market, there was no economic incentives for doctors to use new medicines and prescriptions. Second, because of the fear of being reprimanded for the death of the criminal, using classical prescriptions was a way for doctors to defend the adequacy of their medical practice. From an institutional perspective, medical care for criminals through government doctors was guaranteed during the Qing era. However, government doctors were not selected for their medical competence, nor were they provided with adequate incentives to practice good medical care. Even some government doctors devoted themselves to medical care, the quality of care was not systematically guaranteed. This provides evidence of the poor medical environment surrounding criminals in premodern China.

A "bottom up" Health in All Policies program: Supporting local government wellbeing approaches.

ISSUE ADDRESSED: A wellbeing economy requires multiple inputs to enable the wholistic vision of a sustainable healthy population and planet. A Health in All Policies (HiAP) approach is a useful way to support policy makers and planners to implement the activities required to support a wellbeing economy. OUTLINE OF THE PROJECT: Aotearoa New Zealand's Government has explicitly set a path towards a wellbeing economy. Here, we report the utility of a HiAP approach in Greater Christchurch, the largest urban area in the South Island of New Zealand, to achieving the shared societal goals of a sustainable healthy population and environment. We use the World Health Organisation draft Four Pillars for HiAP implementation as a framework for discussion. SO WHAT?: The paper adds to the growing number of examples of city and regions supporting a wellbeing agenda, specifically focused on some of the successes and challenges for local HiAP practitioners working within a public health unit in influencing this work.

Co-implementing vitamin A supplementation with seasonal malaria chemoprevention in Sokoto State, Nigeria: a feasibility and acceptability study.

BACKGROUND: Bi-annual high dose vitamin A supplements administered to children aged 6-59 months can significantly reduce child mortality, but vitamin A supplementation (VAS) coverage is low in Nigeria. The World Health Organization recommends that VAS be integrated into other public health programmes which are aimed at improving child survival. Seasonal malaria chemoprevention (SMC) provides a ready platform for VAS integration to improve health outcomes. This study explored the feasibility and acceptability of integrating VAS with SMC in one local government area in Sokoto State. METHODS: A concurrent QUAN-QUAL mixed methods study was used to assess the feasibility and acceptability of co-implementing VAS with SMC in one LGA of Sokoto state. Existing SMC implementation tools and job aids were revised and SMC and VAS were delivered using a door-to-door approach. VAS and SMC coverage were subsequently assessed using questionnaires administered to 188 and 197 households at baseline and endline respectively. The qualitative component involved key informant interviews and focus group discussions with policymakers, programme officials and technical partners to explore feasibility and acceptability. Thematic analysis was carried out on the qualitative data. RESULTS: At endline, the proportion of children who received at least one dose of VAS in the last six months increased significantly from 2 to 59% (p < 0.001). There were no adverse effects on the coverage of SMC delivery with 70% eligible children reached at baseline, increasing to 76% (p = 0.412) at endline. There was no significant change (p = 0.264) in the quality of SMC, measured by proportion of children receiving their first dose as directly observed treatment (DOT), at baseline (54%) compared to endline (68%). The qualitative findings are presented as two overarching themes relating to feasibility and acceptability of the integrated VAS-SMC strategy, and within each, a series of sub-themes describe study participants' views of important considerations in implementing the strategy. CONCLUSION: This study showed that it is feasible and acceptable to integrate VAS with SMC delivery in areas of high seasonal malaria transmission such as northern Nigeria, where SMC campaigns are implemented. SMC-VAS integrated campaigns can significantly increase vitamin A coverage but more research is required to demonstrate the feasibility of this integration in different settings and on a larger scale.

Regionalização e Rede de Atenção à Saúde em Mato Grosso / Regionalization and Health Care Network in Mato Grosso, Brazil

Resumo Este estudo analisa a estruturação da Rede de Atenção à Saúde nas regiões de saúde do estado de Mato Grosso, considerando as ações planejadas nos instrumentos de gestão do governo do estado e da Secretaria de Estado de Saúde (SES), nos anos de 2012 a 2017, em conformidade com as diretrizes da Portaria MS/GM nº 4.279, de 30 de dezembro de 2010, que orienta o processo de conformação das redes de atenção à saúde no âmbito do Sistema Único de Saúde (SUS). Trata-se de estudo qualitativo, de natureza exploratório-descritiva, do tipo documental, que analisou os documentos públicos referentes ao planejamento do governo na especificidade do setor de saúde, o que inclui o Plano Plurianual, o Plano Estadual de Saúde e o Plano Estratégico da SES. Os achados do estudo mostram que, embora algumas ações/atividades relacionadas às diretrizes da portaria estivessem contempladas nos documentos pesquisados, ainda não foram suficientes para o estabelecimento de uma rede de atenção regionalizada de qualidade e para o fortalecimento da Atenção Primária à Saúde (APS) com capacidade de ser coordenadora do cuidado e ordenadora da rede no estado de Mato Grosso.

Abstract This study analyzes the structuring of the Health Care Network in the health regions of the state of Mato Grosso, considering the actions planned in the management instruments of the State government and the State Department of Health (SES), in the years of 2012 to 2017, in accordance with the guidelines of Ordinance MS/GM No 4.279, of December 30, 2010, which guides the process of conformation of Health Care Networks within the scope of the Brazilian National Health System (SUS). This is a qualitative, exploratory-descriptive study, of documentary type, which analyzed the public documents related to government planning on the specificity of the health sector, which includes the Pluriannual Plan, the State Health Plan and the Strategic Plan of the SES. The findings of the study show that, although some actions/activities related to the guidelines of the Ordinance were included in the researched documents, they were not yet sufficient for establishing a quality regionalized care network and for strengthening the Primary Health Care (PHC) with the capacity to coordinate care and order the network in the state of Mato Grosso.

Reshaping the Regional Order of Health Care Resources in China: The Institutional Participants in an Inter-City Integrated Delivery System.

Over the past decades, pro-growth policies in China led to rapid economic development but overlooked the provision of health care services. Recently, increasing attention is paid to the emergence of integrated delivery systems (IDS) in China, which is envisioned to consolidate regional health care resources more effectively by facilitating patient referral among hospitals. IDS at an inter-city scale is particularly interesting because it involves both the local governments and the hospitals. Incentives among them will affect the development of an inter-city IDS. This paper thereby builds an economic model to examine both the inter-local government and inter-hospital incentives when participating in an inter-city IDS in China. The findings suggest that while inter-hospital incentives matter, inter-local government incentives should also be considered because the missing incentives at the local government level may oppose the development of inter-city IDSs.

The Development and Operation of a Home Management System during the COVID-19 Pandemic: Experience of the Local Government Gyeonggi-do in Korea.

During the three the coronavirus disease 2019 (COVID-19) surges in South Korea, there was a shortage of hospital beds for COVID-19 patients, and as a result, there were cases of death while waiting for hospitalization. To minimize the risk of death and to allow those confirmed with COVID-19 to safely wait for hospitalization at home, the local government of Gyeonggi-do in South Korea developed a novel home management system (HMS). The HMS team, comprised of doctors and nurses, was organized to operate HMS. HMS provided a two-way channel for the taskforce and patients to monitor the severity of patient's condition and to provide healthcare counseling as needed. In addition, the HMS team cooperated with a triage/bed assignment team to expedite the response in case of an emergency, and managed a database of severity for real-time monitoring of patients. The HMS became operational for the first time in August 2020, initially managing only 181 patients; it currently manages a total of 3,707 patients. The HMS supplemented the government's COVID-19 confirmed case management framework by managing patients waiting at home for hospitalization due to lack of hospital and residential treatment center beds. HMS also could contribute a sense of psychological stability in patients and prevented the situation from worsening by efficient management of hospital beds and reduction of workloads on public healthcare centers. To stabilize and improve the management of COVID-19 confirmed cases, governments should organically develop self-treatment and HMS, and implement a decisive division of roles within the local governments.

The health effects of work-family conflict in men and women Japanese civil servants: a longitudinal study.

High level of work-family conflict (WFC) is an important risk factor for stress-related health outcomes. However, many studies are cross-sectional studies. In this study, we aimed to clarify how changes in WFC levels over a period 5 yr can affect workers' mental and physical health, and to clarify whether there are gender differences of them. This study examined 1,808 civil servants (1,258 men and 550 women) aged 20-65 yr working in a local government in the west coast of Japan from 2003 to 2008. Logistic regression analyses were used to examine whether the change in WFC contributes to workers' health problems and whether there are gender differences. This study revealed association sustained high WFC and deterioration of WFC conflict with poor mental health and poor job satisfaction for both men and women. In men high WFC conflict and deterioration was associated with poor mental health (OR=2.74). On the other hand, women had strong relationship between WFC changes and poor physical health (OR=2.64). WFC was an important factor as a social determinant of health of Japanese civil servants, and the change in WFC affects subsequent health problems with different trends in men and women.

Predictive factors to access and use of family planning services by rural and semi-urban dwellers in Afikpo North Local Government area, Ebonyi State, Nigeria.

Pregnancy and childbirth are important periods when women of reproductive age frequently come in contact with healthcare facilities and providers. These periods afford them the privilege for discussion and decision on post-partum family planning with healthcare providers. Male partner consent has been shown to have a positive impact on access and uptake of modern contraception. This study was aimed at assessing the availability, uptake and male partner consent for post-partum family planning (PPFP) amongst rural and semi-urban dwellers in Afikpo North local government area of Ebonyi state, Nigeria. The study conducted on 205 postpartum women, 40 health workers at the primary health centres (PHCs) and traditional birth attendants (TBAs) in Afikpo North LGA were selected by a random sampling technique. Information was obtained via 3 categories of interviewer-administered questionnaire for the different categories of individuals involved in the study. Data analyses was done using SPSS version 21.0. The overall findings showed a high prevalence of grand multiparity (51.2%) and child-bearing at extremities of reproductive age (20.5%) despite generally good awareness of modern contraception (92.7%) and availability of family planning services and modern birth control methods in all the PHC facilities. Of note is that a good percentage of the women received antenatal care (38.1%) or had their last delivery at TBAs places (42.4%) despite the fact that only 60% of the TBAs are aware of modern family planning methods and none of them offer family planning services. The prevalence of modern contraceptive usage was 41.5% and the male partner consent was present in 72.9% of modern contraceptive users. Despite high level of awareness and availability of modern family planning services, the TBAs should be more sensitized in order to improve the uptake of PPFP.

[Facilitators and Challenges of Community-based Prevention Programmes for Children - Results of a Qualitative Study]. / Chancen und Herausforderungen von Präventionsketten ­ Ergebnisse qualitativer Experteninterviews in deutschen Kommunen.

BACKGROUND AND OBJECTIVE: Prevention strategies in community settings for children and youth are integrative health promotion strategies with cross-sector partnerships to improve health and social participation in children and youth at the community level. The objective of the qualitative study was to investigate cross-sector partnerships in German communities when implementing community-based prevention strategies targeting health of children and youth. Such strategies of health promotion have included complex interventions involving multiple stakeholders from different sectors jointly working together. The specific aims were: (1) to explore the structure and organization of the cross-sector partnerships and (2) to identify facilitating and hindering factors when implementing community-based prevention strategies targeting health of children and youth from the perspective of stakeholders. METHODS: Data were collected using semi-structured interviews with eight experts of local governments in German municipalities. RESULTS AND CONCLUSION: Our results show that mechanisms of interagency collaborations in child and youth health programs included networking processes on a vertical and horizontal level. These included the creation of inter-sectoral networks for joint development of structures and actions. Inter-sectoral networks were accompanied by network moderators. Successful cooperation was promoted through engagement, joint goal-setting, political support and use of existing resources. Lack of resources, a low engagement of local actors and a lack of acceptance of the aspirations are identified as barriers. The extent of facilitating and hindering factors varied depending on the local structures of municipalities.

Spatial-temporal characteristics and causes of changes to the county-level administrative toponyms cultural landscape in the eastern plains of China.

As part of the cultural landscape, administrative toponyms do not only reflect natural and sociocultural phenomena, but also help with related management and naming work. Historically, county-level administrative districts have been stable and basic administrative regions in China, playing a role in the country's management. We explore the spatio-temporal evolutionary characteristics of the county-level administrative toponyms cultural landscape in China's eastern plains areas. A Geographical Information System (GIS) analysis, Geo-Informatic Tupu, Kernel Density Estimation, and correlation coefficients were conducted. We constructed a GIS database of county-level administrative toponyms from the Sui dynasty onward using the Northeast China, North China, and Yangtze Plains as examples. We then summarized the spatio-temporal evolutionary characteristics of the county-level administrative toponyms cultural landscape in China's eastern plains areas. The results indicate that (1) the number of toponyms has roughly increased over time; (2) toponym densities on the three plains are higher than the national average in the corresponding timeframe since the Sui; and (3) county-level administrative toponyms related to mountains and hydrological features accounted for more than 30% of the total in 2010. However, the percentage of county-level administrative toponyms related to natural factors on the three plains has decreased since the Sui. To explore the factors influencing this spatio-temporal evolution, we analyzed the correlations between the toponyms and natural factors and human/social factors. The correlation degree between toponym density and population density is the highest, and that between toponym density and Digital Elevation Model (DEM) the lowest. Temperature changes were important in toponym changes, and population changes have influenced toponym changes over the last 400 years in China.

Effectiveness of NGO-government partnership to prevent and treat child wasting in urban India.

This study reviews the performance of a community-based nutrition programme in preventing and treating wasting without complications among children under age three in urban informal settlements of India. Implemented by a non-profit organization, with national (Integrated Child Development Services [ICDS]) and city-level (Municipal Corporation of Greater Mumbai [MCGM]) government partners, the programme screened 7,759 children between May 2014 and April 2015. During this period, the programme admitted 705 moderately wasted and 189 severely wasted children into the treatment group and 6,820 not wasted children into the prevention group. Both prevention and treatment groups received growth monitoring, referrals to public health facilities, and home-based counselling (if <6 months) by community health workers. Treatment groups received additional home-based counselling and access to medical screenings. Severely wasted children also received access to ready-to-use therapeutic food. The study assessed default rates, wasting status, and average weight gain 3 months after admission. Factors associated with growth faltering in the prevention group were explored using logistic regression. Default rates for the severely wasted, moderately wasted, and prevention group were 12.7%, 20.4%, and 22.1%, respectively. Recovery rate was 42.4% for the severely wasted and 61.3% for the moderately wasted. For the moderately wasted, mean weight gain was 2.1 g/kg/day, 95% confidence interval (CI) [1.6, 2.6], and 4.5 g/kg/day for the severely wasted, 95% CI [3.1, 5.9]. Among prevention group children, 3.6% faltered into wasting-3.2% into moderate and 0.4% into severe. The paper gives insights into ways in which ICDS and MCGM can successfully integrate large-scale community-based acute malnutrition programming.

A qualitative study on the perceived impact of using an integrated community-based supportive cancer service.

OBJECTIVE: "Improving the Cancer Journey" (ICJ) is an original, community-based, multidisciplinary service offering holistic support to people diagnosed with cancer in Scotland. It is the first service of its kind in the UK. The aim of this qualitative study was to explore the experiences of people who have used this service. METHOD: Twenty service users were purposively sampled to capture a diverse range of age, sex, cancer types, and deprivation status. Semi-structured interviews explored their experiences of using ICJ. Interviews were transcribed verbatim and thematically analysed. RESULTS: Thirteen women and seven men (mean age 58 years) were interviewed. Three themes were identified: "one person, one place," "routes to unexpected support" and "safety net." CONCLUSION: Improving the Cancer Journey was perceived to be beneficial because it met the holistic needs of the ICJ service users. By helping people address concerns earlier rather than later, it prevented problems becoming unmanageable. Having an accessible expert to guide and support them through a range of services provided reassurance and created the space to self-manage at a time of distress. These original findings are internationally relevant because there is little evidence on the impact of holistic support services from the patient perspective.

The Effect of Self Reflection Meditation Program on the Job Stress and Psychosocial Health of Government Staffs / 의료커뮤니케이션

BACKGROUND: The government staffs studied in this research has been easily exposed to excessive job stress, which can lead to a variety of psychosocial problems and poor quality of life. In this study, we examined the effect of the self reflection meditation program on the psychosocial health and stress responses of government staffs, to suggest the intervention program improving psychosocial health and quality of life in government staffs.METHODS: In this study, we measured the conditions of 36 local government staffs based on self reflection scale, psychosocial health and stress score before and after implementing the short-term intensive meditation program.RESULTS: The results showed that there were significant increase in social role performance and self confidence(p=.003), general health and vitality(p=.019) and significant decrease in stress(p=.010). This change was prominently showed in administrative officer and depression and anxiety(p=.034) also significantly decreased after program.CONCLUSION: Self reflection meditation program was effective in improving the psychosocial health and physical health of government staffs. Therefore, self reflection meditation program could be proposed as program for stress management and promotion of quality of life in government staff.

Cultivation of microalgae Chlorella zofingiensis on municipal wastewater and biogas slurry towards bioenergy.

The high cost of large-scale cultivation of microalgae has limited their industrial application. This study investigated the potential use of mixed biogas slurry and municipal wastewater to cultivate microalgae. Pig biogas slurry as the sole nutrient supplement, was assessed for the cultivation of Chlorella zofingiensis in municipal wastewater. Batch culture of various ratios of pig biogas slurry and municipal wastewater were compared. The characteristics of algal growth and lipid production were analyzed, and the removal rates of nitrogen and phosphate were examined. Results indicate that 8% pig bio-gas slurry in municipal wastewater, had a significant effect on microalgal growth. C. zofingiensis, with 2.5 g L-1 biomass, 93% total nitrogen and 90% total phosphorus removal. Lipid content was improved by 8% compared to BG11 medium. These findings show that mixing pig biogas slurry and municipal wastewater, without additional nutrition sources, allows efficient cultivation of C. zofingiensis. This is of high research and industrial significance, allowing cultivation of C. zofingiensis in mixed waste culture solution without additional nutrition sources.

A qualitative exploration of stakeholder perceptions of the implementation of place-based working and its potential to reduce health inequality.

Background: Local authorities (LAs) have statutory responsibility to reduce health inequalities and improve public health. Place-based approaches may positively influence service provision yet little is known about their implementation and potential for reducing inequality through health and wellbeing improvements. An English LA implemented a place-based working (PBW) pilot in a small geography during austerity measures in the north of England. This involved three strands (early intervention, estate services and community intelligence) which were introduced separately and covered overlapping geographies. Predominantly focusing on early intervention, this qualitative study investigates stakeholders' perceptions of the pilot and its potential to improve health and wellbeing by reducing inequality. Methods: In total, 15 face-to-face qualitative interviews with stakeholders were completed. Thematic analysis produced context, mechanism and outcome configurations in a process adapted from realist evaluation methodology. Results: Stakeholders described PBW as holistic, upstream and cutting across departmental boundaries to engage staff and the community. Collaborative working was considered important and was aided by PBW in our study. Conclusions: PBW has the potential to reduce health inequalities by improving health and wellbeing. LAs deliver services that affect health and wellbeing and PBW may help develop a more coordinated response to improve outcomes and potentially save money.

Association of the Overall Well-being of a Population With Health Care Spending for People 65 Years of Age or Older.

Importance: New US health care payment models have increasingly incentivized health care systems to promote health and reduce health care spending at the population level, with Medicare beneficiaries representing one of the largest populations affected by new payment models. Identifying novel strategies to promote health and reduce health care spending is necessary. Objective: To assess whether the overall well-being of a population is associated with health care spending for people 65 years of age or older. Design, Setting, and Participants: This US national, population-based cross-sectional study examined the association between county well-being and Medicare fee-for-service (FFS) spending. Population well-being, a holistic assessment of the overall health of the population comprising interrelated domains, including physical, mental, and social health, as measured by the Gallup-Sharecare Well-Being Index (2010), was linked to the mean spending per Medicare FFS beneficiary (2010) and county characteristics data for all US counties assessed. The data were adjusted for prevalence of 4 low-variation conditions (hip fracture, stroke, colorectal cancer, and acute myocardial infarction) and regional penetration of Medicare Advantage. Data analyses were conducted October 13, 2016, to October 31, 2017. Main Outcomes and Measures: Mean spending per Medicare FFS beneficiary per county. Results: In total, 2998 counties were assessed using county-level mean values, with 4 to 7317 participants (mean [SD] number of participants, 755 [1220]) per county. The mean (SD) values of the demographic characteristics of the participants were 50.8% (1.3%) female, 74.9% (16.5%) white, 12.1% (13.0%) black, 4.0% (5.3%) Asian, and 13.7% (14.8%) Hispanic with a mean (SD) of the median county age of 38.2 (4.4) years. Medicare spent a mean (SE) of $992 ($110) less per Medicare FFS beneficiary in counties in the highest quintile of well-being compared with counties in the lowest well-being quintile. This inverse association persisted after accounting for key population characteristics such as median household income and contextual factors such as urbanicity and health care system capacity. Medicare spent a mean (SE) of $1233 ($104) less per Medicare FFS beneficiary in counties with the greatest access to basic needs than in those with the lowest access. Conclusions and Relevance: In this US national study, the overall well-being of a geographically defined population was inversely associated with its health care spending for people 65 years and older. Identifying this association between well-being and health care spending at the population level may help to lay the foundation for further study to first illuminate the mechanisms underlying the association and to second study interventions aimed at creating greater well-being and lower health care spending at the population level.

High-Performing Local Health Departments Relate Their Experiences at Community Engagement in Emergency Preparedness.

CONTEXT: Local health departments (LHDs) are implementing a national mandate to engage community partners, including individuals, businesses, and community- and faith-based organizations in the larger public health emergency preparedness (PHEP) enterprise. OBJECTIVE: Investigate how LHDs of varying size and resource levels successfully engage the community in PHEP to help uncover "best practices" that aspiring agencies can replicate, particularly in low-resource environments. DESIGN: In-depth, semistructured qualitative interviews with practitioners from 9 highly performing LHDs. SETTING: Participating agencies comprised equal amounts of small (serving <50 000 residents), medium (serving 50 000-500 000 residents), and large (serving >500 000 residents) LHDs and were diverse in terms of geographic region, rural-urban environment, and governance structure. PARTICIPANTS: A cross section of LHD staff (n = 34) including agency leaders, preparedness coordinators, public information officers, and health educators/promoters. MAIN OUTCOME MEASURE: Local health department performance at community engagement as determined by top scores in 2 national LHD surveys (2012, 2015) regarding community engagement in PHEP. RESULTS: Based on key informant accounts, high-performing LHDs show a holistic, organization-wide commitment to, rather than discrete focus on, community engagement. Best practices clustered around 5 domains: administration (eg, top executive who models collaborative behavior), organizational culture (eg, solicitous rather than prescriptive posture regarding community needs), social capital (eg, mining preexisting community connections held by other LHD programs), workforce skills (eg, cultural competence), and methods/tactics (eg, visibility in community events unrelated to PHEP). CONCLUSIONS: For LHDs that wish to enhance their performance at community engagement in PHEP, change will entail adoption of evidence-based interventions (the technical "what") as well as evidence-based administrative approaches (the managerial "how"). Smaller, rural LHDs should be encouraged that, in the case of PHEP community engagement, they have unique social assets that may help offset advantages that larger, more materially resourced metropolitan health departments may have.

Health and equity in all policies in local government: processes and outcomes in two Norwegian municipalities.

AIMS: To identify key factors in implementing Health and Equity in All Policies (HEiAP) at the local level in two Norwegian municipalities in order to accelerate the progress of promoting health, well-being and equity in other local governments. APPROACH: This case study is presented as a narrative from policy-making processes in two Norwegian municipalities. The story is told from an insider perspective, with a focus on HEiAP policy makers in these two municipalities. RESULTS: The narrative identified key learning from implementing HEiAP at the local level, i.e. the importance of strengthening system and human capacities. System capacity is strengthened by governing HEiAP according to national legislation and a holistic governance system at the local level. Municipal plans are based on theory, evidence and local data. A 'main story' is developed to support the vision, defining joint societal goals and co-creation strategies. Policies are anchored by measuring and monitoring outcomes, sharing accountability and continuous dialogue to ensure political commitment. Human capacity is strengthened through participatory leadership, soft skills and health promotion competences across sectors. Health promotion competence at a strategic level in the organization, participation in professional networks, crowd sourcing toward common goals, and commitment through winning hearts and minds of politicians and other stakeholders are vital aspects. CONCLUSIONS: Our experience pinpoints the importance of strengthening system and human capacity in local governments. Further, we found it important to focus on the two strategic objectives in the European strategy 'Health 2020': (1) Improving health for all and reducing health inequalities; (2) improving leadership and participatory governance for health.