Child health promotion : Analyses of activities and policy processes in 25 Swedish municipalities

Abstract: The Swedish municipalities are important actors that offer appropriate environments for healthpromoting activities directed at children and adolescents. Enhanced understanding on how such activities develop is needed to improve local public health action. The overall objective of this thesis was to describe potential explanatory factors in municipal health-promoting measures directed at children and adolescents, in order to facilitate for national actors to support healthpromoting action in the municipalities. In the first three papers of this thesis the intentions of 25 Swedish municipalities to promote children and adolescents' health are described. Safety promotion (Study I), health promotion in preschools (Study II) and health promotion in schools (Study III) were of primary interest. In the next step policy processes and factors that might explain municipal public health action were analysed (Study IV). Finally, data from Study 1 were used to test correlations between municipal safety-promoting activities and health outcome (Study V). Although intentions to promote children's health were in general quite well developed, there were some exceptions and variations among the municipalities. Significant correlations between municipal healthpromoting activities and outcome variables were revealed on injuries (Study V) but not on youth behaviour (Study III). Municipal socio-economic status, measured as proportion adults with more than 12 years of education, did not predict the level of healthpromoting measures, whereas municipal growth seemed to have a hampering effect. These results were consistently observed in Studies I-III. Faster growing municipalities reported fewer safety-promoting measures, a lower fraction of preschool staff with a university degree and a lower fraction of full-time employed teachers with a university degree than slower growing municipalities. Five potential explanatory factors for policy process development were identified in Study IV: financial problems, perceived local needs, external funding, national and international policy documents and presence of a local public health sector. Politicians, public officials and nongovernmental organisations were important actors in different phases of the policy process, with strong commitment, professional skills and powerful position in the organisation as main characteristics. The health sector in general, epidemiological statistics and evidence-based methods were seldom mentioned in Study IV. Potential policy implications based on the results presented in this thesis are that disseminating public health-related knowledge through international and national policy documents and supporting institutionalisation of a local public health sector might be useful methods to stimulate and support municipal public health action. Further, means to introduce and distribute epidemiological statistics and evidence-based methods to the municipalities ought to be considered. Increased and improved cooperation between public health sciences and political sciences (e.g., by integrated courses and shared research projects) could be helpful in developing public health research within the municipal arena.