English summary of Fafo-rapport 2023:23
Evaluation of the health promotion programme in Holmestrand municipality
Lise Lien og Anne Inga Hilsen
01 October 2023
Purpose and background
The purpose of this project has been to evaluate the health promotion programme in Holmestrand municipality (Program for folkehelsearbeid i Holmestrand kommune) for the period 2018–2022. During the programme period, Holmestrand underwent two municipality mergers, first with Hof and later with Sande. There was also a merger at county level between the former counties of Vestfold and Telemark, but the former county of Vestfold continued to follow up the participating municipalities after it merged with Telemark.
We have examined which areas of Holmestrand’s efforts in the programme have been successful/unsuccessful. In order to gain insight into this, we interviewed relevant stakeholders who have participated in the project, and we also carried out a document review. It is important to note that our findings reflect the perspectives and experiences of the interviewees and are not therefore representative of all stakeholders.
The programme in the former Holmestrand municipality was intended to promote the mental health and quality of life of children and young people, as well as to promote local substance abuse prevention efforts. There are two focus areas:
- To develop and implement measures and strategies that focus on and have a positive influence on the self-esteem and coping skills of children and young people
- To strengthen and further develop the cooperation with civil society and voluntary organisations in order to create supportive environments for children and young people by developing and implementing leisure activities that focus on children and young people’s participation, self-esteem and coping skills.
Holmestrand municipality’s public health efforts have included a number of subprojects.
Anchoring and cooperation
Our findings suggest that significant efforts have been made to anchor the programme’s work at both the county and the municipal level. The anchoring work at the municipal level has been both political and administrative. The health promotion programme in Vestfold was discussed and approved in August/September 2018 in arenas such as the council for people with disabilities, the council for the elderly, the committee for childhood care, and the local council – in addition to multidisciplinary and cross-sectoral anchoring that aimed to ensure continuation and anchoring of a long-standing cooperation between the local authority and the voluntary sector and civil society (reporting form for 2018).
Sande also anchored its project work politically – through the municipal plan and the local authority’s action programme for 2018 – and administratively through the Chief Municipal Executive’s management group. Where the local/county authorities have found cooperation with voluntary organisations to be appropriate, the Norwegian Directorate of Health has taken a positive view of this. It is worth noting that volunteers have not received funding for this work, and it is the local authorities that therefore need to provide funds from their programme budget or from other municipal funds. We find that there has been cooperation with voluntary organisations at both the county and the municipal level. A four-year partnership agreement with voluntary organisations was entered into at the county level in 2018, and both Holmestrand and Sande entered into a public health cooperation with volunteers/clubs/associations.
Methods and training
The Norwegian Directorate of Health has provided few guidelines for the local and county authorities for this health promotion work, which distinguishes this initiative from traditional programme efforts. It also means that the Norwegian Directorate of Health has not imposed any requirements for which measures or methods are to be used in the programme work. This has allowed the local and county authorities to decide for themselves which measures and methods they wish to use, according to their local needs.
According to our data, some county authorities have guided the decisions on methods more than others, and Vestfold county authority seems to be among those that wanted the participating municipalities to choose ‘learning reporting’ as a method. This was discussed and decided jointly with the participating municipalities at a network meeting in 2019. Holmestrand did not participate in this meeting. ‘Learning reporting’ was not a requirement when the local authorities in the former county of Vestfold applied to participate in the programme. The county authority’s preferred choice of method appears to have created a number of challenges in Holmestrand’s programme work beyond some cooperation problems with the county authority. An important reason why Holmestrand chose co-creation using the tools SAMSON and SoImpact instead of ‘learning reporting’ is that the local authority at an overarching level has an ambition to move towards ‘Municipality 3.0’, which implies a co-creating municipality. Holmestrand’s choice of co-creation is thus both rational and well-founded.
The county authority’s choice of a common method for participating municipalities, on the other hand, can be interpreted as rational from their perspective, as they have been tasked with ensuring the establishment of various support structures such as expert and learning networks. This work is more manageable when the participating municipalities use a roughly similar method and methodology.
Differing methodological approaches contributed to Holmestrand perceiving the county authority’s support structures as not particularly relevant:
‘[The] methodological approach in local projects, with co-creation as a method and individual forms of evaluation, has not aligned with expectations regarding municipal skills enhancement in facilitation and process evaluation or the mandatory requirement for process evaluation/reporting that apply to the programme work in Vestfold. The notion of sharing experiences about different approaches, methods or forms of evaluation in local public health work has not been raised in programme meetings for the local authorities in Vestfold.’ 
This perception of the limited usefulness of the county authority’s various support structures may be one of several explanations for why some network meetings and support structures have been considered not particularly beneficial. Employees from Holmestrand participated in a full-day course in co-creation, but this has not been sufficient to effectively implement the cooperation model in the programme work. Since the other participating municipalities in the former county of Vestfold chose the ‘learning reporting’ method, they also have not had other local authorities to work with on this.
Co-creation, participation and contextual challenges
Co-creation is a demanding form of collaboration because it requires major changes in both thinking and working methods within the organisation. Consequently, it is a major undertaking for a project manager to bring about co-creation in municipal public health work. Key events that appear to have contributed to capacity challenges in the project work include Holmestrand’s two municipality mergers (Hof with effect from 1 January 2018 and Sande with effect from 22 February 2018). This required considerable personnel resources and focus. Holmestrand expressed a wish to skip participation in joint meetings for a three-month period in 2019 due to capacity challenges and unfilled posts. This appears to be a rational decision from the local authority’s perspective, particularly if the perceived benefit of participation was limited. However, it also represents a breach of the local authority’s contract with the county authority regarding participation in a minimum number of meetings. Disagreements between the participating county authority and Holmestrand contributed to a challenging and strained collaborative climate for a while, but they eventually reached a compromise.
True co-creation requires a transfer of power from various municipal stakeholders and room for more equitable collaboration among the different parties, such as the voluntary sector, various councils and associations, and various representatives of residents’ groups etc., who together need to agree on the problem descriptions, issues, methods and implementation. Our findings suggest that in Holmestrand’s project work, efforts have been made to work towards the ideal of co-creation. Interdisciplinary and cross-sectoral discussion forums have been created, dialogue conferences have been held, and a broadly composed project group was created and later disbanded. We also see traces of work aimed at co-creation in various documents. It is perhaps not possible to say that Holmestrand has succeeded in achieving co-creation at this point, but it can probably not be expected, given that it is a demanding and painstaking process that extends far beyond the scope of the programme work.
The public health work in Holmestrand and Sande has been organised in very different ways. Sande, with its environmental work initiative, can be said to have had a more defined and manageable approach than Holmestrand, which was aiming for the more general goal of co-creation. Sande’s environmental worker has had a relatively limited mandate, the initiative was geographically defined, and it targeted a relatively manageable group of young individuals. The suitability of the environmental worker for the position, combined with these factors, has probably contributed to success and goal achievement. Sande chose to continue the environmental worker initiative after the programme work was completed. The funding of Holmestrand’s measures has also differed from that of Sande’s measures, with the latter having a more limited initiative in which it received NOK 5 million during the project period, while Holmestrand received NOK 3 million. Whether this has affected goal achievement is difficult to say, as the data from Holmestrand suggests capacity challenges in relation to municipality mergers, the pandemic and a demanding methodology that extends beyond the project itself.
The results of Holmestrand’s programme work may seem somewhat harder to discern than Sande’s, particularly when viewed through a traditional and formal understanding of goal achievement. Our data shows that Holmestrand has carried out numerous measures and activities for the target group, and the organisation has developed a greater awareness of co-creation as an approach to municipal work.
 Reporting grants. Initiative development in the health promotion programme in the municipalities (Program for folkehelsearbeid i kommunene) 2019 ‘Vestfold på laget’ (2 March 2020, p. 6)
 Archive no. 201700595-69