Perceptions of coherence during planning for local Public Health Work: building capacity and developing theory through collaborative action research

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We apply the theory of Salutogenesis to unravel how actors developed coherent perspectives during a collaboration linked to the development and implementation of a health promoting measure. Methods Collaborative action research was applied to develop relevant and generalizable knowledge applicable for municipal practice. Data was gathered through in-depth interviews with municipal actors across 7 municipalities; and a follow-up workshop with municipal participants (n = 40) to validate and elaborate findings. During analysis, an abductive approach utilizing Salutogenesis was applied to develop practical knowledge, while also developing the theoretical framework in line with emerging insights Results Collaborators developed coherent perspectives during participation in the collaboration, suggesting that perceptions of coherence are influenced by processes and structures during collaboration that contribute to form actor’s experiences and perceptions. Perceptions of comprehensibility were linked to awareness of shared goals, disciplinary and contextual knowledge as well as clearly defined roles and responsibilities. Manageability was described as matters of perceiving challenges as resolve-able in the local context; being able to identify, activate and adapt resources, as well as supportive structures and personal competence. Meaningfulness was experienced through being able to define processes; perceptions of goal-attainment; visibility of contributions and impact, as well as experiences of learning and social cohesion. Implications of findings for practice and theory are discussed. Conclusions Applying Salutogenesis unto municipal collaboration processes yielded valid insights into how coherence can be understood and assessed beyond individual experiences. A shared vision about the common aims; the anchoring goals and procedures; the structure and content of collaboration activities (inclusive joined and mutual learning sessions) as well as the presence of feed-back loops emerge as important assets and valid entry points to facilitate for coherent experiences and processes in municipalities. The novel application of the theoretical framework can contribute to develop Salutogenesis as a sound theory for settings-based approaches within Health Promotion. Policy coherence health promotion Salutogenesis health in all policies whole-of-community health equity local planning collaboration co-creation Figures Figure 1 Introduction The development and implementation of Health Promotion and Public Health approaches locally demands for extensive, committed and long-term collaboration ( 1 – 3 ). This is acknowledged in the Norwegian Public Health Act; which aims for Health-in-all-Policies (HiAP) and advocates for Health Equity and a whole-of-government approach to realize these intentions ( 4 – 6 ). HiAP implies treating health as a Human Right; recognizing the Social Determinants of health (SDoH) as major drivers of Health Inequities and emphasizes the importance of intersectoral collaboration and policy-making ( 7 , 8 ). To carry out systematic local Public Health Work (PHW) and achieve HiAP, actors across sectors and levels should be able to participate in common efforts and to pursue overarching aims independently in between shared activities ( 9 – 11 ). This is challenged by the well-known problems with multi-sector collaboration, such as “silo-thinking”, implying different professional and contextual understandings, conflict over resources and ownership over approaches and a fragmentation of efforts ( 1 ). To achieve HiAP, these issues must be addressed during the planning, development and implementation of local policies ( 12 ). Accordingly, municipal planning and local policies emerge as a central resource for local PHW ( 1 , 10 , 11 ). Regional and local “strategic planning” focuses on developing and implementing plans to achieve specific long-term goals and priorities ( 13 ). Strategic planning is characterized by tangible actions, implementation of measures, and the alignment of plans and policies across sectors and stakeholders ( 8 ). Strategic planning thereby seeks to combine aspects of rational and dialogue-based planning approaches ( 2 , 6 ). Rationalistic approaches are goal-oriented, relying on structured and knowledge/data-driven processes ( 2 , 13 ). In contrast, dialogue-based approaches view planning as a democratic process and emphasize negotiation, consensus-building and collaborative decision-making ( 11 , 13 ). Power dynamics are addressed, and planning is seen as a constant process aiming at creating engagement, ownership and social cohesion. Combining these approaches is challenging, and even more so when considering increased demands to apply inclusive and participatory approaches and involve stakeholders, target audience and even the general public in the development and implementation of measures ( 3 , 7 , 8 , 13 , 14 ). Participatory approaches aim at increasing health equity by addressing matters of distributional as well as procedural justice ( 14 ) and hold the potential to make major contributions to goal achievement (e.g. developing relevant resources for the local community) while applying democratic and socially inclusive processes. However, evaluations of HiAP still reveal challenges in resolving the so-called “wicked problems”, as for example reducing health inequalities ( 6 , 7 ). Wicked problems are complex, interconnected issues sustained by societal systems, where efforts to solve challenges from one part of the system often face resistance or draw-backs from others, making lasting, profound change difficult ( 6 , 15 ). Attempts to implement HiAP-approaches often fail to resolve these issues due to fragmented efforts; a lack of effectiveness of measures as well as the risk of widening the gap in health and on the SDoH ( 5 , 6 , 8 , 16 ); and a lack of financing and prioritization that reinforce tendencies of projectification ( 17 ). Challenges are also linked to conflicting goals as well as lacking opportunities and resources for goal-driven activities to fulfill role obligations ( 10 , 11 ). These challenges also highlight the importance of organizational factors, such as high internal turnover: Collaborative processes that are not sufficiently incorporated into the wider organization contribute to personal learning, but fail to facilitate organizational development ( 17 ). One of the major challenges in this regard is the complexity of issues, increasing the risk of incoherent approaches that built on too-narrow perspectives ( 10 ). Another main challenge lies in creating spaces for co-creation, and in achieving de-facto power sharing and collaborative decision-making ( 2 , 13 , 14 ): Even participatory approaches, aimed at levelling out such inequalities, are heavily influenced, and do often reproduce, existing power relations ( 14 ). Especially vulnerable populations experience trouble with influencing outcomes in meaningful ways, which spoils for both process- and goal-oriented benefits of inclusive approaches ( 13 , 14 ). These incoherencies contribute to perceptions of fragmentation and challenges the integration across perspectives and actions, as well as actors and levels-of-governance; and represent a major barrier for both individual and collective (e.g., municipal) capacity for action ( 9 , 10 ). This highlights the importance of combining rationalistic and dialogue-based planning approaches to develop a valid framework for strategic, coherent planning contributing to policy coherence ( 2 , 14 , 18 ). Policy coherence emerges as an important driver for coordinated, goal-oriented approaches supporting health equity ( 9 , 10 , 18 ). Planning for policy coherence implies that development must occur within people (PHW-actors) and in their supporting surroundings (municipal organization); as well as in the relationships (activities, tasks and processes) between these. A special focus on conditions that support the development of coherent perspectives and purposeful actions across actors and sectors during the planning of policies is needed. To unravel these complex issues, Salutogenesis, the theory about “the origins of health” and it’s inherent conceptualization of “sense of coherence (SOC)” is applied ( 19 – 21 ). In the salutogenic model, a strong SOC is a central individual resource that enables individuals to apply flexible strategies while pursuing desired outcomes ( 20 ); a beneficial condition for being able to work independently towards common efforts. “Coherence” is conceptualized as an interplay between individual perceptions on the one, and challenges and resources provided by relevant settings and the wider societal context on the other hand ( 9 , 10 , 22 ). Perceptions of coherence (SOC) are structured along the dimensions of comprehensibility, manageability and meaningfulness, which are linked to distinct experiences: Comprehensibility describes “the feeling of having a clear mental representation of what is going on and what is expected” ( 20 ) and “understanding the challenge” ( 23 ). It represents the cognitive dimension of SOC; the mental picture of the world and your place in it, developed on the base of (culturally defined) narratives and personal experiences ( 24 ). Manageability is understood as the behavioral component of SOC ( 20 ), the ability to “overcome challenges” ( 23 ) and “to identify and adequately apply resources to achieve desired outcomes” ( 24 ). Manageability depends on perceptions of challenges as well as available resources ( 20 ). Meaningfulness is the emotional component of SOC, and describes perceptions of being engaged, “motivated to take on the challenge”; experiences of being able to influence outcomes and emotional closeness to applied values, aims and/or processes ( 20 , 23 , 24 ). Applying Salutogenesis allows to unravel matters of coherence during local collaboration for PHW-work by exploring “coherence” as an interplay between individual, procedural and contextual factors ( 18 ). This study aims to explore how actors involved in the development and implementation of a local public health initiative targeting children and adolescents’ mental health describe experiences of coherence and how coherent perspectives, as described by Salutogenesis, were achieved throughout the process. “Coherent perspectives” can, in this context, be understood as an outlook on local PHW as being comprehensible, manageable and meaningful, as described above. Furthermore, this study critically investigates how collaboration within PHW can support coherent experiences among diverse actors across municipal contexts, with the aim of advancing the conceptual understanding of coherence as a process and informing strategic planning for policy coherence in local public health governance. Methods Methodologically, this study builds on co-creation and collaborative action research (CAR); a dynamic and collaborative approach to research emphasizing practical outcomes and opportunities for local capacity building ( 25 ). To develop relevant knowledge about how coherent experiences can be facilitated in the context of PHW, we apply a mixed methods approach with predominantly qualitative analysis-strategies. Research was carried out in the context of the national and regional initiative, Program for Public Health Work in Municipalities ( 26 , 27 ). Data was gathered through a series of in-depth interviews and a follow-up workshop with municipal stakeholders. Salutogenesis was used as a framework to guide the analyses and inform the follow-up workshop. An abductive approach was applied to support the data-driven development of knowledge and theory, including to further develop and expand the theoretical framework ( 28 , 29 ). Context for research (Program for Public Health Work) Launched by the Norwegian Directorate of Health in 2017, the Program for Public Health Work in Municipalities is a ten-year national initiative (2017–2027) aimed at building local capacity for public health efforts ( 26 ). The program focuses on promoting mental health and improving quality-of-life among children and youths. In the county of Trondelag, a lasting cooperation between county authorities, municipalities and a range of researchers and research- and development (R&D) institutions was established, providing a fruitful research context for the co-creation of knowledge and approaches for local PHW ( 27 ). The program emphasizes evidence-based practices and aims to reduce social health disparities through capacity-building, data-driven planning (e.g., via Ungdata surveys), and knowledge and methods for cross-sectoral cooperation. Municipalities are supported financially and organizationally to develop and implement a PHW-measure in collaboration with research environments by applying The Trondelag Model for Public Health Work (TMPHW) ( 30 ). The TMPHW is a structured, evidence-based framework for local public health work that operationalizes systematic methods for translating knowledge into targeted interventions; and integrates cross-sectoral collaboration and participatory processes to support a sustainable community development. Data gathering Interviews In-depth interviews with key stakeholders were conducted in 8 municipalities. Stakeholders were recruited strategically, based on having similar roles and responsibilities within their municipality, and included: a) mayors (political leaders); b) administrative leaders c) Chief Municipal Executives d) Public Health Coordinators; e) Project leader/collaborators. Interviews were conducted in two waves; the first (2017) conducted before, and the second (2022) after the measure had been implemented. An interview-guide (see supplementary materials) focusing on experiences during collaboration linked to the implementation of a local measure was developed and applied rigorously. As our main interest was in how planning and implementation processes were experienced; only interviews from wave 2 (n = 29) were analyzed for this paper. Workshop After the initial phase-of-analysis, emerging understandings were communicated and discussed in a half-day workshop with municipal stakeholders. The workshop was coordinated with other activities in the Program, and conducted in collaboration with regional authorities. Forty (n = 40) Stakeholders (including Public Health Coordinators, administrative leaders, project participants etc.) from regional municipalities participated. The first part of the workshop aimed at validating emerging findings, both in respect to securing that emerging understandings represent the lived experience in municipalities, and in respect to relevance of the applied theory: while understandings by large had emerged bottom-up during the analysis of the interviews, participants now were invited to reflect upon the previously described dimensions from a top-down viewpoint. Each dimension was presented individually and illustrated by quotes from the interviews. Participants were then encouraged to reflect upon related experiences and perceptions from the collaboration around the local PHW-measure, and to begin exploring how the framework could be applied to analyze processes and local approaches. Discussions took place in fixed groups, consisting of participants from different municipalities to increase diversity of experiences. Paper and pens were provided at each table, and the groups were encouraged to produce notes/thoughts-charts etc. during the discussions. A researcher was seated at every table to facilitate the discussion and take further notes. All written and graphic materials were collected and informed subsequent steps-of-analysis. Strategy-of-analysis Analysis was carried out in a co-creation approach between researchers and practice; and follows by large an abductive approach ( 28 , 29 ). Initial analysis, aiming at making sense of the gathered data and developing a broad picture of what is going on, was carried out by the first and the last author (both researchers). Analysis began with an inductive exploration of the open interviews, allowing themes to emerge from participants’ lived experiences. In the next step, these insights were structured deductively by applying the theory of Salutogenesis and the dimensions of coherence ( 20 ) in a co-creation approach between researchers and a municipal planner (2nd author); to ensure the development of context- sensitive knowledge as well as the relevance and applicability of emerging findings. Data was prepared and presented for validation in a follow-up workshop; in which participants were asked to reflect on their experiences in light of the theory. This iterative movement between data and theory enabled the refinement and expansion of the original framework, grounded in empirical understanding. Here, elements of constructivist Grounded Theory, such as constant comparison and focused coding, were applied to ensure that theoretical advancements are firmly grounded in the empirical material ( 31 ). Interviews Initial coding consisted of an inductive, contextual content analysis of the interview data to develop knowledge about how coherent perceptions of the setting (PHW) are described and achieved from various positions in the municipal organization ( 29 , 31 ). The aim was to describe and link individual perceptions of coherence and experiences made in the context of PHW through constant comparison, and develop an initial understanding about what is going on in this context. The framework for the deductive part of analysis was developed based on the 3-factor model of coherence as described in Salutogenesis: Comprehensibility was operationalized as notions of professional, contextual and generic understandings and knowledge, as well as experiences of how these understandings were developed during the project. Such experiences were interpreted as pinpoints towards the experience and development of comprehensibility. Manageability was understood as perceptions of challenges and available resources; as well as experiences of resolving (or not resolving) challenges during the project. Meaningfulness was assessed through tales of being motivated (or not) to engage in the collaboration; perceptions of the approach “making sense” and notions of ownership. This operationalization provided the base for focused coding ( 31 ); linking experiences and perceptions during PHW closer to the applied framework and facilitating for new knowledge (hypothesis) to emerge. Workshop The aim of the workshop was a) to validate emerging findings and b) link experiences closer to processes and structures during PHW, to start exploring if and how the framework might support analysis and the facilitation of coherent experiences for various actors throughout the described processes. The workshop was conducted and analyzed in close collaboration between researchers and practice. During analysis, practice partners were responsible to ensure that emerging knowledge is relevant and applicable for local PHW; while researchers were responsible for grounding emerging insights in the theoretical framework. Notes from researchers and notes produced at the tables were analyzed in an abductive approach, examining if the applied framework structures and explains experiences in meaningful ways; exploring if this application provides new insights into the complex interplay between people and processes; and examining if and how the theoretical framework might be further developed to enhance it’s relevance and practical applicability within the field of local HP-work ( 25 , 29 ). In line with principles from constructivist grounded theory ( 31 ), the focus is on allowing empirical findings to inform and refine the theoretical framework, increasing its contextual sensitivity and potential for use in practice. Table 1 summarizes main findings and provides some insights into how categories were developed in dialogue between theory and data: The right column; “What is this about” illustrates themes (initial codes) that emerged from the inductive bottom-up analysis of interviews and validation during the workshop; while the left column “Dimensions of SOC” displays the theoretical dimension of coherence that these experiences were associated with during the deductive part of the workshop and further analysis. Main findings, the categories developed through focused coding and theory-development, are displayed in the middle column and understood as “operationalizations of the dimensions in the context of PHW”. Table 1 operationalizing coherence in the context of PHW Dimen-sion of SOC Operationalisa-tion in respect to PHW/multi-sector collab What is this about? Comprehensibility Awareness of shared goals What are we trying to achieve? What is our aim? What objectives do we pursuit do fulfill this aim? Knowledge about how to achieve them How do we approach the issue? What kind of perspectives, methods, tools etc do we apply? How? What kind of resources do we need? Disciplinary knowledge What is the state-of-the-art? What are a valid approaches to achieve our goals? What do we know about downfalls and how to avoid them? Contextual knowledge What are resources and challenges in this context? Who participates, and in which role(s)? How can I activate resources (who do I need to talk to)? What kind of structures, processes etc do exist? Roles and responsibilities How can I impact the issue from my position? What is my role in the collaboration? What are my responsibilities? Tasks and activities Which tasks, activities, (part)-goals etc are my responsibility? How do these align with other activities tasks etc? What do collaborators expect me to do? Contributions How do my tasks and responsibilities contribute to the shared aim? How do they contribute to avoid challenges? Manageability Overcome-able challenges Is the challenge resolve-able? Can we (contribute to) resolve it here, in this context? Resources Can we resolve the challenge with the resources available in this context? How do we need to apply the resources in order to resolve the challenge? Identification How can we identify valid resources? What are the valid resources in this context? Where can we find them in this context? Distribution/ Activation Are resources available (for me or collaborators)? Are they easily accessible (for me or collaborators)? How can we activate/access resources? How are resources distributed- and how does the distribution happen? Adequacy Are the resources I can access valid for our purpose? Do they fit aims, target group and context? If not, can they be adapted to be more adequate? Supportive structures Do I have support (practically and emotionally) for my tasks and responsibilities in the structures around me- colleagues; tools, utilize-able processes etc? Can I assume that my efforts will be met with support (or with sabotage)? Can I expect others to do tasks and take their responsibilities to fulfill shared aims- and run processes as planned? Personal competence What do I know about the issue- the approach, the target group and the local context? What other personal resources do I have that might be valuable? How can I utilize this knowledge and resources to achieve goals and contribute to shared aims? Meaningfulness Influence outcomes Am I able to participate in shaping the process, aims and approaches; influence over structures, specific aims etc. we are going to pursue during these processes? For me or significant others Am I actively involved in outlining my own role and responsibilities; shape (part) and sector-specific aims and approaches identifying and activating resources for our contributions? In the organisation Can I participate in negotiating shared aims; distributing responsibilities and tasks and identifying and activating resources? Are we able to adapt/innovate/abolish existing structures (plans, processes, activities)? Making a difference (on the shared aim) Can we make sound contributions to resolve identified challenges and to achieving the shared and specific aims- Goal achievement! Mattering Perceptions of being personally (or organisatorically, e.g. public health coordinator) important for making achievements, being valued for contributions, “would not have happened without you” Visibility of contributions It is visible for myself and others how I (we) contribute to resolve challenges and achieve the shared goal. Our specific goals are linked to the shared aim. Visibility of impact It is visible for myself and others how my contributions impact goal-attainment an to resolving challenges: our contributions make a difference for the target group (and the local context) Visibility of Co-benefits It is visible for myself and others how my contributions can benefit other parts of the project/organization; how I support goal-attainment beyond my (sector-) specific goals and act as supportive structure for collaborators or other parts of the organisation Do what is “right” Perceptions of doing the right thing, being confident that aims and approaches are valid and match. Disciplinary/ Strategically Is there a clear connection between the overarching and specific goals? Are applied approaches, methods and tools in line with the state-of-the-art? Do approaches align strategically with overarching aims or developments in the local context? Ethical/morally Our goals, aims and approaches reflect the overarching values I hold personally and/or the values we agree upon as an organization and as collaborators. There are clear congruencies between these levels-of-values; and moral conflict can be resolved in satisfactory manners Learning and growing Perception of developing personally and/or as an organization, learning and growing (modning); being able to see progress in respect to competence, developing expertise and a repertoire of strategies that can help to resolve later challenges. Personally Perception of developing personally, learning and growing (modning); “becoming good as something, developing expertise and a repertoire of strategies that can help to resolve later challenges. As an organisation Perception of developing an organization; becoming better at resolving challenges and work across sectors and levels; utilizing, adapting and/or innovating structures to implement emerging knowledge about approaches, activities etc; developing a repertoire of strategies that can help to resolve later challenges. Social cohesion and support I am part of team that pursues shared values. I feel connected and appreciated by co-workers and collaborators. I believe that my social relationships can contribute to cope with future challenges. Results In this section, we first give a short overview over how the context of PHW is described throughout the interviews and during the workshop, and outline main challenges for coherence and coherent experiences during PHW. Then, we describe how comprehensibility, manageability and meaningfulness are experienced and add to perceptions of coherent processes individually, and in relation to the mutual interdependence of these dimensions of coherence ( 20 , 21 ). The setting: Public Health Work Public Health Work was by large described as profoundly fragmented by participants: It is hard. All the time the responsibility to try and influence the systematic work… but if the system is constantly changing, it’s like, you finally manage to establish a system, and then suddenly the ground is pulled out under your feet- new people come in, and they don’t have the background knowledge, not like the ones that have left. New leaders, that do not share a history with me or the few others that are still there. [They] talk about Public health from their prior knowledge, which does not necessarily fit with the others’ conceptions. [We also meet] quite some resistance from leaders that come from other places; they want to implement things they have experienced to work in a different context, but that might not work as good in a smaller context. It takes a long time before we talk the same language ! This description of PHW was supported across municipalities: participants described fragmentation in time, across actors, goals and objectives, approaches and methods, as well as economic funding: “Support for Public Health Work can be high on paper; but as soon as we are talking about funding or prioritizing measures, Public Health is often skipped”. To ensure financing often demanded to participate in externally funded projects; which again demands to adopt top-down defined goals, approaches or methods ( 17 ). This carries the risk of applying approaches that fail to address local challenges, and experiencing frequent shift in focus or methods, reinforcing perceptions of fragmentation. When methods are motivated by the need to secure external funding, it limits actors to develop familiarity, competence and confidence in their work ( 17 ). Measures were often described as short-lived and could appear isolated, with no lasting impact on municipal organization or processes. Even the establishment of positions (jobs) was often linked to and limited by project-periods and -funding. Thus, depending on external resources which demand the adoption of top-down objectives and means also implies that PHW is sensitive to changes in the political agenda and support ( 17 , 18 ). Moreover, even if goals and ambitions for Public Health are emphasized in overarching documents; the development and implementation of measures targeting these goals are often lacking or insufficient. Additionally, fragmentation of Public Health Work is described in relation to municipal organization and the so-called sectorial “silos”, representing a barrier for effective collaboration ( 10 ): We have a competent director in the municipality, who is actively challenging silo-thinking. In the weekly gathering for administrative leaders, a lot of focus linked to developing the organization is about being good at working together across sectors and levels. (…) Earlier, you worked within your silo, and maybe you worked on the same issues without knowing about each other. And maybe some measures even counter-acted approaches in other sectors! This illustrates how a lack of knowledge about what is going on in other sectors might imply both parallel and conflicting approaches, hazarding for effectiveness and possible synergies of efforts. During the workshops, perceptions of “fragmentation” were described in respect to the applied knowledge-base; in persons, time, funding and applied approaches, as well as between overarching and sector-specific goals and plans and between “project”- and “every-day” -work. These experiences mirror well-known challenges linked to silo-thinking; including differing understanding of challenges and possible solutions; unclear responsibilities; a lack of resources (distributed through internal competition) and isolated efforts, that fail to inform or impact the wider municipal environment ( 6 , 7 , 11 ). This demands PH-workers to continuously follow-up and anchor their work, which is experienced as tiresome and a kind of “Sissyphous”-work that never ends and seldom yields meaningful results: I looked at the numbers, and involvement and everything…we had to take many rounds before we figured out what we can do. Then, we conducted the search conference, but that was way too early, so we did not agree on a measure, as we were supposed to. We also had a working group, but the brainstorming session was too big so we did not manage to sketch a measure that could be evaluated. We were in that phase for quite a long time…. In the end, we had to start over again. We announced we were going to screen the services, to find out where the problem is. We made a huge effort there! That also increased knowledge about us across the services. And with that background, we were able to develop a measure. However, the challenge was that no one was responsible for the whole thing, and the coordination with families in vulnerable situations, in respect to marginalization. Everyone found it hard to take responsibility if they perceived others to be responsible. Such perceptions represent a barrier for progress and developing feelings of competence in itself, and challenge perceptions of meaningfulness and the development of coherent perspectives during PHW ( 10 ). All in all, findings suggest that fragmentation challenges coherence and the development of coherent perspectives both on the organizational and on the personal level; thereby emerging as a main barrier for systematic developmental work. Coherent experiences during PHW In this section, we disclose participants’ descriptions of aspects of comprehensibility, manageability and meaningfulness during local collaboration, as well as participants’ reflections about how these contributed to resolving some of the challenges brought by the above-described fragmentation of local PHW. All in all, participants described the proposed framework as valid and relevant for describing their lived experiences. Participants also described that perceptions of coherence in respect to PHW increased during the project period; indicating that experiences from the collaboration contributed to the development of more coherent perspectives about PHW also beyond the specific project. Below, we want to describe each dimension, and how it is experienced during multi-sector collaboration in- depth. Comprehensibility- to understand Findings indicate that comprehensibility in respect to local PHW is about having an idea about “the bigger picture”, what PHW is and what one wants to achieve within the local context, how to approach the issue (develop coherent agency) as an organization, as well as having a sound idea about how oneself might contribute to the common effort. As shown in Table 1 ; are such perceptions linked to 1.) Awareness of shared goals; 2.) Knowledge about how to achieve them (disciplinary and contextual), and 3. Awareness of role and responsibilities; including specific tasks and activities, as well as understanding how these contribute to the common effort. Awareness of shared goals Awareness of shared goals was tightly linked to knowledge about PHW. Participants emphasized the importance of having a sound understanding about Public Health: The most important thing, that is to understand what Public Health is. That Public Health, that’s everything we do! That those around us have to thrive so we can thrive as well… It’s important that politicians understand the whole picture: Public Health is about life! Public health and PHW were consistently framed as “complex matters”, with a huge range of approaches and understandings present in the field. Moving beyond narrow understandings of health promotion and life-style based approaches was considered essential to fulfill Program obligations ( 26 , 27 ) and pursue valid goals within HP and health equity ( 3 , 6 , 20 ). Accordingly, participants described that they used a lot of time and effort to increase their competence about PHW; to teach and inform collaborators, decision-makers and others in the wider municipal context; and to anchor broad understandings of PHW in municipal documents and plans (compare 1, 11). Setting valid, knowledge-based and locally relevant aims for the whole organization played a major role in this regard, according to participants. Having common goals to relate to enabled collaborators to outline strategies as to how to pursue these goals from their position, which is a pre-requisite for independent efforts ( 10 , 11 , 32 ). Moreover, participants described how common aims contributed to manageability by providing more support in the surrounding structures (compare “manageability”), as well as to meaningfulness through positive feedback and the visibility of contributions (compare “meaningfulness”). This emphasizes the intertwined nature of the dimensions, which is already anticipated in the original literature ( 19 , 20 ). Roles and responsibilities Meanwhile, even if establishing common aims seems to benefit shared understandings about where “we” want to go, outlining how “I” can contribute to get us there requires a certain idea about valid approaches. The need to deepen one’s understanding about PHW was often highlighted by insecurities regarding how to approach issues: When we started, it was so unbelievable open, that we did not have a clue where to begin. The definition was so broad, we did use a lot of time to find out what we were supposed to do! Participants described that roles and responsibilities regarding PHW often were unclear at the beginning of the project period, or when they started in a job linked to PHW. However, this uncertainty was not always framed as a draw-back; some participants even emphasized the process of “finding out” as a positive experience: “ I figured out what was expected of me along the way. I like responsibilities and tasks, we paved the way along as we marched!”. In line with research on salutogenic learning, “paving your own way” and learn through reflection and experience can increase notions of ownership and competence; and increase the likelihood that collaborators are engaged and find meaning in the tasks and activities they are assigned ( 33 ). Knowledge about how to achieve aims To be able to take part in outlining one’s own role and responsibilities craves an understanding about how goals can be achieved, which is partly linked to the above-described disciplinary understanding of PHW (knowledge about valid approaches and tools, e.g.). Participants who initially lacked this knowledge regularly described how they developed their understanding during the applied processes; such as joined and mutual learning activities. However, disciplinary understandings about broad relationships were not sufficient for understanding how matters can be approached in the local context, and how one can contribute from the specific position in the municipal organization: «It’s important to know, like facts, how things are around here- if not, you don’t know where to place efforts! It’s important to understand municipalities, how a municipality works. Important to know people. Alone, you’ll get nowhere. Knowledge about relationships and causal relations, so you understand what can impact what and in which direction.” This includes knowledge about the municipality and it’s organization, as well as knowledge about collaboration processes: who is involved, when, how, and to which purpose? Contextual knowledge, such as being aware of local conflicts and/or interests, was also described as crucial to understand how approaches might be met in the local context. This also includes to have a sound understanding about how activities in other sectors or levels might impact approaches: for example, planning for intensive involvement of youths during exam-periods hazards manageability, thereby adding to incoherent approaches. Contextual and process- knowledge was described as crucial to be able to identify and activate resources (see “manageability”) as well as to outline valid tasks and activities to pursue common goals (and avoid unforeseen draw-backs due to local issues). Thus, while disciplinary knowledge supports coherent understanding about how to approach issues; is contextual knowledge also crucial for developing coherent agency: a coherent and context-sensitive understanding about how we get from where we are to where we want to be. Manageability- to handle Matters of manageability, how challenges are approached and resolved (or not), emerged as a central theme throughout the data material. Perceptions of manageability were linked to perceiving challenges as overcome-able, as well as the availability of relevant resources. Thus, according to Table 1 , manageability during local PHW was linked to 1.) outlining overcome-able challenges; 2.) perceived availability of resources, including aspects of a.) identification, b) distribution (activation) and c.) adequacy of resources; 3.) supportive structures in the wider municipal environment and 4.) personal competence, including aspects of disciplinary and contextual knowledge (compare “comprehensibility”). Overcome-able challenges The importance of perceiving challenges as overcome-able became visible at many levels during analysis. For example, participants expressed concerns in respect to new approaches, goals etc. adding extra hassles and increasing work-load. Meanwhile, anticipations of “extra hassles” were often turned into experiences of gaining resources and raising capacity in the long run: “It works quite well, and has become a stronger collaboration. We were quite conscious about not creating new groups, but rather utilize already-composed ones. I mean, we did create some new groups to work with the volunteer sector. But the collaboration between health and school has been good all along. It worked really well. (…) But then we needed a broader group for the hearing processes around the measure; with people from the cultural sector and many more. (…). Here, we have good, systematic approaches.» This illustrates how perceived challenges can develop into resources if they are resolved. This is in line with salutogenic theory, which described stressors and resources as “two sides of the same coin” ( 19 , 24 ). Moreover, experiences of overcoming and resolving challenges promotes the believe that also later challenges can be overcome ( 20 , 34 ). Perceiving challenges as resolve-able is a crucial condition for perceptions of manageability; and for engaging in trying to resolve them. In this regard, the overarching aim of the Program, “ to reduce inequalities in health ”, was repeatedly framed and understood as “ too big ” an issue to be resolved through single measures, or even in the local context. Accordingly, unravelling how a specific project can contribute to this overarching goal was a major issue during collaboration: translating overarching aims into locally resolvable challenges was crucial for understanding how the challenges can be approached, and raised motivation to engage in the common effort through expectations of success (rather than failure or insufficiency) ( 1 , 10 ). In this context, defining resolvable challenges and outline responsibilities ( 32 ), as also described under comprehensibility, was described as beneficial: «Far too often do we develop plans that never get to become anything else than a plan- we have a job to do when it comes to emphasizing that this is a working plan, that is meant to be realized! To make the plan so specific) that we can just tick whatever we have realized…A clear plan for implementation. And emphasize it. That’s the recipe!» Thus, how challenges were perceived and framed in the local context had major implications for how issues were approached and perceived by collaborators. Perceiving challenges as resolvable, and having a clear mental and/or organizational plan about how the issue can be approached from one’s position is a major pre-requisite for developing coherent agency: the capacity to overcome challenges in ways that contribute to pursue goals and supports a favorable development for the individual and it’s surroundings ( 21 , 22 ). Coherent agency is a central condition for being able to pursue goals and work independently towards common aims, which has earlier been described as important for collaboration ( 9 , 10 , 20 ). As illustrated above, developing coherent agency is highly influenced by matters of comprehensibility, as well as by earlier experiences of resolving challenges. This also illustrates how matters of manageability (the believe to be able to resolve a challenge) are intertwined with matters of meaningfulness (motivation to engage in resolving the challenge) and comprehensibility (understanding how the challenge can be approached). However, resolving challenges is not only linked to understanding how; it also depends on having the resources at hand that are needed to realize intentions ( 20 , 22 ). Resources and personal competence In line with theory, matters of being able to identify and activate resources in the local context emerged as central assets for PHW ( 20 , 23 , 24 ). Being able to identify resources was partly linked to disciplinary and contextual knowledge; and did thus also reflect personal competence: I have a professional background, that helps me understand a lot, but for the politicians it’s all gibberish. Like for me, when they talk about Salmon-farming, I don’t know anything in that context. We need to phrase things in understandable ways. Easy-to-grasp explanations of concepts, what do they mean? Municipal organization and practice influenced how easy it was to identify resources, and might thereby contribute to the identification of resources independent of personal prior knowledge. Resources in PHW were consistently described as money (funding), attention (priority), time and knowledge, as well as access to decision-making forums: «Now, the group consists of administrative leaders- before, it was mostly enthusiasts, but they did not have any decision-making power, and that was the problem. The first group was established at the wrong level!» Thus, access to decision-making and resource-distributing forums emerges as a central resource for PHW. This supports earlier described findings, where a lack of/inconsistent funding and priority were described as main challenges for PHW, as it limits access to resources- and increases projectification ( 17 ). Accordingly, while PHW was repeatedly framed as a “whole-of-community”-responsibility ( 7 ); did PH-coordinators also point to a lack of commitment from and delegative power over collaborators as a major challenge: having the overarching responsibility for local PHW, but no means to activate central resources besides others “goodwill” for the common effort was described as difficult, de-motivating and little coherent. Moreover, the importance of anchoring sector-specific goals was described as beneficial to distribute responsibilities and emphasize commitment to the common effort ( 32 ). For PH-coordinators, such goals became a major asset, and could even turn perceptions of PHW and the PHW-coordinator in the wider municipality: «Suddenly, it became important to include me, when they found out they could use me in respect to the municipal planning- suddenly, Public Health became important. It’s a lot of stress, if you don’t get distributed resources for it. I was not part of the administrative leaders, and did not have access to the right forums to be included in the discussion- however, in small municipalities, you have to use whatever persons you have… now, I talk with the leaders, and are included into discussions!” Thus, from having to ask others to put efforts into the common aim; could they now provide knowledge and support in respect to realizing goals in other sectors. Moreover, defining sector-specific goals can contribute to make the challenge appear more resolve-able for collaborators; contributing to increase perceptions manageability in the long run ( 10 , 18 , 32 ). However, being able to identify and activate resources is not always sufficient for realizing intentions; resources also have to fit, and be applied in ways that contribute to goal attainment in order to contribute to systematic, coherent approaches. Recall the initial example, emphasizing the importance of being able to adapt resources: while the initial thought was to utilize existing groups to support manageability (and not put the extra strain of establishing new groups into the process); they learned that being able to adapt the group to varying needs makes for more adequate resources over time; such as involving people from the cultural sector before the political hearing (see above). Thus, the adequacy of resources- their “fit” with the context and the role they are assigned in respect to resolving challenges- as well as the ability to adapt existing, or even create new resources also emerged as an important aspect of coherent collaboration. Supportive structures Municipal structure and -culture emerges as a possible barrier as well as a central asset in this context, beyond the mere distribution of resources specifically assigned PHW. This is linked to the collaborative nature of PHW, which by large depends on common efforts and how these are received by collaborators, stakeholders, audience and target group(s): “A positive internal culture, and attitudes that emphasize contributions!” were repeatedly described as major assets to support lasting changes. Moreover, experiencing that other parts of the municipal organization do their share of the common effort, and/or engage in activities pursuing related goals made substantial contributions to perceptions of “ being on the same team, and pushing into the same direction ” associated with supportive structures, which also touches into meaningfulness (see below). Perceiving that efforts are supported even indirectly in the municipal organization is especially important in this context, which emphasizes broad coalitions and systematic changes ( 6 , 7 ). Organizational change theory describes organizations as resistant to change: even if changes are implemented in one part of the (municipal) system, are other parts still designed to maintain the status quo, and would as such often hinder or even draw-back new approaches ( 6 , 15 ). Thus, perceptions of supportive structures, which react positively to, and support PHW through political, public and administrative attention emerged as a major asset for perceptions of manageability, as well as for maintained motivation to engage in PHW (compare “meaningfulness”). Meaningfulness- to feel Matters of meaningfulness became visible in various forms across interviews and workshop-notes, and included matters of influencing processes, perceptions of making a difference and “being on the right track”, learning and growing as well as matters of social and organizational feedback. These are linked to experiences of being able 1.) influence outcomes and processes a.) for myself, my sector and relevant others as well as b.) on an organizational level, 2.) making a difference in respect to pursuing shared aims and resolving challenges, including perceptions of a.) mattering (personally or role-wise), being important for the achievements that are made; b.) visibility of contributions (what I did) as well as c.) visibility of impact (what I and we achieved); 3.) feeling that aims and approaches are “right” both a.) disciplinary/strategically and b.) morally; 4.) experiences of learning and growing a.) personally and b.) as an organization; as well as 5.) Experiences of social cohesion and support Influencing outcomes Generally, participants expressed that engagement and perceptions of meaningfulness increased during the project period: “We made a lot of positive experiences. We passed on the message and initiated a process. And something happened out in the schools- it received a lot more attention! The families have received information at parent-meetings and got these hand-outs. I am convinced that this had a positive effect on adolescents’ public health. And for a more conscious attitude. That contributes to making us more resilient. For me, an important driver was meeting the other municipalities. “ Positive experiences during PHW could thus contribute to build motivation, a crucial condition for sustained engagement necessary to pursue goals over time ( 9 , 10 ). As illustrated, and in line with theory ( 20 , 21 ), were such experiences often intertwined with perceptions of having an impact; both in respect to agreeing on common aims and outlining process; defining one’s own role and tasks; and in respect to goal attainment and making a difference for the target group(s). During further analysis, a distinction was made between experiences linked to respectively: “influencing outcomes” is operationalized as having an impact on internal issues, organization and shaping processes; while “making a difference” describes perceptions of contributing to goal-attainment. Both types of experiences contributed to perceptions of meaningfulness, but were associated with different processes during collaboration. “Influencing outcomes” was tightly linked to outlining one’s own role and responsibilities, as described earlier; to be involved in outlining collaboration processes; setting goals for the common effort to inform plans; as well as to raise fundings and activate resources to realize intentions. Here, major differences in the role of the Public Health Coordinators in respect to shaping processes became visible across municipalities: When we do project-work, we don’t want it to be the PH-coordinators responsibility, we prefer it to by placed “in the line” (within a municipal sector)- because we want others to focus on PHW. So that we do not depend so much to money assigned «Public health», because that’s not what is important, but how the sectors work with PHW, that’s important! And there, we face a lot of challenges… for example, within the Health Services, how much resources should we assign to preventive work? After some rounds with thematic plans, can we see that these planning processes emphasize the focus on prevention and health promotion within the services- they indicate we have to turn distribution upside-down In some municipalities, PH-coordinators were able to influence outcomes due to personal resources and relationships; in others; such processes were more formalized and integrated into the municipal organization and thus, had a more lasting impact in processes and municipal structure. Being able to set the agenda and influence structures for present as well as future efforts was described as motivating for sustained engagement in PHW across sectors and actors. Especially being able to influence municipal processes and organization beyond the specific action was emphasized as a way to “shape outcomes” and develop capacity for PHW, and thus, contribute to organizational learning. Accordingly, a lot of efforts were put on exploring collaboration processes and favorable structures during the development of the specific action; to ensure that they could inform later approaches. Being able to influence outcomes for oneself and/or significant others, in this case, collaborators and stakeholders is closely linked to perceptions of meaningfulness ( 20 ), increases perceptions of ownership over approaches; and simultaneously contributes to comprehensibility (understanding the purpose of processes etc.) and manageability (providing relevant structures and resources). Thus, applying collaborative methods and engage stakeholders into such processes might contribute to the development of a shared, coherent understandings locally. Making a difference However, a too-narrow focus on internal processes and collaboration, without linking these firmly to goals and ambitions within PHW, was described as “meaningless ” and “ collaborating for the sake of collaboration” . Experiences of “ making a difference ” and contribute to resolve challenges were central for perceptions of meaningfulness ( 19 , 20 , 24 ). Making a difference for the target group is linked to goal attainment and working in line with disciplinary understandings about valid approaches: «My experience is that it works very well for the target group. We do have structures and collaborations in the back, where we can raise themes, and agree on future efforts. That works well. It’s not easy, as these are difficult decisions, but in respect to what you can realistically expect, it works really well” Perceptions of «success» and mastery were closely linked to perceiving the common effort as meaningful ( 10 , 18 ). Meanwhile, success could not only be experienced by fulfilling main aims, but even while developing processes that support these aims, and contribute to fulfill process goals (e.g. “involving youths in developing the knowledge-base”): «Vi utilize the (national)youthData. There, we managed to achieve good involvement in working with the results. It’s about developing ownership over it. And that we worked with the youngsters in a good way when the results arrived, and even before we chose questions. We really succeeded there!» Thus, and in line with theory, experiences of being able to influence the context at any level; from negotiating one’s own role to making a lasting impact on municipal organization were closely linked to experiencing processes as meaningful ( 19 , 20 ). This might also point towards matters of “mattering”; being personally (or organizational) important for how things are going ( 35 ). Perceptions of mattering were also described as dependent on social feedback and experiences of appreciation and visibility: “ We forget appreciation, and that what is so important! To see each other. Really important for all of us. We see that in school already-people need to be seen!”. Visibility and appreciation of contributions and impact here emerge as crucial assets for coherent collaboration; and especially, for experiencing collaboration as meaningful: «We were able to offer support, that was nice. We can help! And it’s important that we from the municipality thank the volunteers for their efforts. (…) And the local media has been very supportive and positive to everything- they always showed up when I was willing to talk about stuff, and have my photos taken. I have become the “Join in!»-lady: «Everyone come and join in” or something like that. And within our sector- health and family- we really elevated ourselves. Received support for working preventive, and support for those working directly with children and adolescents” Both visibility of contributions from collaborators, as well as visibility of the common action in the local context could contribute to perceptions of meaningfulness: «We emphasized the focus on PHW, and formalized our work. To get into the municipal plans; and have it as a red threat during the development of the plans. Even while being a legal obligation; the fact that it is given so much attention [here], that really changed a lot. Maybe that is the most important change, that the focus on PHW is broader and has moved beyond less drinking and more exercise. Now, while planning the centrum and such, there is much more focus on green-spaces! ” Visibility of impact is an important pre-requisite for perceptions of making a difference: being able to observe changes was described as motivating, and emphasizing perceptions of doing something important and “meaningful”. Doing “what is right” Receiving appreciation and seeing impact of actions does thereby also contribute to perceptions of “ being on the right track ” and “ going somewhere ”, which also emerged as important conditions for experiencing meaningfulness: “ you are on the way to something- everyone understands their role, this is our community, our Youth !”. Experiencing progress did in itself raise perceptions of meaningfulness; as also illustrated above. Disciplinary knowledge about “ what works and why ” could contribute to perceptions of progress in a field in which progress can be hard to measure; e.g. through awareness of indicators, or by re-assuring actors that they are applying “best practices”. Even anchoring approaches in strategic plans, from international documents, such as the sustainable development goals (SDG) to municipal and thematic plans was described as favorable for perceptions of “ doing the right thing ” ( 11 , 32 ). Nowadays, I can influence PHW through working with the knowledge-base for public health. It’s one of our most important tools, and it’s mandatory to apply it during all planning work: everything from the municipal master plan to thematic plans for water, sanitation, mental health, the ageing population… Every sector-plan and all municipal plans, and even the SDG in the municipality- the indictors we develop for the knowledge-base are really important indicators for the SDG. We did it once first, but the second time we did it differently, and looked at it in relation to how we operationalize the SDG. That way, you can emphasize issues to the politicians and even the municipality. You can even use it for teaching and learning: what is important here in this village?” Embedding approaches in the agreed-upon strategies provided a valid and shared framework which could be used to raise attention and provide reasons for efforts by emphasizing them as contributions to higher-level obligations and create engagement in actors from other sectors ( 9 , 10 ). Learning, growing and social cohesion Last, experiences of learning and growing were repeatedly described as meaningful and motivating ( 33 ): We develop new knowledge all the time- and we are learning continuously! That’s what is nice about being in a big group, there is always someone who brings something new to the table, which we others haven’t heard about yet! While personal learning contributes with positive experiences for the actors and individual competence-building, does it also emphasize one of the main challenges in PHW: to develop organizational capacity for PHW ( 1 , 2 , 7 ). In the above-described context for PHW, characterized by high-turn-over, was building organizational capacity described as central to enable systematic approaches over time: We regularly stop along the way and look at what we are doing: are we doing the right things, and are we doing them in the right way? We conducted a check-in, and we also look at things like; are there any new guidelines, new information, new knowledge? A systematic evaluation of what we are doing. We have a system for that. That’s in our backbone. If there are bigger issues we conduct a new search for knowledge, but that demands for financing or even a new project. Our mindset is that we are not evaluating just to evaluate! Thus, providing actors with opportunities to build personal competence is not enough: learning must occur in municipal structures and applied processes to have a lasting effect ( 6 , 15 ). Moreover, experiences of joined and mutual learning were repeatedly described as contributing to perceptions of cohesion and/or social capital; expressed thorough notions like “building a network and get to know each other. Get ideas and learn from each other. That was really a tremendous lift, in my opinion!”. In this context, also earlier discussed matters of visibility, experiences of appreciation and positive feedback; as well as being “on the same team” were crucial, and contributed to organizational development through supporting cohesive networks within as well as between municipalities. Building cohesive networks was associated with meaningfulness, as well as progress and the development of (social) resources that can help to resolve later challenges ( 12 , 36 ). Discussion All in all, applying Salutogenesis and its inherent framework of coherence unto perceptions and experiences during collaboration for local PHW yielded interesting insights, which can support the development of coherent approaches to planning for PHW. Initially, local PHW has been described as largely fragmented and incoherent, due to differing understandings of challenges and possible solutions; conflicting aims; unclear responsibilities; a lack of, and internal competition over, resources; instable funding and shifting objectives as well as short-lived interventions that fail to impact the wider municipal organization and later working processes. This poses major challenges for the establishment of systematic processes for coherent planning of local development in line with PHW-intentions and highlights the needs to combine rationalistic and dialogue-based planning approaches as well as to facilitate for personal and organizational learning ( 2 , 7 , 8 , 10 – 14 ). Findings indicate that collaborators developed coherent perspectives during participation in the multi-sector collaboration, suggesting that perceptions of coherence are influenced by the processes and structures that guide collaboration processes and contribute to form actor’s experiences and perceptions ( 22 ). Perceptions of comprehensibility were linked to awareness of shared goals, disciplinary and contextual knowledge for outlining approaches as well as clearly defined roles and responsibilities. Manageability was described as matters of perceiving challenges as resolve-able in the local context; being able to identify, activate and, if necessary, adapt or create relevant resources, as well as supportive structures and personal competence. Meaningfulness was experienced through being able to define processes; perceptions of goal-attainment; visibility of contributions and impact, as well as experiences of learning and social cohesion. Coherent processes for coherent planning Applying Salutogenesis to unravel these complex issues enabled us to link experiences of coherence and/or incoherence to collaboration processes; rather than framing them as internal, individual resources ( 10 , 18 , 22 ). While individual resources, such as knowledge about PHW, did play a role; could applied processes provide or prevent opportunities to apply and promote resources and resolve challenges. In line with theory, did overcoming challenges contribute to strengthen perceptions of being able to resolve (future) challenges- individually and as an organization ( 20 , 34 ). The applied operationalizations of the three dimensions of coherence; comprehensibility; manageability and meaningfulness respectively (see Table 1 ), captured participants’ experiences, and enabled them to reflect upon how collaboration processes did influence and shape these perceptions. This provides us with process-related pinpoints to describe (and maybe even facilitate for) coherent processes ( 10 , 22 ). Furthermore, applying the framework of coherence unto matters of strategic local planning addressed some of the above-described challenges with combining dialogue-based and rationalistic planning approaches and support HiAP ( 2 , 12 , 13 , 16 ). For example, opportunities to develop relevant knowledge through the applied processes was linked to perceptions of coherence and ownership, social cohesion and “ being on the same team ”. These notions are linked to dialogue-based planning, aiming at more democratic processes and experiences of social cohesion during collaboration ( 2 , 13 , 14 ). Meanwhile, stakeholders also described how their understandings and raised awareness of how activities contributed to resolve challenges and realize aims increased during the project. Such perceptions, linked to making a difference, being on the right track and contribute to realize shared aims were described as important aspects of coherence. Thus, the framework simultaneously highlights matters of goal-attainment, emphasized in strategic planning literature ( 2 ), as well as matters of empowerment, democratic organization and social cohesion, as emphasized in dialogue-based planning approaches ( 12 , 13 ). It thereby provides a valid framework to realize the intentions of strategic planning for HiAP, enables collaborators to work independently over time towards shared, long-term objectives, and facilitates for organizational learning ( 14 , 16 ). Utilizing the framework to outline approaches Applying the dimensions of comprehensibility, manageability and meaningfulness unto processes and assets allows to approach these issues from distinct, yet inter-related perspectives: For example, knowledge about PHW emerged as a major asset for comprehensibility, such as making sense of the complex field and outline approaches, as well as for manageability through the development of coherent agency and experiencing support from the wider municipality, along with meaningfulness through perceptions of being on the right track and positive feedback from others. This illustrates how the intertwined nature of the dimensions enables us to address the issue from any of these perspectives: teaching and learning about PHW can contribute to meaningfulness through experiences of learning and growing , while enhancing comprehensibility through awareness of shared goals and knowledge about valid approaches ; thereby supporting manageability through better knowledge about resources and the experience of supportive structures - based on shared knowledge about PHW- which, again, can promote meaningfulness through visible contributions and perceptions of social cohesion . Providing collaborators and stakeholders with relevant disciplinary knowledge seemed to initiate an upwards-spiral, in which this knowledge became a resource for developing coherent perspectives across all three dimensions- and apply these to outline and pursue coherent approaches in the local context ( 19 – 22 ). In Salutogenesis, experiences touching into matters of comprehensibility, manageability and meaningfulness are described as “significant life events” crucial for the development of generalized resistance resources- thus, resolving such challenges contribute to strengthen SOC and enable healthy future coping ( 20 , 21 , 23 ). Identifying such “entry points” for facilitating coherent experiences might thus be a valuable approach to build coherence locally, as it enables us to address matters of comprehensibility, manageability and meaningfulness simultaneously, thereby hopefully fueling a salutogenic development in actors as well as in the organization. Unravelling these impacts thereby allows to outline approaches for targeted interventions along the three dimensions. Activating resources Next, manageability emerged as the most challenging dimension: Difficulties s with being able to activate and adapt resources did pose major challenges for the development of coherent agency for PHW and the establishment of systematic processes locally. Partly, this focus on manageability might be due to the professional, goal-oriented context (see also “methodological considerations”). However, difficulties with being prioritized economically in the municipal context implied to apply for external, project-based funding, demanding to pursue (top-down defined) specific goals, approaches or tools; or to target specific groups- all of which are defined top-down, thereby challenging perceptions of coherence and hazarding for personal as well as organizational learning ( 17 , 33 ). Turned around, and in line with the above argument that improvements in one dimension might contribute to changes on the other dimensions, do we argue that a focus on increasing manageability also can contribute to facilitate for comprehensibility and meaningfulness; e g. by allowing actors to gain experiences that improve their practice and develop a deeper understandings about PHW ( 33 ). Besides funding did resources such as having dedicated time, firmly anchored aims, personal competence, authority as well as joined and mutual learning opportunities emerge as major resources. Providing collaborators with specific aims and coherent “roadmaps” outlining their contributions and valid approaches might make major contributions in this regard, especially in respect to enabling collaborators without profound knowledge about PHW to develop coherent agency ( 10 , 11 , 32 ). Municipal structure and -culture emerge as possible barriers, as well as central assets: Perceiving that efforts are supported even indirectly in the municipal organization is especially important in this context, which emphasizes broad coalitions and systematic changes ( 1 , 6 ). Supportive structures also emerges as a central asset in the face of the so-called “wicked problems” and organizational resistance to change even if changes are implemented in one part of the (municipal) system, are other parts still designed to maintain the status quo, and would as such often hinder or even draw-back changes ( 6 , 15 ). Here, the above-described knowledge about PHW in the organization facilitated for perceptions of structures that support PHW through political, public and administrative attention, thus emerging as a major asset for perceptions of manageability, as well as for maintained motivation to engage in PHW (meaningfulness). Anchoring approaches Taken together, awareness about aims, ways to activate resources and visible support for local PHW can make major contributions to more coherent approaches ( 10 , 18 ). This again highlights matter of anchoring and embedding approaches in agreed-upon strategies as a beneficial approach to providing a valid and shared framework that links efforts firmly to higher-level obligations and thereby, hopefully increases political and financial support ( 18 , 22 ). Simultaneously, such strategies work best if there is high commitment to goals and strategies throughout the organization and among actors. Utilizing strategic goals also holds the danger of linking them tightly to political matters and thus, potentially contribute to polarization ( 18 , 22 ). This implies that approaches can lose political support due to shifts in the political majority, which is a major barrier for systematic approaches over time. Simultaneously, actors might experience conflict between shared approaches and personal values and/or moral believes. Such experiences are a barrier for committing to shared efforts and might cause internal conflict or moral tension which threatens actors’ motivation and perceptions of coherence ( 10 , 20 ). Careful screening of the social context and sensitivity for diverse believes during the development of shared goals can help to mitigate this risk. Even focusing on local issues, rather than issues that are discussed and decided at higher levels, can help to reduce tension and emphasize common aspirations. For example, actors from rural communities often easily agreed on goals linked to local thriving and social cohesion- helping collaborators to move beyond political divisions and engage in a common effort ( 18 , 22 ). The importance of including stakeholders in relevant processes is emphasized: Being actively involved in staking out the way is directly linked to perceptions of meaningfulness and increases ownership over approaches simultaneously as this also contributes to comprehensibility (understanding the purpose of processes etc.) and manageability (providing relevant structures and resources). All in all, do findings indicate that applying Salutogenesis and its inherent framework of coherence unto collaboration processes for PHW yielded meaningful results, which help us to understand what is going on during collaboration, and how processes and structures can contribute or hazard for coherent experiences. Below, we discuss methodological issues, before summarizing our insights by providing implications for practice as well as research. Methodological considerations This project builds on a co-creation approach (CAR). Deemed a beneficial approach to ensure the development of relevant and applicable knowledge ( 25 ), can this strategy also increase the risk to encounter conflict-of-interests: Pointing out challenges can be experienced as stigmatizing by collaborators, implying that researchers have to be cautious about how findings are framed and communicated to not hazard research aims or damage trust between collaborators. In this project, the established long-term collaboration, and the strong focus on joined and mutual learning over time contributed to diminish this issue, and provided practitioners with a safe context to discuss their experiences and share valuable knowledge with the researchers. Another possible draw-back of this approach is linked to generalizability: Is locally developed knowledge valid for other municipalities, and/or planning processes in other regions and nations? Can insights be applied beyond the local context? A rigorous and explicit application of theory contributes to meet these challenges, as it allows to develop general knowledge about actors` experiences and perceptions, while reflecting (varying) processes. For example, having a clear mental representation of one’s role and responsibilities might be an important pre-requisite for outlining approaches to any issue across contexts. How this mental representation can be achieved through applied processes might, however, differ across municipalities, regions and nations. In a related issue, the generalizability of findings beyond the setting of PHW can be challenging, for example, manageability emerged as the most important dimension of coherence, challenging earlier assumptions about meaningfulness being “the most important dimension” of coherence ( 20 ). This might reflect priorities in the setting of PHW, which is by large a professional, goal -oriented setting occupied with resolving challenges ( 3 ). Thus, the relative importance of the three dimensions might vary across contexts, which again highlights the importance of understanding coherence as an interplay between actors and settings ( 22 ). Next, applying an abductive approach during analysis increases dangers of confirmation bias or applying non-circular processes in which theory guides the development of insights ( 28 ). To mitigate this risk, participants were asked to validate, as well as reflect upon and apply emerging concepts back unto described processes to expose shortcomings and contradictions in the emerging understanding, which then must be examined critically in the further process. Implications for practice Findings indicate that it is possible to facilitate coherent experiences during the planning and implementation of PHW. Based on the above-presented findings and discussion, the following recommendations for practice can be made: Coherence is developed in the interplay between actors, settings and processes, emphasizing the importance of stakeholder-involvement and co-creation to support the development of coherent perspectives and approaches in actors as well as the municipal organization. Manageability emerges as the most challenging dimension for PHW. Increasing prioritization and availability of crucial resources for PHW might make major contributions to more systematic, coherent and locally anchored approaches. Unravelling matters of comprehensibility, manageability and meaningfulness can contribute to facilitate for describing coherence at a process- and settings-level and to outline tailored approaches. Anticipating mutual influences and possible synergies between the three dimensions of coherence is advised and can be utilized to initiate a positive development: Resources and activities touching into all three dimensions of coherence provide interesting entry points fuel an upwards spiral towards more coherent approaches. In this article, entry points such as a.) anchoring knowledge and approaches in municipal plans and the wider organization; b.) the structure, timing and content of collaboration activities, as well as c.) the presence of relevant feed-back loops are identified: Knowledge and awareness about shared aims for PHW were closely linked to comprehensibility but also emphasized in the context of manageability and meaningfulness. Anchoring and embedding approaches in such agreed-upon aims links efforts firmly to higher-level obligations, and can increase prioritization, political support and the availability of resources. Moreover, providing sector- and level-specific roadmaps makes major contributions the development of coherent agency and thereby, enables collaborators to work independently over time towards shared aims ( 32 ). Collaboration activities that contribute to shared and/or mutual learning, as well as activities that develop and define local aims, approaches and strategies emerge as crucial assets for learning how to approach the issue as an organization and from the individual position; as well as to facilitating for experiences of social cohesion and support within municipalities. The existence of feed-back loops in the municipal organization was linked to perceptions of visibility of efforts and contributions; as well as disciplinary knowledge and perceptions of being on the right track and making a difference. Feedback loops enabled actors to see how their efforts are received and impact municipal organization, deepening comprehensibility, manageability and meaningfulness simultaneously. They emerged as crucial assets for maintaining coherent perspectives and -agency over time; and help to navigate changing conditions; adverse side-effects and/or applying new knowledge, as often encountered during long-term efforts. Taken together, applying the framework of Salutogenesis yielded interesting insights, and highlights the importance of applying coherent processes during planning for PHW. More knowledge about how emerging knowledge can be to facilitate for coherent planning approaches is needed. Implications for theory In this study, we applied the three dimensions of SOC to understand how experiences and processes during multi-sector collaboration for PHW contributed to perceptions of coherence. This is a new approach to applying the concept of SOC; which has earlier been understood and treated as more or less stable individual resource ( 20 , 21 ) enabling healthy coping ( 34 ): Instead of linking perceptions of coherence to individual SOC, we here use the framework to describe the development of coherent perspective during multi-sector collaboration for PHW. Matters of coherence are thereby moved from a more-or-less individual to a relational understanding, which is already anticipated in the original framework ( 20 , 22 , 24 ): coherence is created in the interplay between people, places and processes ( 22 ). Deepening our understanding about these interrelations and mutual influences might contribute to develop Salutogenesis as a sound theory for health promotion: Anticipating that matters of coherence can be addressed beyond individual perceptions enables HP-practitioners to develop new approaches that fit the predominant settings-approach and support the implementation of HiAP locally ( 7 , 12 , 13 ). Thus, a closer look at the above-described entry points; touching all three dimensions of coherence, and unravel how characteristics, processes and activities within this setting can support such developments in individuals, settings and organizations, would make major contributions to develop a sense for coherence in the context of PHW and municipal planning ( 10 , 18 , 37 ). Moreover, developing a sense of coherent agency, a coherent understanding about how one can act to achieve desired outcomes from one’s specific position, emerges a central concept, which has not been addressed explicitly by the salutogenic literature earlier. To work as a central coping resource, perceptions must include an idea about how to address issues, an important condition for coherent agency. These issues are briefly addressed in the original literature; e.g. by pointing out that coherence is not only about perceiving stimuli as meaningful information, but also about managing to send stimuli that are received without (or little) distortion and the importance of “putting feedback into the system and see how it reacts” ( 19 , p.126) in order to develop awareness about how one can impact the situation-preferably, for better. A stronger focus on exploring matters of manageability and conditions for developing coherent agency can contribute to further develop the theoretical framework as a central theory for Health Promotion. Concluding remarks All in all, applying the framework of coherence, as described in Salutogenesis, yielded valid insights into how coherence can be understood and assessed beyond individual experiences. Linking perceptions of coherence to experiences during PHW-collaboration enables us to start outlining how such experiences can be facilitated for. A shared vision about the common aims, as well as availably of resources emerge as central resources in this context. Especially anchoring goals and procedures; the structure and content of collaboration activities (inclusive joined and mutual learning sessions) as well as the presence of feed-back loops emerge as important assets and valid entry points to facilitate for coherent experiences and processes in municipalities. The novelty of this approach lies in combining aspects of dialogue-based and strategic planning approaches: While focusing on coherent experiences and opportunities for individual sense-making, are perceptions of coherence also closely linked to goal attainment and de-facto impact of the developed approaches. It thereby answers needs to combine rationalistic and dialogue-based approaches, as voiced in the planning literature; and emerges as a beneficial approach for strategic planning ( 2 , 6 , 7 , 12 – 14 ).’ Abbreviations CAR Collaborative action research HiAP Health in all policies HP Health Ptomotion PHW Public Health Work SDG sustainable development goals SDoH Social determinants of Health SOC Sense of Coherence TMPHW Trøndelag Model of Public Health Work Declarations Ethics approval and consent to participate Research in this project was carried out in accordance with the Helsinki declaration ( https://www.wma.net/policies-post/wma-declaration-of-helsinki/ ). The project was approved by the Norwegian Agency for Shared Servies in Education and research, Sikt (sikt.no), license number 451348. All data gathering was carried out in the context of the National and regional Program for Public Health Work, informants participated in this project in their role as professionals working with PHW. An informed consent to participate was given municipal-wise through the collaboration contract signed at the start of the period; as well as individually for participation in the interviews/workshops. Funding The Program is funded by the Norwegian Directorate of Health; additional research for this study was financed by the Norwegian Research Counsil. Competing interests No competing interests were identified. Data availability This article generates and analyses new data produced in the context of the Program for Public Health Work and the specific NFR project “Evidence for action to reduce social inequalities in health”. Data is not made publicly available due to challenges with anonymization/identification of participants and participating municipalities in small populations/regions. This is done to protect the privacy of individual participants, as outlined in the given consent; as well as to avoid potential stigmatization of participating municipalities. Availability of the interview-guide The interviews were developed and conducted for the sake of the project. Data from the interviews has not been published earlier; but has informed regional co-creation and competence building workshops as part of the project (see “methods”). Material used during the workshops is not publicly available. An English translation of the interview-guide is included in the supplementary materials. Clinical trial number not applicable Author Contribution First (RM), third (GG) and last (ML) author contributed to data-gathering through interviews, and to development of the interview-guide. All four authors participates in the follow-up workshop, RM and second author (KJ) as organizers, GG and ML as facilitators. Analysis was carried out in close collaboration between RM and KJ; and emerging insights actively discussed with ML and GG ongoingly. ML acted as project leader for the main project (evidence for action to reduce social inequalities in health; NFR 302705) which constitutes the context for this research. RM (corresponding author) was the main responsible for writing the article; however, all authors made active contributions to the manuscript, and approved this version for submission. Acknowledgement We want to thank the Norwegian Directorate of Health for launching the Program for Public Health Work in Municipalities which enabled this project. Further, we deeply appreciate the efforts undertaken by the County of Trondelag to administer the regional collaboration, and to the participating municipalities for sharing their experiences and committed part-taking in the workshop and other activities informing this research. Data Availability This article generates and analyses new data produced in the context of the Program for Public Health Work and the specific NFR project “Evidence for action to reduce social inequalities in health”. Data is not made publicly available due to challenges with anonymization/identification of participants and participating municipalities in small populations/regions. This is done to protect the privacy of individual participants, as outlined in the given consent; as well as to avoid potential stigmatization of participating municipalities. References Lillefjell M, Maass REK. Involvement and multi-sectoral collaboration: applying principles of health promotion during the implementation of local policies and measures—a case study. Societies. 2021;11(4):xx–xx. Synnevåg ES, Amdam R, Fosse E. Intersectoral planning for public health: dilemmas and challenges. Int J Health Policy Manag. 2018;7(11):982–90. Act on Public Health Work (Public Health Act), LOV-2011-06-24-29 [Internet]. 2011 Jun 24 [cited 2025 Dec 17]. Available from: https://lovdata.no/dokument/NL/lov/2011-06-24-29 Lillefjell M, Anthun KS, Maass REK, Innstrand ST, Espnes GA. A salutogenic, participatory and settings-based model of research for the development and evaluation of complex interventions: the Trøndelag model for public health work. Cham: Springer Nature; 2022. Fosse E, Helgesen MK, Hagen S, Torp S. Addressing the social determinants of health at the local level: opportunities and challenges. Scand J Public Health. 2018;46(20suppl):47–52. Fosse E. Norwegian policies to reduce social inequalities in health: developments from 1987 to 2021. Scand J Public Health. 2022;50(7):882–6. Ortenzi F, Marten R, Valentine NB, Kwamie A, Rasanathan K. Whole of government and whole of society approaches: call for further research to improve population health and health equity. BMJ Glob Health. 2022;7(7):e009972. Cairney P, StDenny E, Mitchell H. The future of public health policymaking after COVID-19: a qualitative systematic review of lessons from Health in All Policies. Open Res Eur. 2021;1:13178. 10.12688/openreseurope.13178.2 . Franklin P, Greer SL, Falkenbach M. Policy coherence as a driver of health equity. Copenhagen: WHO Regional Office for Europe; 2019. Maass REK, Lillefjell M. Can the theory of salutogenesis offer a framework to enhance policy coherence during policy development and implementation in municipalities? Societies. 2022;12(3). Lillefjell M, Hope S, Anthun KS, Hermansen E, Vik JT, Sund ER, et al. Planning for health equity: how municipal strategic documents and project plans reflect intentions instructed by the Norwegian Public Health Act. Societies. 2023;13(3):74. Lindström B, Eriksson M. The salutogenic approach to the making of HiAP/healthy public policy: illustrated by a case study. Glob Health Promot. 2009;16(1):17–28. 10.1177/1757975908100747 . De Leeuw E, Lin V. Local health planning and governance. Healthy cities: the theory, policy, and practice of value-based urban planning. New York: Springer; 2017. pp. 395–405. Schmitt P, Weck S. Towards just planning: on the relationship between procedural and distributive justice in local development actions. Plan Pract Res. 2024;39(5):753–71. 10.1080/02697459.2024.2359221 . Walls HL. Wicked problems and a ‘wicked’ solution. Glob Health. 2018;14:34. 10.1186/s12992-018-0353-x . Ramirez-Rubio O, Daher C, Fanjul G, Gascon M, Mueller N, Pajín L, et al. Urban health: an example of a health in all policies approach in the context of SDGs implementation. Global Health. 2019;15(1):87. Jacobsen R. Public sector projectification–a systematic review of the literature. Scand J Public Adm. 2022;26(4):91–112. Maass R, Kiland C, Espnes GA, Lillefjell M. The application of salutogenesis in politics and public policy-making. The handbook of salutogenesis. Cham: Springer; 2022. pp. 239–48. Antonovsky A. Health, stress, and coping. San Francisco: Jossey-Bass; 1979. Antonovsky A. Unraveling the mystery of health: how people manage stress and stay well. San Francisco: Jossey-Bass; 1987. Eriksson M. The sense of coherence: the concept and its relationship to health. The handbook of salutogenesis. Cham: Springer; 2022. pp. 61–8. Maass R, Vaandrager L, Sallaway-Costello J. Salutogenesis in the context of society. In: Eriksson M, Vaandrager L, Lindström B, editors. The Hitchhiker's Guide to Salutogenesis: from the Ottawa Charter for Health Promotion to Planetary Health. Cham: Springer Nature Switzerland; 2025. pp. 89–102. Bull T, Mittelmark MB, Kanyeka NE. Assets for well-being for women living in deep poverty: through a salutogenic looking-glass. Crit Public Health. 2013;23(2):160–73. Maass REK. The neighborhood as a salutogenic setting: how can salutogenesis contribute to the development of strategies for promoting health and strengthening SOC through a focus on neighborhood-resources? [doctoral thesis]. Trondheim: NTNU; 2018. Ness O, von Heimburg D. Collaborative action research: co-constructing social change for the common good. SAGE Handbook of Social Constructionist Practice. London: Sage; 2020. pp. 34–45. Directorate of Health [Internet]. 2018 [cited 2025 Oct 14]. Available from: https://www.helsedirektoratet.no/forebygging-diagnose-og-behandling/forebygging-og-levevaner/folkehelsearbeid-i-kommunen/program-for-folkehelsearbeid-i-kommunene County. of Trøndelag [Internet]. n.y. [cited 2025 Oct 14]. Available from: https://www.trondelagfylke.no/vare-tjenester/folkehelse-idrett-frivillighet/folkehelse/programmet/ Philipsen K, Hjalager AM. Theory building using abductive search strategies. In: Freytag PV, Young L, Evald MR, editors. Collaborative research design. Cham: Springer; 2024. 10.1007/978-3-031-70149-8_3 . Dubois A, Gadde LE. Systematic combining: an abductive approach to case research. J Bus Res. 2002;55(7):553–60. 10.1016/S0148-2963(00)00195-8 . Lillefjell M, Magnus E, Knudtsen MS, Wist G, Horghagen S, Espnes GA, et al. Governance for public health and health equity: the Trøndelag model for public health work. Scand J Public Health. 2018;46(22suppl):37–47. Charmaz K. Constructing grounded theory. 2nd ed. London: Sage; 2014. Maass R, Hope S, Lillefjell M. Trickle-down policies: utilizing strategic plans to facilitate local public health work. Eur J Public Health. 2023;33(Suppl 2):ckad160–1666. Vaandrager L, Koelen M, Bouwman L. Salutogenesis in the context of learning processes. In: Eriksson M, Vaandrager L, Lindström B, editors. The Hitchhiker's Guide to Salutogenesis. Cham: Springer; 2025. Eriksson M. Key concepts in the salutogenic model of health. The handbook of salutogenesis. Cham: Springer; 2022. pp. 59–60. Cook-Sather A, Wald M. Who I am is more than enough’: how multiple forms of co-creation foster belonging and mattering for well-being. Student belonging in higher education. London: Routledge; 2025. pp. 200–15. Maass R, Kloeckner CA, Lindström B, Lillefjell M. The impact of neighborhood social capital on life satisfaction and self-rated health: a possible pathway for health promotion? Health Place. 2016;42:120–8. Meier Magistretti C, Topalidou A, Meinecke F. Sense FOR coherence–der Sinn FÜR Kohärenz: annäherungen an ein mögliches Konzept. Salutogenese kennen und verstehen. Cham: Springer; 2019. pp. 119–35. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 27 Apr, 2026 Reviews received at journal 16 Apr, 2026 Reviewers agreed at journal 13 Apr, 2026 Reviewers agreed at journal 10 Apr, 2026 Reviewers agreed at journal 09 Apr, 2026 Reviewers invited by journal 07 Jan, 2026 Editor assigned by journal 07 Jan, 2026 Editor invited by journal 07 Jan, 2026 Submission checks completed at journal 07 Jan, 2026 First submitted to journal 07 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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1","display":"","copyAsset":false,"role":"figure","size":114723,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eStrategy-of-analysis\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8395684/v1/b73fdffa6306cfa08ef760d0.png"},{"id":100381305,"identity":"651da2d5-ee41-40ba-846f-022a3a767473","added_by":"auto","created_at":"2026-01-16 10:38:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1207070,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8395684/v1/05849d8e-4161-43b6-9038-8926dfb0214e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Perceptions of coherence during planning for local Public Health Work: building capacity and developing theory through collaborative action research","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe development and implementation of Health Promotion and Public Health approaches locally demands for extensive, committed and long-term collaboration (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e–\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). This is acknowledged in the Norwegian Public Health Act; which aims for Health-in-all-Policies (HiAP) and advocates for Health Equity and a whole-of-government approach to realize these intentions (\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e–\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). HiAP implies treating health as a Human Right; recognizing the Social Determinants of health (SDoH) as major drivers of Health Inequities and emphasizes the importance of intersectoral collaboration and policy-making (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). To carry out systematic local Public Health Work (PHW) and achieve HiAP, actors across sectors and levels should be able to participate in common efforts and to pursue overarching aims independently in between shared activities (\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e–\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). This is challenged by the well-known problems with multi-sector collaboration, such as “silo-thinking”, implying different professional and contextual understandings, conflict over resources and ownership over approaches and a fragmentation of efforts (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). To achieve HiAP, these issues must be addressed during the planning, development and implementation of local policies (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Accordingly, municipal planning and local policies emerge as a central resource for local PHW (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRegional and local “strategic planning” focuses on developing and implementing plans to achieve specific long-term goals and priorities (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Strategic planning is characterized by tangible actions, implementation of measures, and the alignment of plans and policies across sectors and stakeholders (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Strategic planning thereby seeks to combine aspects of rational and dialogue-based planning approaches (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Rationalistic approaches are goal-oriented, relying on structured and knowledge/data-driven processes (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). In contrast, dialogue-based approaches view planning as a democratic process and emphasize negotiation, consensus-building and collaborative decision-making (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Power dynamics are addressed, and planning is seen as a constant process aiming at creating engagement, ownership and social cohesion. Combining these approaches is challenging, and even more so when considering increased demands to apply inclusive and participatory approaches and involve stakeholders, target audience and even the general public in the development and implementation of measures (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Participatory approaches aim at increasing health equity by addressing matters of distributional as well as procedural justice (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) and hold the potential to make major contributions to goal achievement (e.g. developing relevant resources for the local community) while applying democratic and socially inclusive processes.\u003c/p\u003e \u003cp\u003eHowever, evaluations of HiAP still reveal challenges in resolving the so-called “wicked problems”, as for example reducing health inequalities (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Wicked problems are complex, interconnected issues sustained by societal systems, where efforts to solve challenges from one part of the system often face resistance or draw-backs from others, making lasting, profound change difficult (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Attempts to implement HiAP-approaches often fail to resolve these issues due to fragmented efforts; a lack of effectiveness of measures as well as the risk of widening the gap in health and on the SDoH (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e); and a lack of financing and prioritization that reinforce tendencies of projectification (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Challenges are also linked to conflicting goals as well as lacking opportunities and resources for goal-driven activities to fulfill role obligations (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). These challenges also highlight the importance of organizational factors, such as high internal turnover: Collaborative processes that are not sufficiently incorporated into the wider organization contribute to personal learning, but fail to facilitate organizational development (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOne of the major challenges in this regard is the complexity of issues, increasing the risk of incoherent approaches that built on too-narrow perspectives (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Another main challenge lies in creating spaces for co-creation, and in achieving de-facto power sharing and collaborative decision-making (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e): Even participatory approaches, aimed at levelling out such inequalities, are heavily influenced, and do often reproduce, existing power relations (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Especially vulnerable populations experience trouble with influencing outcomes in meaningful ways, which spoils for both process- and goal-oriented benefits of inclusive approaches (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). These incoherencies contribute to perceptions of fragmentation and challenges the integration across perspectives and actions, as well as actors and levels-of-governance; and represent a major barrier for both individual and collective (e.g., municipal) capacity for action (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis highlights the importance of combining rationalistic and dialogue-based planning approaches to develop a valid framework for strategic, coherent planning contributing to policy coherence (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Policy coherence emerges as an important driver for coordinated, goal-oriented approaches supporting health equity (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Planning for policy coherence implies that development must occur within people (PHW-actors) and in their supporting surroundings (municipal organization); as well as in the relationships (activities, tasks and processes) between these. A special focus on conditions that support the development of coherent perspectives and purposeful actions across actors and sectors during the planning of policies is needed.\u003c/p\u003e \u003cp\u003eTo unravel these complex issues, Salutogenesis, the theory about “the origins of health” and it’s inherent conceptualization of “sense of coherence (SOC)” is applied (\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e–\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). In the salutogenic model, a strong SOC is a central individual resource that enables individuals to apply flexible strategies while pursuing desired outcomes (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e); a beneficial condition for being able to work independently towards common efforts. “Coherence” is conceptualized as an interplay between individual perceptions on the one, and challenges and resources provided by relevant settings and the wider societal context on the other hand (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Perceptions of coherence (SOC) are structured along the dimensions of comprehensibility, manageability and meaningfulness, which are linked to distinct experiences: Comprehensibility describes “the feeling of having a clear mental representation of what is going on and what is expected” (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) and “understanding the challenge” (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). It represents the cognitive dimension of SOC; the mental picture of the world and your place in it, developed on the base of (culturally defined) narratives and personal experiences (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Manageability is understood as the behavioral component of SOC (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), the ability to “overcome challenges” (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) and “to identify and adequately apply resources to achieve desired outcomes” (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Manageability depends on perceptions of challenges as well as available resources (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Meaningfulness is the emotional component of SOC, and describes perceptions of being engaged, “motivated to take on the challenge”; experiences of being able to influence outcomes and emotional closeness to applied values, aims and/or processes (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Applying Salutogenesis allows to unravel matters of coherence during local collaboration for PHW-work by exploring “coherence” as an interplay between individual, procedural and contextual factors (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis study aims to explore how actors involved in the development and implementation of a local public health initiative targeting children and adolescents’ mental health describe experiences of coherence and how coherent perspectives, as described by Salutogenesis, were achieved throughout the process. “Coherent perspectives” can, in this context, be understood as an outlook on local PHW as being comprehensible, manageable and meaningful, as described above.\u003c/p\u003e \u003cp\u003eFurthermore, this study critically investigates how collaboration within PHW can support coherent experiences among diverse actors across municipal contexts, with the aim of advancing the conceptual understanding of coherence as a process and informing strategic planning for policy coherence in local public health governance.\u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003eMethodologically, this study builds on co-creation and collaborative action research (CAR); a dynamic and collaborative approach to research emphasizing practical outcomes and opportunities for local capacity building (\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e). To develop relevant knowledge about how coherent experiences can be facilitated in the context of PHW, we apply a mixed methods approach with predominantly qualitative analysis-strategies. Research was carried out in the context of the national and regional initiative, Program for Public Health Work in Municipalities (\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e). Data was gathered through a series of in-depth interviews and a follow-up workshop with municipal stakeholders. Salutogenesis was used as a framework to guide the analyses and inform the follow-up workshop. An abductive approach was applied to support the data-driven development of knowledge and theory, including to further develop and expand the theoretical framework (\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eContext for research (Program for Public Health Work)\u003c/p\u003e\n\u003cp\u003eLaunched by the Norwegian Directorate of Health in 2017, the \u003cem\u003eProgram for Public Health Work in Municipalities\u003c/em\u003e is a ten-year national initiative (2017\u0026ndash;2027) aimed at building local capacity for public health efforts (\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e). The program focuses on promoting mental health and improving quality-of-life among children and youths. In the county of Trondelag, a lasting cooperation between county authorities, municipalities and a range of researchers and research- and development (R\u0026amp;D) institutions was established, providing a fruitful research context for the co-creation of knowledge and approaches for local PHW (\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e). The program emphasizes evidence-based practices and aims to reduce social health disparities through capacity-building, data-driven planning (e.g., via Ungdata surveys), and knowledge and methods for cross-sectoral cooperation. Municipalities are supported financially and organizationally to develop and implement a PHW-measure in collaboration with research environments by applying The Trondelag Model for Public Health Work (TMPHW) (\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e). The TMPHW is a structured, evidence-based framework for local public health work that operationalizes systematic methods for translating knowledge into targeted interventions; and integrates cross-sectoral collaboration and participatory processes to support a sustainable community development.\u003c/p\u003e\n\u003cp\u003eData gathering\u003c/p\u003e\n\u003ch3\u003eInterviews\u003c/h3\u003e\n\u003cp\u003eIn-depth interviews with key stakeholders were conducted in 8 municipalities. Stakeholders were recruited strategically, based on having similar roles and responsibilities within their municipality, and included: a) mayors (political leaders); b) administrative leaders c) Chief Municipal Executives d) Public Health Coordinators; e) Project leader/collaborators. Interviews were conducted in two waves; the first (2017) conducted before, and the second (2022) after the measure had been implemented. An interview-guide (see supplementary materials) focusing on experiences during collaboration linked to the implementation of a local measure was developed and applied rigorously. As our main interest was in how planning and implementation processes were experienced; only interviews from wave 2 (n\u0026thinsp;=\u0026thinsp;29) were analyzed for this paper.\u003c/p\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003eWorkshop\u003c/h2\u003e\n\u003cp\u003eAfter the initial phase-of-analysis, emerging understandings were communicated and discussed in a half-day workshop with municipal stakeholders. The workshop was coordinated with other activities in the Program, and conducted in collaboration with regional authorities. Forty (n\u0026thinsp;=\u0026thinsp;40) Stakeholders (including Public Health Coordinators, administrative leaders, project participants etc.) from regional municipalities participated.\u003c/p\u003e\n\u003cp\u003eThe first part of the workshop aimed at validating emerging findings, both in respect to securing that emerging understandings represent the lived experience in municipalities, and in respect to relevance of the applied theory: while understandings by large had emerged bottom-up during the analysis of the interviews, participants now were invited to reflect upon the previously described dimensions from a top-down viewpoint. Each dimension was presented individually and illustrated by quotes from the interviews. Participants were then encouraged to reflect upon related experiences and perceptions from the collaboration around the local PHW-measure, and to begin exploring how the framework could be applied to analyze processes and local approaches.\u003c/p\u003e\n\u003cp\u003eDiscussions took place in fixed groups, consisting of participants from different municipalities to increase diversity of experiences. Paper and pens were provided at each table, and the groups were encouraged to produce notes/thoughts-charts etc. during the discussions. A researcher was seated at every table to facilitate the discussion and take further notes. All written and graphic materials were collected and informed subsequent steps-of-analysis.\u003c/p\u003e\n\u003cp\u003eStrategy-of-analysis\u003c/p\u003e\n\u003cp\u003eAnalysis was carried out in a co-creation approach between researchers and practice; and follows by large an abductive approach (\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e). Initial analysis, aiming at making sense of the gathered data and developing a broad picture of what is going on, was carried out by the first and the last author (both researchers). Analysis began with an inductive exploration of the open interviews, allowing themes to emerge from participants\u0026rsquo; lived experiences. In the next step, these insights were structured deductively by applying the theory of Salutogenesis and the dimensions of coherence (\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e) in a co-creation approach between researchers and a municipal planner (2nd author); to ensure the development of context- sensitive knowledge as well as the relevance and applicability of emerging findings.\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eData was prepared and presented for validation in a follow-up workshop; in which participants were asked to reflect on their experiences in light of the theory. This iterative movement between data and theory enabled the refinement and expansion of the original framework, grounded in empirical understanding. Here, elements of constructivist Grounded Theory, such as constant comparison and focused coding, were applied to ensure that theoretical advancements are firmly grounded in the empirical material (\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eInterviews\u003c/h3\u003e\n\u003cp\u003eInitial coding consisted of an inductive, contextual content analysis of the interview data to develop knowledge about how coherent perceptions of the setting (PHW) are described and achieved from various positions in the municipal organization (\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e). The aim was to describe and link individual perceptions of coherence and experiences made in the context of PHW through constant comparison, and develop an initial understanding about what is going on in this context.\u003c/p\u003e\n\u003cp\u003eThe framework for the deductive part of analysis was developed based on the 3-factor model of coherence as described in Salutogenesis: \u003cem\u003eComprehensibility\u003c/em\u003e was operationalized as notions of professional, contextual and generic understandings and knowledge, as well as experiences of how these understandings were developed during the project. Such experiences were interpreted as pinpoints towards the experience and development of comprehensibility. \u003cem\u003eManageability\u003c/em\u003e was understood as perceptions of challenges and available resources; as well as experiences of resolving (or not resolving) challenges during the project. \u003cem\u003eMeaningfulness\u003c/em\u003e was assessed through tales of being motivated (or not) to engage in the collaboration; perceptions of the approach \u0026ldquo;making sense\u0026rdquo; and notions of ownership. This operationalization provided the base for focused coding (\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e); linking experiences and perceptions during PHW closer to the applied framework and facilitating for new knowledge (hypothesis) to emerge.\u003c/p\u003e\n\u003ch3\u003eWorkshop\u003c/h3\u003e\n\u003cp\u003eThe aim of the workshop was a) to validate emerging findings and b) link experiences closer to processes and structures during PHW, to start exploring if and how the framework might support analysis and the facilitation of coherent experiences for various actors throughout the described processes. The workshop was conducted and analyzed in close collaboration between researchers and practice. During analysis, practice partners were responsible to ensure that emerging knowledge is relevant and applicable for local PHW; while researchers were responsible for grounding emerging insights in the theoretical framework. Notes from researchers and notes produced at the tables were analyzed in an abductive approach, examining if the applied framework structures and explains experiences in meaningful ways; exploring if this application provides new insights into the complex interplay between people and processes; and examining if and how the theoretical framework might be further developed to enhance it\u0026rsquo;s relevance and practical applicability within the field of local HP-work (\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e). In line with principles from constructivist grounded theory (\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e), the focus is on allowing empirical findings to inform and refine the theoretical framework, increasing its contextual sensitivity and potential for use in practice.\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes main findings and provides some insights into how categories were developed in dialogue between theory and data: The right column; \u0026ldquo;What is this about\u0026rdquo; illustrates themes (initial codes) that emerged from the inductive bottom-up analysis of interviews and validation during the workshop; while the left column \u0026ldquo;Dimensions of SOC\u0026rdquo; displays the theoretical dimension of coherence that these experiences were associated with during the deductive part of the workshop and further analysis. Main findings, the categories developed through focused coding and theory-development, are displayed in the middle column and understood as \u0026ldquo;operationalizations of the dimensions in the context of PHW\u0026rdquo;.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eoperationalizing coherence in the context of PHW\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eDimen-sion of SOC\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eOperationalisa-tion in respect to PHW/multi-sector collab\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eWhat is this about?\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"7\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eComprehensibility\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eAwareness of shared goals\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWhat are we trying to achieve? What is our aim? What objectives do we pursuit do fulfill this aim?\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eKnowledge about how to achieve them\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHow do we approach the issue? What kind of perspectives, methods, tools etc do we apply? How? What kind of resources do we need?\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eDisciplinary knowledge\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWhat is the state-of-the-art? What are a valid approaches to achieve our goals? What do we know about downfalls and how to avoid them?\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eContextual knowledge\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWhat are resources and challenges in this context? Who participates, and in which role(s)? How can I activate resources (who do I need to talk to)? What kind of structures, processes etc do exist?\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eRoles and responsibilities\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHow can I impact the issue from my position? What is my role in the collaboration? What are my responsibilities?\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eTasks and activities\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWhich tasks, activities, (part)-goals etc are my responsibility? How do these align with other activities tasks etc? What do collaborators expect me to do?\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eContributions\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHow do my tasks and responsibilities contribute to the shared aim? How do they contribute to avoid challenges?\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"7\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eManageability\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eOvercome-able challenges\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eIs the challenge resolve-able? Can we (contribute to) resolve it here, in this context?\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eResources\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCan we resolve the challenge with the resources available in this context? How do we need to apply the resources in order to resolve the challenge?\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eIdentification\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHow can we identify valid resources? What are the valid resources in this context? Where can we find them in this context?\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eDistribution/\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eActivation\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAre resources available (for me or collaborators)? Are they easily accessible (for me or collaborators)? How can we activate/access resources? How are resources distributed- and how does the distribution happen?\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eAdequacy\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAre the resources I can access valid for our purpose? Do they fit aims, target group and context? If not, can they be adapted to be more adequate?\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eSupportive structures\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDo I have support (practically and emotionally) for my tasks and responsibilities in the structures around me- colleagues; tools, utilize-able processes etc? Can I assume that my efforts will be met with support (or with sabotage)? Can I expect others to do tasks and take their responsibilities to fulfill shared aims- and run processes as planned?\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003ePersonal competence\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWhat do I know about the issue- the approach, the target group and the local context? What other personal resources do I have that might be valuable? How can I utilize this knowledge and resources to achieve goals and contribute to shared aims?\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"15\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eMeaningfulness\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eInfluence outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAm I able to participate in shaping the process, aims and approaches; influence over structures, specific aims etc. we are going to pursue during these processes?\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eFor me or significant others\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAm I actively involved in outlining my own role and responsibilities; shape (part) and sector-specific aims and approaches identifying and activating resources for our contributions?\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eIn the organisation\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCan I participate in negotiating shared aims; distributing responsibilities and tasks and identifying and activating resources? Are we able to adapt/innovate/abolish existing structures (plans, processes, activities)?\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eMaking a difference (on the shared aim)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCan we make sound contributions to resolve identified challenges and to achieving the shared and specific aims- Goal achievement!\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eMattering\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePerceptions of being personally (or organisatorically, e.g. public health coordinator) important for making achievements, being valued for contributions, \u0026ldquo;would not have happened without you\u0026rdquo;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eVisibility of contributions\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eIt is visible for myself and others how I (we) contribute to resolve challenges and achieve the shared goal. Our specific goals are linked to the shared aim.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eVisibility of impact\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eIt is visible for myself and others how my contributions impact goal-attainment an to resolving challenges: our contributions make a difference for the target group (and the local context)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eVisibility of Co-benefits\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eIt is visible for myself and others how my contributions can benefit other parts of the project/organization; how I support goal-attainment beyond my (sector-) specific goals and act as supportive structure for collaborators or other parts of the organisation\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eDo what is \u0026ldquo;right\u0026rdquo;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePerceptions of doing the right thing, being confident that aims and approaches are valid and match.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eDisciplinary/\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStrategically\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eIs there a clear connection between the overarching and specific goals? Are applied approaches, methods and tools in line with the state-of-the-art? Do approaches align strategically with overarching aims or developments in the local context?\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eEthical/morally\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOur goals, aims and approaches reflect the overarching values I hold personally and/or the values we agree upon as an organization and as collaborators. There are clear congruencies between these levels-of-values; and moral conflict can be resolved in satisfactory manners\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eLearning and growing\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePerception of developing personally and/or as an organization, learning and growing (modning); being able to see progress in respect to competence, developing expertise and a repertoire of strategies that can help to resolve later challenges.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003ePersonally\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePerception of developing personally, learning and growing (modning); \u0026ldquo;becoming good as something, developing expertise and a repertoire of strategies that can help to resolve later challenges.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eAs an organisation\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePerception of developing an organization; becoming better at resolving challenges and work across sectors and levels; utilizing, adapting and/or innovating structures to implement emerging knowledge about approaches, activities etc; developing a repertoire of strategies that can help to resolve later challenges.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eSocial cohesion and support\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eI am part of team that pursues shared values. I feel connected and appreciated by co-workers and collaborators. I believe that my social relationships can contribute to cope with future challenges.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIn this section, we first give a short overview over how the context of PHW is described throughout the interviews and during the workshop, and outline main challenges for coherence and coherent experiences during PHW. Then, we describe how comprehensibility, manageability and meaningfulness are experienced and add to perceptions of coherent processes individually, and in relation to the mutual interdependence of these dimensions of coherence (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe setting: Public Health Work\u003c/p\u003e \u003cp\u003ePublic Health Work was by large described as profoundly fragmented by participants:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eIt is hard. All the time the responsibility to try and influence the systematic work\u0026hellip; but if the system is constantly changing, it\u0026rsquo;s like, you finally manage to establish a system, and then suddenly the ground is pulled out under your feet- new people come in, and they don\u0026rsquo;t have the background knowledge, not like the ones that have left. New leaders, that do not share a history with me or the few others that are still there. [They] talk about Public health from their prior knowledge, which does not necessarily fit with the others\u0026rsquo; conceptions. [We also meet] quite some resistance from leaders that come from other places; they want to implement things they have experienced to work in a different context, but that might not work as good in a smaller context. It takes a long time before we talk the same language\u003c/em\u003e!\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis description of PHW was supported across municipalities: participants described fragmentation in time, across actors, goals and objectives, approaches and methods, as well as economic funding: \u003cem\u003e\u0026ldquo;Support for Public Health Work can be high on paper; but as soon as we are talking about funding or prioritizing measures, Public Health is often skipped\u0026rdquo;.\u003c/em\u003e To ensure financing often demanded to participate in externally funded projects; which again demands to adopt top-down defined goals, approaches or methods (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). This carries the risk of applying approaches that fail to address local challenges, and experiencing frequent shift in focus or methods, reinforcing perceptions of fragmentation. When methods are motivated by the need to secure external funding, it limits actors to develop familiarity, competence and confidence in their work (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMeasures were often described as short-lived and could appear isolated, with no lasting impact on municipal organization or processes. Even the establishment of positions (jobs) was often linked to and limited by project-periods and -funding. Thus, depending on external resources which demand the adoption of top-down objectives and means also implies that PHW is sensitive to changes in the political agenda and support (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Moreover, even if goals and ambitions for Public Health are emphasized in overarching documents; the development and implementation of measures targeting these goals are often lacking or insufficient.\u003c/p\u003e \u003cp\u003eAdditionally, fragmentation of Public Health Work is described in relation to municipal organization and the so-called sectorial \u0026ldquo;silos\u0026rdquo;, representing a barrier for effective collaboration (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e):\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eWe have a competent director in the municipality, who is actively challenging silo-thinking. In the weekly gathering for administrative leaders, a lot of focus linked to developing the organization is about being good at working together across sectors and levels. (\u0026hellip;) Earlier, you worked within your silo, and maybe you worked on the same issues without knowing about each other. And maybe some measures even counter-acted approaches in other sectors!\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis illustrates how a lack of knowledge about what is going on in other sectors might imply both parallel and conflicting approaches, hazarding for effectiveness and possible synergies of efforts. During the workshops, perceptions of \u0026ldquo;fragmentation\u0026rdquo; were described in respect to the applied knowledge-base; in persons, time, funding and applied approaches, as well as between overarching and sector-specific goals and plans and between \u0026ldquo;project\u0026rdquo;- and \u0026ldquo;every-day\u0026rdquo; -work.\u003c/p\u003e \u003cp\u003eThese experiences mirror well-known challenges linked to silo-thinking; including differing understanding of challenges and possible solutions; unclear responsibilities; a lack of resources (distributed through internal competition) and isolated efforts, that fail to inform or impact the wider municipal environment (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). This demands PH-workers to continuously follow-up and anchor their work, which is experienced as tiresome and a kind of \u0026ldquo;Sissyphous\u0026rdquo;-work that never ends and seldom yields meaningful results:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI looked at the numbers, and involvement and everything\u0026hellip;we had to take many rounds before we figured out what we can do. Then, we conducted the search conference, but that was way too early, so we did not agree on a measure, as we were supposed to. We also had a working group, but the brainstorming session was too big so we did not manage to sketch a measure that could be evaluated. We were in that phase for quite a long time\u0026hellip;. In the end, we had to start over again. We announced we were going to screen the services, to find out where the problem is. We made a huge effort there! That also increased knowledge about us across the services. And with that background, we were able to develop a measure. However, the challenge was that no one was responsible for the whole thing, and the coordination with families in vulnerable situations, in respect to marginalization. Everyone found it hard to take responsibility if they perceived others to be responsible.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSuch perceptions represent a barrier for progress and developing feelings of competence in itself, and challenge perceptions of meaningfulness and the development of coherent perspectives during PHW (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). All in all, findings suggest that fragmentation challenges coherence and the development of coherent perspectives both on the organizational and on the personal level; thereby emerging as a main barrier for systematic developmental work.\u003c/p\u003e \u003cp\u003eCoherent experiences during PHW\u003c/p\u003e \u003cp\u003eIn this section, we disclose participants\u0026rsquo; descriptions of aspects of comprehensibility, manageability and meaningfulness during local collaboration, as well as participants\u0026rsquo; reflections about how these contributed to resolving some of the challenges brought by the above-described fragmentation of local PHW.\u003c/p\u003e \u003cp\u003eAll in all, participants described the proposed framework as valid and relevant for describing their lived experiences. Participants also described that perceptions of coherence in respect to PHW increased during the project period; indicating that experiences from the collaboration contributed to the development of more coherent perspectives about PHW also beyond the specific project.\u003c/p\u003e \u003cp\u003eBelow, we want to describe each dimension, and how it is experienced during multi-sector collaboration in- depth.\u003c/p\u003e \u003cp\u003eComprehensibility- to understand\u003c/p\u003e \u003cp\u003eFindings indicate that comprehensibility in respect to local PHW is about having an idea about \u0026ldquo;the bigger picture\u0026rdquo;, what PHW is and what one wants to achieve within the local context, how to approach the issue (develop coherent agency) as an organization, as well as having a sound idea about how oneself might contribute to the common effort. As shown in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e; are such perceptions linked to 1.) Awareness of shared goals; 2.) Knowledge about how to achieve them (disciplinary and contextual), and 3. Awareness of role and responsibilities; including specific tasks and activities, as well as understanding how these contribute to the common effort.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAwareness of shared goals\u003c/h3\u003e\n\u003cp\u003eAwareness of shared goals was tightly linked to knowledge about PHW. Participants emphasized the importance of having a sound understanding about Public Health:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eThe most important thing, that is to understand what Public Health is. That Public Health, that\u0026rsquo;s everything we do! That those around us have to thrive so we can thrive as well\u0026hellip; It\u0026rsquo;s important that politicians understand the whole picture: Public Health is about life!\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePublic health and PHW were consistently framed as \u0026ldquo;complex matters\u0026rdquo;, with a huge range of approaches and understandings present in the field. Moving beyond narrow understandings of health promotion and life-style based approaches was considered essential to fulfill Program obligations (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) and pursue valid goals within HP and health equity (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAccordingly, participants described that they used a lot of time and effort to increase their competence about PHW; to teach and inform collaborators, decision-makers and others in the wider municipal context; and to anchor broad understandings of PHW in municipal documents and plans (compare 1, 11). Setting valid, knowledge-based and locally relevant aims for the whole organization played a major role in this regard, according to participants. Having common goals to relate to enabled collaborators to outline strategies as to how to pursue these goals from their position, which is a pre-requisite for independent efforts (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Moreover, participants described how common aims contributed to manageability by providing more support in the surrounding structures (compare \u0026ldquo;manageability\u0026rdquo;), as well as to meaningfulness through positive feedback and the visibility of contributions (compare \u0026ldquo;meaningfulness\u0026rdquo;). This emphasizes the intertwined nature of the dimensions, which is already anticipated in the original literature (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eRoles and responsibilities\u003c/h3\u003e\n\u003cp\u003eMeanwhile, even if establishing common aims seems to benefit shared understandings about where \u0026ldquo;we\u0026rdquo; want to go, outlining how \u0026ldquo;I\u0026rdquo; can contribute to get us there requires a certain idea about valid approaches. The need to deepen one\u0026rsquo;s understanding about PHW was often highlighted by insecurities regarding how to approach issues:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWhen we started, it was so unbelievable open, that we did not have a clue where to begin. The definition was so broad, we did use a lot of time to find out what we were supposed to do!\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants described that roles and responsibilities regarding PHW often were unclear at the beginning of the project period, or when they started in a job linked to PHW. However, this uncertainty was not always framed as a draw-back; some participants even emphasized the process of \u0026ldquo;finding out\u0026rdquo; as a positive experience: \u0026ldquo;\u003cem\u003eI figured out what was expected of me along the way. I like responsibilities and tasks, we paved the way along as we marched!\u0026rdquo;.\u003c/em\u003e In line with research on salutogenic learning, \u0026ldquo;paving your own way\u0026rdquo; and learn through reflection and experience can increase notions of ownership and competence; and increase the likelihood that collaborators are engaged and find meaning in the tasks and activities they are assigned (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eKnowledge about how to achieve aims\u003c/h2\u003e \u003cp\u003eTo be able to take part in outlining one\u0026rsquo;s own role and responsibilities craves an understanding about how goals can be achieved, which is partly linked to the above-described disciplinary understanding of PHW (knowledge about valid approaches and tools, e.g.). Participants who initially lacked this knowledge regularly described how they developed their understanding during the applied processes; such as joined and mutual learning activities. However, disciplinary understandings about broad relationships were not sufficient for understanding how matters can be approached in the local context, and how one can contribute from the specific position in the municipal organization:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026laquo;It\u0026rsquo;s important to know, like facts, how things are around here- if not, you don\u0026rsquo;t know where to place efforts! It\u0026rsquo;s important to understand municipalities, how a municipality works. Important to know people. Alone, you\u0026rsquo;ll get nowhere. Knowledge about relationships and causal relations, so you understand what can impact what and in which direction.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis includes knowledge about the municipality and it\u0026rsquo;s organization, as well as knowledge about collaboration processes: who is involved, when, how, and to which purpose? Contextual knowledge, such as being aware of local conflicts and/or interests, was also described as crucial to understand how approaches might be met in the local context. This also includes to have a sound understanding about how activities in other sectors or levels might impact approaches: for example, planning for intensive involvement of youths during exam-periods hazards manageability, thereby adding to incoherent approaches. Contextual and process- knowledge was described as crucial to be able to identify and activate resources (see \u0026ldquo;manageability\u0026rdquo;) as well as to outline valid tasks and activities to pursue common goals (and avoid unforeseen draw-backs due to local issues). Thus, while disciplinary knowledge supports coherent understanding about how to approach issues; is contextual knowledge also crucial for developing coherent agency: a coherent and context-sensitive understanding about how we get from where we are to where we want to be.\u003c/p\u003e \u003cp\u003eManageability- to handle\u003c/p\u003e \u003cp\u003eMatters of manageability, how challenges are approached and resolved (or not), emerged as a central theme throughout the data material. Perceptions of manageability were linked to perceiving challenges as overcome-able, as well as the availability of relevant resources. Thus, according to Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, manageability during local PHW was linked to 1.) outlining overcome-able challenges; 2.) perceived availability of resources, including aspects of a.) identification, b) distribution (activation) and c.) adequacy of resources; 3.) supportive structures in the wider municipal environment and 4.) personal competence, including aspects of disciplinary and contextual knowledge (compare \u0026ldquo;comprehensibility\u0026rdquo;).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eOvercome-able challenges\u003c/h2\u003e \u003cp\u003eThe importance of perceiving challenges as overcome-able became visible at many levels during analysis. For example, participants expressed concerns in respect to new approaches, goals etc. adding extra hassles and increasing work-load. Meanwhile, anticipations of \u0026ldquo;extra hassles\u0026rdquo; were often turned into experiences of gaining resources and raising capacity in the long run:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It works quite well, and has become a stronger collaboration. We were quite conscious about not creating new groups, but rather utilize already-composed ones. I mean, we did create some new groups to work with the volunteer sector. But the collaboration between health and school has been good all along. It worked really well. (\u0026hellip;) But then we needed a broader group for the hearing processes around the measure; with people from the cultural sector and many more. (\u0026hellip;). Here, we have good, systematic approaches.\u0026raquo;\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis illustrates how perceived challenges can develop into resources if they are resolved. This is in line with salutogenic theory, which described stressors and resources as \u0026ldquo;two sides of the same coin\u0026rdquo; (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Moreover, experiences of overcoming and resolving challenges promotes the believe that also later challenges can be overcome (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Perceiving challenges as resolve-able is a crucial condition for perceptions of manageability; and for engaging in trying to resolve them. In this regard, the overarching aim of the Program, \u0026ldquo;\u003cem\u003eto reduce inequalities in health\u003c/em\u003e\u0026rdquo;, was repeatedly framed and understood as \u0026ldquo;\u003cem\u003etoo big\u003c/em\u003e\u0026rdquo; an issue to be resolved through single measures, or even in the local context. Accordingly, unravelling how a specific project can contribute to this overarching goal was a major issue during collaboration: translating overarching aims into locally resolvable challenges was crucial for understanding how the challenges can be approached, and raised motivation to engage in the common effort through expectations of success (rather than failure or insufficiency) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). In this context, defining resolvable challenges and outline responsibilities (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), as also described under comprehensibility, was described as beneficial:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026laquo;Far too often do we develop plans that never get to become anything else than a plan- we have a job to do when it comes to emphasizing that this is a working plan, that is meant to be realized! To make the plan so specific) that we can just tick whatever we have realized\u0026hellip;A clear plan for implementation. And emphasize it. That\u0026rsquo;s the recipe!\u0026raquo;\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThus, how challenges were perceived and framed in the local context had major implications for how issues were approached and perceived by collaborators. Perceiving challenges as resolvable, and having a clear mental and/or organizational plan about how the issue can be approached from one\u0026rsquo;s position is a major pre-requisite for developing coherent agency: the capacity to overcome challenges in ways that contribute to pursue goals and supports a favorable development for the individual and it\u0026rsquo;s surroundings (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Coherent agency is a central condition for being able to pursue goals and work independently towards common aims, which has earlier been described as important for collaboration (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). As illustrated above, developing coherent agency is highly influenced by matters of comprehensibility, as well as by earlier experiences of resolving challenges. This also illustrates how matters of manageability (the believe to be able to resolve a challenge) are intertwined with matters of meaningfulness (motivation to engage in resolving the challenge) and comprehensibility (understanding how the challenge can be approached). However, resolving challenges is not only linked to understanding how; it also depends on having the resources at hand that are needed to realize intentions (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eResources and personal competence\u003c/h2\u003e \u003cp\u003eIn line with theory, matters of being able to identify and activate resources in the local context emerged as central assets for PHW (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Being able to identify resources was partly linked to disciplinary and contextual knowledge; and did thus also reflect personal competence:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI have a professional background, that helps me understand a lot, but for the politicians it\u0026rsquo;s all gibberish. Like for me, when they talk about Salmon-farming, I don\u0026rsquo;t know anything in that context. We need to phrase things in understandable ways. Easy-to-grasp explanations of concepts, what do they mean?\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMunicipal organization and practice influenced how easy it was to identify resources, and might thereby contribute to the identification of resources independent of personal prior knowledge. Resources in PHW were consistently described as money (funding), attention (priority), time and knowledge, as well as access to decision-making forums:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026laquo;Now, the group consists of administrative leaders- before, it was mostly enthusiasts, but they did not have any decision-making power, and that was the problem. The first group was established at the wrong level!\u0026raquo;\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThus, access to decision-making and resource-distributing forums emerges as a central resource for PHW. This supports earlier described findings, where a lack of/inconsistent funding and priority were described as main challenges for PHW, as it limits access to resources- and increases projectification (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Accordingly, while PHW was repeatedly framed as a \u0026ldquo;whole-of-community\u0026rdquo;-responsibility (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e); did PH-coordinators also point to a lack of commitment from and delegative power over collaborators as a major challenge: having the overarching responsibility for local PHW, but no means to activate central resources besides others \u0026ldquo;goodwill\u0026rdquo; for the common effort was described as difficult, de-motivating and little coherent.\u003c/p\u003e \u003cp\u003eMoreover, the importance of anchoring sector-specific goals was described as beneficial to distribute responsibilities and emphasize commitment to the common effort (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). For PH-coordinators, such goals became a major asset, and could even turn perceptions of PHW and the PHW-coordinator in the wider municipality:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026laquo;Suddenly, it became important to include me, when they found out they could use me in respect to the municipal planning- suddenly, Public Health became important. It\u0026rsquo;s a lot of stress, if you don\u0026rsquo;t get distributed resources for it. I was not part of the administrative leaders, and did not have access to the right forums to be included in the discussion- however, in small municipalities, you have to use whatever persons you have\u0026hellip; now, I talk with the leaders, and are included into discussions!\u0026rdquo;\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThus, from having to ask others to put efforts into the common aim; could they now provide knowledge and support in respect to realizing goals in other sectors. Moreover, defining sector-specific goals can contribute to make the challenge appear more resolve-able for collaborators; contributing to increase perceptions manageability in the long run (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, being able to identify and activate resources is not always sufficient for realizing intentions; resources also have to fit, and be applied in ways that contribute to goal attainment in order to contribute to systematic, coherent approaches. Recall the initial example, emphasizing the importance of being able to adapt resources: while the initial thought was to utilize existing groups to support manageability (and not put the extra strain of establishing new groups into the process); they learned that being able to adapt the group to varying needs makes for more adequate resources over time; such as involving people from the cultural sector before the political hearing (see above). Thus, the adequacy of resources- their \u0026ldquo;fit\u0026rdquo; with the context and the role they are assigned in respect to resolving challenges- as well as the ability to adapt existing, or even create new resources also emerged as an important aspect of coherent collaboration.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eSupportive structures\u003c/h2\u003e \u003cp\u003eMunicipal structure and -culture emerges as a possible barrier as well as a central asset in this context, beyond the mere distribution of resources specifically assigned PHW. This is linked to the collaborative nature of PHW, which by large depends on common efforts and how these are received by collaborators, stakeholders, audience and target group(s): \u003cem\u003e\u0026ldquo;A positive internal culture, and attitudes that emphasize contributions!\u0026rdquo;\u003c/em\u003e were repeatedly described as major assets to support lasting changes. Moreover, experiencing that other parts of the municipal organization do their share of the common effort, and/or engage in activities pursuing related goals made substantial contributions to perceptions of \u0026ldquo;\u003cem\u003ebeing on the same team, and pushing into the same direction\u003c/em\u003e\u0026rdquo; associated with supportive structures, which also touches into meaningfulness (see below). Perceiving that efforts are supported even indirectly in the municipal organization is especially important in this context, which emphasizes broad coalitions and systematic changes (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Organizational change theory describes organizations as resistant to change: even if changes are implemented in one part of the (municipal) system, are other parts still designed to maintain the status quo, and would as such often hinder or even draw-back new approaches (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Thus, perceptions of supportive structures, which react positively to, and support PHW through political, public and administrative attention emerged as a major asset for perceptions of manageability, as well as for maintained motivation to engage in PHW (compare \u0026ldquo;meaningfulness\u0026rdquo;).\u003c/p\u003e \u003cp\u003eMeaningfulness- to feel\u003c/p\u003e \u003cp\u003eMatters of meaningfulness became visible in various forms across interviews and workshop-notes, and included matters of influencing processes, perceptions of making a difference and \u0026ldquo;being on the right track\u0026rdquo;, learning and growing as well as matters of social and organizational feedback. These are linked to experiences of being able 1.) influence outcomes and processes a.) for myself, my sector and relevant others as well as b.) on an organizational level, 2.) making a difference in respect to pursuing shared aims and resolving challenges, including perceptions of a.) mattering (personally or role-wise), being important for the achievements that are made; b.) visibility of contributions (what I did) as well as c.) visibility of impact (what I and we achieved); 3.) feeling that aims and approaches are \u0026ldquo;right\u0026rdquo; both a.) disciplinary/strategically and b.) morally; 4.) experiences of learning and growing a.) personally and b.) as an organization; as well as 5.) Experiences of social cohesion and support\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eInfluencing outcomes\u003c/h2\u003e \u003cp\u003eGenerally, participants expressed that engagement and perceptions of meaningfulness increased during the project period:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We made a lot of positive experiences. We passed on the message and initiated a process. And something happened out in the schools- it received a lot more attention! The families have received information at parent-meetings and got these hand-outs. I am convinced that this had a positive effect on adolescents\u0026rsquo; public health. And for a more conscious attitude. That contributes to making us more resilient. For me, an important driver was meeting the other municipalities. \u0026ldquo;\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePositive experiences during PHW could thus contribute to build motivation, a crucial condition for sustained engagement necessary to pursue goals over time (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). As illustrated, and in line with theory (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), were such experiences often intertwined with perceptions of having an impact; both in respect to agreeing on common aims and outlining process; defining one\u0026rsquo;s own role and tasks; and in respect to goal attainment and making a difference for the target group(s). During further analysis, a distinction was made between experiences linked to respectively: \u0026ldquo;influencing outcomes\u0026rdquo; is operationalized as having an impact on internal issues, organization and shaping processes; while \u0026ldquo;making a difference\u0026rdquo; describes perceptions of contributing to goal-attainment. Both types of experiences contributed to perceptions of meaningfulness, but were associated with different processes during collaboration.\u003c/p\u003e \u003cp\u003e\u0026ldquo;Influencing outcomes\u0026rdquo; was tightly linked to outlining one\u0026rsquo;s own role and responsibilities, as described earlier; to be involved in outlining collaboration processes; setting goals for the common effort to inform plans; as well as to raise fundings and activate resources to realize intentions. Here, major differences in the role of the Public Health Coordinators in respect to shaping processes became visible across municipalities:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWhen we do project-work, we don\u0026rsquo;t want it to be the PH-coordinators responsibility, we prefer it to by placed \u0026ldquo;in the line\u0026rdquo; (within a municipal sector)- because we want others to focus on PHW. So that we do not depend so much to money assigned \u0026laquo;Public health\u0026raquo;, because that\u0026rsquo;s not what is important, but how the sectors work with PHW, that\u0026rsquo;s important! And there, we face a lot of challenges\u0026hellip; for example, within the Health Services, how much resources should we assign to preventive work? After some rounds with thematic plans, can we see that these planning processes emphasize the focus on prevention and health promotion within the services- they indicate we have to turn distribution upside-down\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn some municipalities, PH-coordinators were able to influence outcomes due to personal resources and relationships; in others; such processes were more formalized and integrated into the municipal organization and thus, had a more lasting impact in processes and municipal structure. Being able to set the agenda and influence structures for present as well as future efforts was described as motivating for sustained engagement in PHW across sectors and actors. Especially being able to influence municipal processes and organization beyond the specific action was emphasized as a way to \u0026ldquo;shape outcomes\u0026rdquo; and develop capacity for PHW, and thus, contribute to organizational learning. Accordingly, a lot of efforts were put on exploring collaboration processes and favorable structures during the development of the specific action; to ensure that they could inform later approaches.\u003c/p\u003e \u003cp\u003eBeing able to influence outcomes for oneself and/or significant others, in this case, collaborators and stakeholders is closely linked to perceptions of meaningfulness (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), increases perceptions of ownership over approaches; and simultaneously contributes to comprehensibility (understanding the purpose of processes etc.) and manageability (providing relevant structures and resources). Thus, applying collaborative methods and engage stakeholders into such processes might contribute to the development of a shared, coherent understandings locally.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eMaking a difference\u003c/h2\u003e \u003cp\u003eHowever, a too-narrow focus on internal processes and collaboration, without linking these firmly to goals and ambitions within PHW, was described as \u003cem\u003e\u0026ldquo;meaningless\u003c/em\u003e\u0026rdquo; and \u0026ldquo;\u003cem\u003ecollaborating for the sake of collaboration\u0026rdquo;\u003c/em\u003e. Experiences of \u0026ldquo;\u003cem\u003emaking a difference\u003c/em\u003e\u0026rdquo; and contribute to resolve challenges were central for perceptions of meaningfulness (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Making a difference for the target group is linked to goal attainment and working in line with disciplinary understandings about valid approaches:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026laquo;My experience is that it works very well for the target group. We do have structures and collaborations in the back, where we can raise themes, and agree on future efforts. That works well. It\u0026rsquo;s not easy, as these are difficult decisions, but in respect to what you can realistically expect, it works really well\u0026rdquo;\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePerceptions of \u0026laquo;success\u0026raquo; and mastery were closely linked to perceiving the common effort as meaningful (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Meanwhile, success could not only be experienced by fulfilling main aims, but even while developing processes that support these aims, and contribute to fulfill process goals (e.g. \u0026ldquo;involving youths in developing the knowledge-base\u0026rdquo;):\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026laquo;Vi utilize the (national)youthData. There, we managed to achieve good involvement in working with the results. It\u0026rsquo;s about developing ownership over it. And that we worked with the youngsters in a good way when the results arrived, and even before we chose questions. We really succeeded there!\u0026raquo;\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThus, and in line with theory, experiences of being able to influence the context at any level; from negotiating one\u0026rsquo;s own role to making a lasting impact on municipal organization were closely linked to experiencing processes as meaningful (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). This might also point towards matters of \u0026ldquo;mattering\u0026rdquo;; being personally (or organizational) important for how things are going (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Perceptions of mattering were also described as dependent on social feedback and experiences of appreciation and visibility: \u0026ldquo;\u003cem\u003eWe forget appreciation, and that what is so important! To see each other. Really important for all of us. We see that in school already-people need to be seen!\u0026rdquo;.\u003c/em\u003e Visibility and appreciation of contributions and impact here emerge as crucial assets for coherent collaboration; and especially, for experiencing collaboration as meaningful:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026laquo;We were able to offer support, that was nice. We can help! And it\u0026rsquo;s important that we from the municipality thank the volunteers for their efforts. (\u0026hellip;) And the local media has been very supportive and positive to everything- they always showed up when I was willing to talk about stuff, and have my photos taken. I have become the \u0026ldquo;Join in!\u0026raquo;-lady: \u0026laquo;Everyone come and join in\u0026rdquo; or something like that. And within our sector- health and family- we really elevated ourselves. Received support for working preventive, and support for those working directly with children and adolescents\u0026rdquo;\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eBoth visibility of contributions from collaborators, as well as visibility of the common action in the local context could contribute to perceptions of meaningfulness:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026laquo;We emphasized the focus on PHW, and formalized our work. To get into the municipal plans; and have it as a red threat during the development of the plans. Even while being a legal obligation; the fact that it is given so much attention [here], that really changed a lot. Maybe that is the most important change, that the focus on PHW is broader and has moved beyond less drinking and more exercise. Now, while planning the centrum and such, there is much more focus on green-spaces!\u003c/em\u003e\u0026rdquo;\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eVisibility of impact is an important pre-requisite for perceptions of making a difference: being able to observe changes was described as motivating, and emphasizing perceptions of doing something important and \u0026ldquo;meaningful\u0026rdquo;.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eDoing \u0026ldquo;what is right\u0026rdquo;\u003c/h2\u003e \u003cp\u003eReceiving appreciation and seeing impact of actions does thereby also contribute to perceptions of \u0026ldquo;\u003cem\u003ebeing on the right track\u003c/em\u003e\u0026rdquo; and \u0026ldquo;\u003cem\u003egoing somewhere\u003c/em\u003e\u0026rdquo;, which also emerged as important conditions for experiencing meaningfulness: \u0026ldquo;\u003cem\u003eyou are on the way to something- everyone understands their role, this is our community, our Youth\u003c/em\u003e!\u0026rdquo;. Experiencing progress did in itself raise perceptions of meaningfulness; as also illustrated above. Disciplinary knowledge about \u0026ldquo;\u003cem\u003ewhat works and why\u003c/em\u003e\u0026rdquo; could contribute to perceptions of progress in a field in which progress can be hard to measure; e.g. through awareness of indicators, or by re-assuring actors that they are applying \u0026ldquo;best practices\u0026rdquo;. Even anchoring approaches in strategic plans, from international documents, such as the sustainable development goals (SDG) to municipal and thematic plans was described as favorable for perceptions of \u0026ldquo;\u003cem\u003edoing the right thing\u003c/em\u003e\u0026rdquo; (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eNowadays, I can influence PHW through working with the knowledge-base for public health. It\u0026rsquo;s one of our most important tools, and it\u0026rsquo;s mandatory to apply it during all planning work: everything from the municipal master plan to thematic plans for water, sanitation, mental health, the ageing population\u0026hellip; Every sector-plan and all municipal plans, and even the SDG in the municipality- the indictors we develop for the knowledge-base are really important indicators for the SDG. We did it once first, but the second time we did it differently, and looked at it in relation to how we operationalize the SDG. That way, you can emphasize issues to the politicians and even the municipality. You can even use it for teaching and learning: what is important here in this village?\u0026rdquo;\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eEmbedding approaches in the agreed-upon strategies provided a valid and shared framework which could be used to raise attention and provide reasons for efforts by emphasizing them as contributions to higher-level obligations and create engagement in actors from other sectors (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eLearning, growing and social cohesion\u003c/h2\u003e \u003cp\u003eLast, experiences of learning and growing were repeatedly described as meaningful and motivating (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e):\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eWe develop new knowledge all the time- and we are learning continuously! That\u0026rsquo;s what is nice about being in a big group, there is always someone who brings something new to the table, which we others haven\u0026rsquo;t heard about yet!\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWhile personal learning contributes with positive experiences for the actors and individual competence-building, does it also emphasize one of the main challenges in PHW: to develop organizational capacity for PHW (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). In the above-described context for PHW, characterized by high-turn-over, was building organizational capacity described as central to enable systematic approaches over time:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eWe regularly stop along the way and look at what we are doing: are we doing the right things, and are we doing them in the right way? We conducted a check-in, and we also look at things like; are there any new guidelines, new information, new knowledge? A systematic evaluation of what we are doing. We have a system for that. That\u0026rsquo;s in our backbone. If there are bigger issues we conduct a new search for knowledge, but that demands for financing or even a new project. Our mindset is that we are not evaluating just to evaluate!\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThus, providing actors with opportunities to build personal competence is not enough: learning must occur in municipal structures and applied processes to have a lasting effect (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMoreover, experiences of joined and mutual learning were repeatedly described as contributing to perceptions of cohesion and/or social capital; expressed thorough notions like \u003cem\u003e\u0026ldquo;building a network and get to know each other. Get ideas and learn from each other. That was really a tremendous lift, in my opinion!\u0026rdquo;.\u003c/em\u003e In this context, also earlier discussed matters of visibility, experiences of appreciation and positive feedback; as well as being \u0026ldquo;on the same team\u0026rdquo; were crucial, and contributed to organizational development through supporting cohesive networks within as well as between municipalities. Building cohesive networks was associated with meaningfulness, as well as progress and the development of (social) resources that can help to resolve later challenges (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eAll in all, applying Salutogenesis and its inherent framework of coherence unto perceptions and experiences during collaboration for local PHW yielded interesting insights, which can support the development of coherent approaches to planning for PHW. Initially, local PHW has been described as largely fragmented and incoherent, due to differing understandings of challenges and possible solutions; conflicting aims; unclear responsibilities; a lack of, and internal competition over, resources; instable funding and shifting objectives as well as short-lived interventions that fail to impact the wider municipal organization and later working processes. This poses major challenges for the establishment of systematic processes for coherent planning of local development in line with PHW-intentions and highlights the needs to combine rationalistic and dialogue-based planning approaches as well as to facilitate for personal and organizational learning (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan additionalcitationids=\"CR11 CR12 CR13\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFindings indicate that collaborators developed coherent perspectives during participation in the multi-sector collaboration, suggesting that perceptions of coherence are influenced by the processes and structures that guide collaboration processes and contribute to form actor\u0026rsquo;s experiences and perceptions (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Perceptions of comprehensibility were linked to awareness of shared goals, disciplinary and contextual knowledge for outlining approaches as well as clearly defined roles and responsibilities. Manageability was described as matters of perceiving challenges as resolve-able in the local context; being able to identify, activate and, if necessary, adapt or create relevant resources, as well as supportive structures and personal competence. Meaningfulness was experienced through being able to define processes; perceptions of goal-attainment; visibility of contributions and impact, as well as experiences of learning and social cohesion.\u003c/p\u003e \u003cp\u003eCoherent processes for coherent planning\u003c/p\u003e \u003cp\u003eApplying Salutogenesis to unravel these complex issues enabled us to link experiences of coherence and/or incoherence to collaboration processes; rather than framing them as internal, individual resources (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). While individual resources, such as knowledge about PHW, did play a role; could applied processes provide or prevent opportunities to apply and promote resources and resolve challenges. In line with theory, did overcoming challenges contribute to strengthen perceptions of being able to resolve (future) challenges- individually and as an organization (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). The applied operationalizations of the three dimensions of coherence; comprehensibility; manageability and meaningfulness respectively (see Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), captured participants\u0026rsquo; experiences, and enabled them to reflect upon how collaboration processes did influence and shape these perceptions. This provides us with process-related pinpoints to describe (and maybe even facilitate for) coherent processes (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFurthermore, applying the framework of coherence unto matters of strategic local planning addressed some of the above-described challenges with combining dialogue-based and rationalistic planning approaches and support HiAP (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). For example, opportunities to develop relevant knowledge through the applied processes was linked to perceptions of coherence and ownership, social cohesion and \u0026ldquo;\u003cem\u003ebeing on the same team\u003c/em\u003e\u0026rdquo;. These notions are linked to dialogue-based planning, aiming at more democratic processes and experiences of social cohesion during collaboration (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Meanwhile, stakeholders also described how their understandings and raised awareness of how activities contributed to resolve challenges and realize aims increased during the project. Such perceptions, linked to \u003cem\u003emaking a difference, being on the right track\u003c/em\u003e and contribute to realize \u003cem\u003eshared aims\u003c/em\u003e were described as important aspects of coherence. Thus, the framework simultaneously highlights matters of goal-attainment, emphasized in strategic planning literature (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), as well as matters of empowerment, democratic organization and social cohesion, as emphasized in dialogue-based planning approaches (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). It thereby provides a valid framework to realize the intentions of strategic planning for HiAP, enables collaborators to work independently over time towards shared, long-term objectives, and facilitates for organizational learning (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUtilizing the framework to outline approaches\u003c/p\u003e \u003cp\u003eApplying the dimensions of comprehensibility, manageability and meaningfulness unto processes and assets allows to approach these issues from distinct, yet inter-related perspectives: For example, knowledge about PHW emerged as a major asset for comprehensibility, such as making sense of the complex field and outline approaches, as well as for manageability through the development of coherent agency and experiencing support from the wider municipality, along with meaningfulness through perceptions of being on the right track and positive feedback from others.\u003c/p\u003e \u003cp\u003eThis illustrates how the intertwined nature of the dimensions enables us to address the issue from any of these perspectives: teaching and learning about PHW can contribute to meaningfulness through experiences of \u003cem\u003elearning and growing\u003c/em\u003e, while enhancing comprehensibility through \u003cem\u003eawareness of shared goals\u003c/em\u003e and \u003cem\u003eknowledge about valid approaches\u003c/em\u003e; thereby supporting manageability through better \u003cem\u003eknowledge about resources\u003c/em\u003e and the experience \u003cem\u003eof supportive structures\u003c/em\u003e- based on shared knowledge about PHW- which, again, can promote meaningfulness through \u003cem\u003evisible contributions\u003c/em\u003e and perceptions of \u003cem\u003esocial cohesion\u003c/em\u003e. Providing collaborators and stakeholders with relevant disciplinary knowledge seemed to initiate an upwards-spiral, in which this knowledge became a resource for developing coherent perspectives across all three dimensions- and apply these to outline and pursue coherent approaches in the local context (\u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Salutogenesis, experiences touching into matters of comprehensibility, manageability and meaningfulness are described as \u0026ldquo;significant life events\u0026rdquo; crucial for the development of generalized resistance resources- thus, resolving such challenges contribute to strengthen SOC and enable healthy future coping (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Identifying such \u0026ldquo;entry points\u0026rdquo; for facilitating coherent experiences might thus be a valuable approach to build coherence locally, as it enables us to address matters of comprehensibility, manageability and meaningfulness simultaneously, thereby hopefully fueling a salutogenic development in actors as well as in the organization. Unravelling these impacts thereby allows to outline approaches for targeted interventions along the three dimensions.\u003c/p\u003e \u003cp\u003eActivating resources\u003c/p\u003e \u003cp\u003eNext, manageability emerged as the most challenging dimension: Difficulties s with being able to activate and adapt resources did pose major challenges for the development of coherent agency for PHW and the establishment of systematic processes locally. Partly, this focus on manageability might be due to the professional, goal-oriented context (see also \u0026ldquo;methodological considerations\u0026rdquo;). However, difficulties with being prioritized economically in the municipal context implied to apply for external, project-based funding, demanding to pursue (top-down defined) specific goals, approaches or tools; or to target specific groups- all of which are defined top-down, thereby challenging perceptions of coherence and hazarding for personal as well as organizational learning (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Turned around, and in line with the above argument that improvements in one dimension might contribute to changes on the other dimensions, do we argue that a focus on increasing manageability also can contribute to facilitate for comprehensibility and meaningfulness; e g. by allowing actors to gain experiences that improve their practice and develop a deeper understandings about PHW (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBesides funding did resources such as having dedicated time, firmly anchored aims, personal competence, authority as well as joined and mutual learning opportunities emerge as major resources. Providing collaborators with specific aims and coherent \u0026ldquo;roadmaps\u0026rdquo; outlining their contributions and valid approaches might make major contributions in this regard, especially in respect to enabling collaborators without profound knowledge about PHW to develop coherent agency (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Municipal structure and -culture emerge as possible barriers, as well as central assets: Perceiving that efforts are supported even indirectly in the municipal organization is especially important in this context, which emphasizes broad coalitions and systematic changes (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Supportive structures also emerges as a central asset in the face of the so-called \u0026ldquo;wicked problems\u0026rdquo; and organizational resistance to change even if changes are implemented in one part of the (municipal) system, are other parts still designed to maintain the status quo, and would as such often hinder or even draw-back changes (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Here, the above-described knowledge about PHW in the organization facilitated for perceptions of structures that support PHW through political, public and administrative attention, thus emerging as a major asset for perceptions of manageability, as well as for maintained motivation to engage in PHW (meaningfulness).\u003c/p\u003e \u003cp\u003eAnchoring approaches\u003c/p\u003e \u003cp\u003eTaken together, awareness about aims, ways to activate resources and visible support for local PHW can make major contributions to more coherent approaches (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). This again highlights matter of anchoring and embedding approaches in agreed-upon strategies as a beneficial approach to providing a valid and shared framework that links efforts firmly to higher-level obligations and thereby, hopefully increases political and financial support (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Simultaneously, such strategies work best if there is high commitment to goals and strategies throughout the organization and among actors. Utilizing strategic goals also holds the danger of linking them tightly to political matters and thus, potentially contribute to polarization (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). This implies that approaches can lose political support due to shifts in the political majority, which is a major barrier for systematic approaches over time.\u003c/p\u003e \u003cp\u003eSimultaneously, actors might experience conflict between shared approaches and personal values and/or moral believes. Such experiences are a barrier for committing to shared efforts and might cause internal conflict or moral tension which threatens actors\u0026rsquo; motivation and perceptions of coherence (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Careful screening of the social context and sensitivity for diverse believes during the development of shared goals can help to mitigate this risk. Even focusing on local issues, rather than issues that are discussed and decided at higher levels, can help to reduce tension and emphasize common aspirations. For example, actors from rural communities often easily agreed on goals linked to local thriving and social cohesion- helping collaborators to move beyond political divisions and engage in a common effort (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The importance of including stakeholders in relevant processes is emphasized: Being actively involved in staking out the way is directly linked to perceptions of meaningfulness and increases ownership over approaches simultaneously as this also contributes to comprehensibility (understanding the purpose of processes etc.) and manageability (providing relevant structures and resources).\u003c/p\u003e \u003cp\u003eAll in all, do findings indicate that applying Salutogenesis and its inherent framework of coherence unto collaboration processes for PHW yielded meaningful results, which help us to understand what is going on during collaboration, and how processes and structures can contribute or hazard for coherent experiences. Below, we discuss methodological issues, before summarizing our insights by providing implications for practice as well as research.\u003c/p\u003e \u003cp\u003eMethodological considerations\u003c/p\u003e \u003cp\u003eThis project builds on a co-creation approach (CAR). Deemed a beneficial approach to ensure the development of relevant and applicable knowledge (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), can this strategy also increase the risk to encounter conflict-of-interests: Pointing out challenges can be experienced as stigmatizing by collaborators, implying that researchers have to be cautious about how findings are framed and communicated to not hazard research aims or damage trust between collaborators. In this project, the established long-term collaboration, and the strong focus on joined and mutual learning over time contributed to diminish this issue, and provided practitioners with a safe context to discuss their experiences and share valuable knowledge with the researchers.\u003c/p\u003e \u003cp\u003eAnother possible draw-back of this approach is linked to generalizability: Is locally developed knowledge valid for other municipalities, and/or planning processes in other regions and nations? Can insights be applied beyond the local context? A rigorous and explicit application of theory contributes to meet these challenges, as it allows to develop general knowledge about actors` experiences and perceptions, while reflecting (varying) processes. For example, having a clear mental representation of one\u0026rsquo;s role and responsibilities might be an important pre-requisite for outlining approaches to any issue across contexts. How this mental representation can be achieved through applied processes might, however, differ across municipalities, regions and nations.\u003c/p\u003e \u003cp\u003eIn a related issue, the generalizability of findings beyond the setting of PHW can be challenging, for example, manageability emerged as the most important dimension of coherence, challenging earlier assumptions about meaningfulness being \u0026ldquo;the most important dimension\u0026rdquo; of coherence (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). This might reflect priorities in the setting of PHW, which is by large a professional, goal -oriented setting occupied with resolving challenges (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Thus, the relative importance of the three dimensions might vary across contexts, which again highlights the importance of understanding coherence as an interplay between actors and settings (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNext, applying an abductive approach during analysis increases dangers of confirmation bias or applying non-circular processes in which theory guides the development of insights (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). To mitigate this risk, participants were asked to validate, as well as reflect upon and apply emerging concepts back unto described processes to expose shortcomings and contradictions in the emerging understanding, which then must be examined critically in the further process.\u003c/p\u003e \u003cp\u003eImplications for practice\u003c/p\u003e \u003cp\u003eFindings indicate that it is possible to facilitate coherent experiences during the planning and implementation of PHW. Based on the above-presented findings and discussion, the following recommendations for practice can be made:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eCoherence is developed in the interplay between actors, settings and processes, emphasizing the importance of stakeholder-involvement and co-creation to support the development of coherent perspectives and approaches in actors as well as the municipal organization.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eManageability emerges as the most challenging dimension for PHW. Increasing prioritization and availability of crucial resources for PHW might make major contributions to more systematic, coherent and locally anchored approaches.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eUnravelling matters of comprehensibility, manageability and meaningfulness can contribute to facilitate for describing coherence at a process- and settings-level and to outline tailored approaches.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAnticipating mutual influences and possible synergies between the three dimensions of coherence is advised and can be utilized to initiate a positive development: Resources and activities touching into all three dimensions of coherence provide interesting entry points fuel an upwards spiral towards more coherent approaches.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eIn this article, entry points such as a.) anchoring knowledge and approaches in municipal plans and the wider organization; b.) the structure, timing and content of collaboration activities, as well as c.) the presence of relevant feed-back loops are identified:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eKnowledge and awareness about shared aims for PHW were closely linked to comprehensibility but also emphasized in the context of manageability and meaningfulness. Anchoring and embedding approaches in such agreed-upon aims links efforts firmly to higher-level obligations, and can increase prioritization, political support and the availability of resources. Moreover, providing sector- and level-specific roadmaps makes major contributions the development of coherent agency and thereby, enables collaborators to work independently over time towards shared aims (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eCollaboration activities that contribute to shared and/or mutual learning, as well as activities that develop and define local aims, approaches and strategies emerge as crucial assets for learning how to approach the issue as an organization and from the individual position; as well as to facilitating for experiences of social cohesion and support within municipalities.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eThe existence of feed-back loops in the municipal organization was linked to perceptions of visibility of efforts and contributions; as well as disciplinary knowledge and perceptions of being on the right track and making a difference. Feedback loops enabled actors to see how their efforts are received and impact municipal organization, deepening comprehensibility, manageability and meaningfulness simultaneously. They emerged as crucial assets for maintaining coherent perspectives and -agency over time; and help to navigate changing conditions; adverse side-effects and/or applying new knowledge, as often encountered during long-term efforts.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eTaken together, applying the framework of Salutogenesis yielded interesting insights, and highlights the importance of applying coherent processes during planning for PHW. More knowledge about how emerging knowledge can be to facilitate for coherent planning approaches is needed.\u003c/p\u003e \u003cp\u003eImplications for theory\u003c/p\u003e \u003cp\u003eIn this study, we applied the three dimensions of SOC to understand how experiences and processes during multi-sector collaboration for PHW contributed to perceptions of coherence. This is a new approach to applying the concept of SOC; which has earlier been understood and treated as more or less stable individual resource (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) enabling healthy coping (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e): Instead of linking perceptions of coherence to individual SOC, we here use the framework to describe the development of coherent perspective during multi-sector collaboration for PHW. Matters of coherence are thereby moved from a more-or-less individual to a relational understanding, which is already anticipated in the original framework (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e): coherence is created in the interplay between people, places and processes (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Deepening our understanding about these interrelations and mutual influences might contribute to develop Salutogenesis as a sound theory for health promotion: Anticipating that matters of coherence can be addressed beyond individual perceptions enables HP-practitioners to develop new approaches that fit the predominant settings-approach and support the implementation of HiAP locally (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Thus, a closer look at the above-described entry points; touching all three dimensions of coherence, and unravel how characteristics, processes and activities within this setting can support such developments in individuals, settings and organizations, would make major contributions to develop a sense for coherence in the context of PHW and municipal planning (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMoreover, developing a sense of coherent agency, a coherent understanding about how one can act to achieve desired outcomes from one\u0026rsquo;s specific position, emerges a central concept, which has not been addressed explicitly by the salutogenic literature earlier. To work as a central coping resource, perceptions must include an idea about how to address issues, an important condition for coherent agency. These issues are briefly addressed in the original literature; e.g. by pointing out that coherence is not only about perceiving stimuli as meaningful information, but also about managing to send stimuli that are received without (or little) distortion and the importance of \u003cem\u003e\u0026ldquo;putting feedback into the system and see how it reacts\u0026rdquo;\u003c/em\u003e (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, p.126) in order to develop awareness about how one can impact the situation-preferably, for better. A stronger focus on exploring matters of manageability and conditions for developing coherent agency can contribute to further develop the theoretical framework as a central theory for Health Promotion.\u003c/p\u003e \u003cp\u003eConcluding remarks\u003c/p\u003e \u003cp\u003eAll in all, applying the framework of coherence, as described in Salutogenesis, yielded valid insights into how coherence can be understood and assessed beyond individual experiences. Linking perceptions of coherence to experiences during PHW-collaboration enables us to start outlining how such experiences can be facilitated for. A shared vision about the common aims, as well as availably of resources emerge as central resources in this context. Especially anchoring goals and procedures; the structure and content of collaboration activities (inclusive joined and mutual learning sessions) as well as the presence of feed-back loops emerge as important assets and valid entry points to facilitate for coherent experiences and processes in municipalities.\u003c/p\u003e \u003cp\u003eThe novelty of this approach lies in combining aspects of dialogue-based and strategic planning approaches: While focusing on coherent experiences and opportunities for individual sense-making, are perceptions of coherence also closely linked to goal attainment and de-facto impact of the developed approaches. It thereby answers needs to combine rationalistic and dialogue-based approaches, as voiced in the planning literature; and emerges as a beneficial approach for strategic planning (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u0026rsquo;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCAR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCollaborative action research\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHiAP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealth in all policies\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealth Ptomotion\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePHW\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePublic Health Work\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSDG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003esustainable development goals\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSDoH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSocial determinants of Health\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSOC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSense of Coherence\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTMPHW\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTr\u0026oslash;ndelag Model of Public Health Work\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003eResearch in this project was carried out in accordance with the Helsinki declaration (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.wma.net/policies-post/wma-declaration-of-helsinki/\u003c/span\u003e\u003cspan address=\"https://www.wma.net/policies-post/wma-declaration-of-helsinki/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). The project was approved by the Norwegian Agency for Shared Servies in Education and research, Sikt (sikt.no), license number 451348. All data gathering was carried out in the context of the National and regional Program for Public Health Work, informants participated in this project in their role as professionals working with PHW. An informed consent to participate was given municipal-wise through the collaboration contract signed at the start of the period; as well as individually for participation in the interviews/workshops.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe Program is funded by the Norwegian Directorate of Health; additional research for this study was financed by the Norwegian Research Counsil.\u003c/p\u003e \u003cp\u003eCompeting interests\u003c/p\u003e \u003cp\u003eNo competing interests were identified.\u003c/p\u003e \u003cp\u003eData availability\u003c/p\u003e \u003cp\u003eThis article generates and analyses new data produced in the context of the Program for Public Health Work and the specific NFR project \u0026ldquo;Evidence for action to reduce social inequalities in health\u0026rdquo;. Data is not made publicly available due to challenges with anonymization/identification of participants and participating municipalities in small populations/regions. This is done to protect the privacy of individual participants, as outlined in the given consent; as well as to avoid potential stigmatization of participating municipalities.\u003c/p\u003e \u003cp\u003eAvailability of the interview-guide\u003c/p\u003e \u003cp\u003eThe interviews were developed and conducted for the sake of the project. Data from the interviews has not been published earlier; but has informed regional co-creation and competence building workshops as part of the project (see \u0026ldquo;methods\u0026rdquo;). Material used during the workshops is not publicly available. An English translation of the interview-guide is included in the supplementary materials.\u003c/p\u003e \u003cp\u003eClinical trial number\u003c/p\u003e \u003cp\u003enot applicable\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eFirst (RM), third (GG) and last (ML) author contributed to data-gathering through interviews, and to development of the interview-guide. All four authors participates in the follow-up workshop, RM and second author (KJ) as organizers, GG and ML as facilitators. Analysis was carried out in close collaboration between RM and KJ; and emerging insights actively discussed with ML and GG ongoingly. ML acted as project leader for the main project (evidence for action to reduce social inequalities in health; NFR 302705) which constitutes the context for this research. RM (corresponding author) was the main responsible for writing the article; however, all authors made active contributions to the manuscript, and approved this version for submission.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe want to thank the Norwegian Directorate of Health for launching the Program for Public Health Work in Municipalities which enabled this project. Further, we deeply appreciate the efforts undertaken by the County of Trondelag to administer the regional collaboration, and to the participating municipalities for sharing their experiences and committed part-taking in the workshop and other activities informing this research.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThis article generates and analyses new data produced in the context of the Program for Public Health Work and the specific NFR project \u0026ldquo;Evidence for action to reduce social inequalities in health\u0026rdquo;. Data is not made publicly available due to challenges with anonymization/identification of participants and participating municipalities in small populations/regions. This is done to protect the privacy of individual participants, as outlined in the given consent; as well as to avoid potential stigmatization of participating municipalities.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLillefjell M, Maass REK. Involvement and multi-sectoral collaboration: applying principles of health promotion during the implementation of local policies and measures\u0026mdash;a case study. Societies. 2021;11(4):xx\u0026ndash;xx.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSynnev\u0026aring;g ES, Amdam R, Fosse E. Intersectoral planning for public health: dilemmas and challenges. Int J Health Policy Manag. 2018;7(11):982\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAct on Public Health Work (Public Health Act), LOV-2011-06-24-29 [Internet]. 2011 Jun 24 [cited 2025 Dec 17]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://lovdata.no/dokument/NL/lov/2011-06-24-29\u003c/span\u003e\u003cspan address=\"https://lovdata.no/dokument/NL/lov/2011-06-24-29\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLillefjell M, Anthun KS, Maass REK, Innstrand ST, Espnes GA. A salutogenic, participatory and settings-based model of research for the development and evaluation of complex interventions: the Tr\u0026oslash;ndelag model for public health work. Cham: Springer Nature; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFosse E, Helgesen MK, Hagen S, Torp S. Addressing the social determinants of health at the local level: opportunities and challenges. Scand J Public Health. 2018;46(20suppl):47\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFosse E. Norwegian policies to reduce social inequalities in health: developments from 1987 to 2021. Scand J Public Health. 2022;50(7):882\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOrtenzi F, Marten R, Valentine NB, Kwamie A, Rasanathan K. Whole of government and whole of society approaches: call for further research to improve population health and health equity. BMJ Glob Health. 2022;7(7):e009972.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCairney P, StDenny E, Mitchell H. The future of public health policymaking after COVID-19: a qualitative systematic review of lessons from Health in All Policies. Open Res Eur. 2021;1:13178. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.12688/openreseurope.13178.2\u003c/span\u003e\u003cspan address=\"10.12688/openreseurope.13178.2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFranklin P, Greer SL, Falkenbach M. Policy coherence as a driver of health equity. Copenhagen: WHO Regional Office for Europe; 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaass REK, Lillefjell M. Can the theory of salutogenesis offer a framework to enhance policy coherence during policy development and implementation in municipalities? Societies. 2022;12(3).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLillefjell M, Hope S, Anthun KS, Hermansen E, Vik JT, Sund ER, et al. Planning for health equity: how municipal strategic documents and project plans reflect intentions instructed by the Norwegian Public Health Act. Societies. 2023;13(3):74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLindstr\u0026ouml;m B, Eriksson M. The salutogenic approach to the making of HiAP/healthy public policy: illustrated by a case study. Glob Health Promot. 2009;16(1):17\u0026ndash;28. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1757975908100747\u003c/span\u003e\u003cspan address=\"10.1177/1757975908100747\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Leeuw E, Lin V. Local health planning and governance. Healthy cities: the theory, policy, and practice of value-based urban planning. New York: Springer; 2017. pp. 395\u0026ndash;405.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchmitt P, Weck S. Towards just planning: on the relationship between procedural and distributive justice in local development actions. Plan Pract Res. 2024;39(5):753\u0026ndash;71. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/02697459.2024.2359221\u003c/span\u003e\u003cspan address=\"10.1080/02697459.2024.2359221\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWalls HL. Wicked problems and a \u0026lsquo;wicked\u0026rsquo; solution. Glob Health. 2018;14:34. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12992-018-0353-x\u003c/span\u003e\u003cspan address=\"10.1186/s12992-018-0353-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRamirez-Rubio O, Daher C, Fanjul G, Gascon M, Mueller N, Paj\u0026iacute;n L, et al. Urban health: an example of a health in all policies approach in the context of SDGs implementation. Global Health. 2019;15(1):87.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJacobsen R. Public sector projectification\u0026ndash;a systematic review of the literature. Scand J Public Adm. 2022;26(4):91\u0026ndash;112.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaass R, Kiland C, Espnes GA, Lillefjell M. The application of salutogenesis in politics and public policy-making. The handbook of salutogenesis. Cham: Springer; 2022. pp. 239\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAntonovsky A. Health, stress, and coping. San Francisco: Jossey-Bass; 1979.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAntonovsky A. Unraveling the mystery of health: how people manage stress and stay well. San Francisco: Jossey-Bass; 1987.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEriksson M. The sense of coherence: the concept and its relationship to health. The handbook of salutogenesis. Cham: Springer; 2022. pp. 61\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaass R, Vaandrager L, Sallaway-Costello J. Salutogenesis in the context of society. In: Eriksson M, Vaandrager L, Lindstr\u0026ouml;m B, editors. The Hitchhiker's Guide to Salutogenesis: from the Ottawa Charter for Health Promotion to Planetary Health. Cham: Springer Nature Switzerland; 2025. pp. 89\u0026ndash;102.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBull T, Mittelmark MB, Kanyeka NE. Assets for well-being for women living in deep poverty: through a salutogenic looking-glass. Crit Public Health. 2013;23(2):160\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaass REK. The neighborhood as a salutogenic setting: how can salutogenesis contribute to the development of strategies for promoting health and strengthening SOC through a focus on neighborhood-resources? [doctoral thesis]. Trondheim: NTNU; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNess O, von Heimburg D. Collaborative action research: co-constructing social change for the common good. SAGE Handbook of Social Constructionist Practice. London: Sage; 2020. pp. 34\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDirectorate of Health [Internet]. 2018 [cited 2025 Oct 14]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.helsedirektoratet.no/forebygging-diagnose-og-behandling/forebygging-og-levevaner/folkehelsearbeid-i-kommunen/program-for-folkehelsearbeid-i-kommunene\u003c/span\u003e\u003cspan address=\"https://www.helsedirektoratet.no/forebygging-diagnose-og-behandling/forebygging-og-levevaner/folkehelsearbeid-i-kommunen/program-for-folkehelsearbeid-i-kommunene\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCounty. of Tr\u0026oslash;ndelag [Internet]. n.y. [cited 2025 Oct 14]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.trondelagfylke.no/vare-tjenester/folkehelse-idrett-frivillighet/folkehelse/programmet/\u003c/span\u003e\u003cspan address=\"https://www.trondelagfylke.no/vare-tjenester/folkehelse-idrett-frivillighet/folkehelse/programmet/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePhilipsen K, Hjalager AM. Theory building using abductive search strategies. In: Freytag PV, Young L, Evald MR, editors. Collaborative research design. Cham: Springer; 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/978-3-031-70149-8_3\u003c/span\u003e\u003cspan address=\"10.1007/978-3-031-70149-8_3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDubois A, Gadde LE. Systematic combining: an abductive approach to case research. J Bus Res. 2002;55(7):553\u0026ndash;60. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S0148-2963(00)00195-8\u003c/span\u003e\u003cspan address=\"10.1016/S0148-2963(00)00195-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLillefjell M, Magnus E, Knudtsen MS, Wist G, Horghagen S, Espnes GA, et al. Governance for public health and health equity: the Tr\u0026oslash;ndelag model for public health work. Scand J Public Health. 2018;46(22suppl):37\u0026ndash;47.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCharmaz K. Constructing grounded theory. 2nd ed. London: Sage; 2014.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaass R, Hope S, Lillefjell M. Trickle-down policies: utilizing strategic plans to facilitate local public health work. Eur J Public Health. 2023;33(Suppl 2):ckad160\u0026ndash;1666.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVaandrager L, Koelen M, Bouwman L. Salutogenesis in the context of learning processes. In: Eriksson M, Vaandrager L, Lindstr\u0026ouml;m B, editors. The Hitchhiker's Guide to Salutogenesis. Cham: Springer; 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEriksson M. Key concepts in the salutogenic model of health. The handbook of salutogenesis. Cham: Springer; 2022. pp. 59\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCook-Sather A, Wald M. Who I am is more than enough\u0026rsquo;: how multiple forms of co-creation foster belonging and mattering for well-being. Student belonging in higher education. London: Routledge; 2025. pp. 200\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaass R, Kloeckner CA, Lindstr\u0026ouml;m B, Lillefjell M. The impact of neighborhood social capital on life satisfaction and self-rated health: a possible pathway for health promotion? Health Place. 2016;42:120\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeier Magistretti C, Topalidou A, Meinecke F. Sense FOR coherence\u0026ndash;der Sinn F\u0026Uuml;R Koh\u0026auml;renz: ann\u0026auml;herungen an ein m\u0026ouml;gliches Konzept. Salutogenese kennen und verstehen. Cham: Springer; 2019. pp. 119\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Policy coherence, health promotion, Salutogenesis, health in all policies, whole-of-community, health equity, local planning, collaboration, co-creation","lastPublishedDoi":"10.21203/rs.3.rs-8395684/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8395684/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eReducing health inequalities and realizing intentions of Health-in-all-policies locally demands to combine aspects of rational and dialogue-based planning approaches to support systematic, long-term collaborations and the development of coherent perspectives locally. We apply the theory of Salutogenesis to unravel how actors developed coherent perspectives during a collaboration linked to the development and implementation of a health promoting measure.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eCollaborative action research was applied to develop relevant and generalizable knowledge applicable for municipal practice. Data was gathered through in-depth interviews with municipal actors across 7 municipalities; and a follow-up workshop with municipal participants (n\u0026thinsp;=\u0026thinsp;40) to validate and elaborate findings. During analysis, an abductive approach utilizing Salutogenesis was applied to develop practical knowledge, while also developing the theoretical framework in line with emerging insights\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eCollaborators developed coherent perspectives during participation in the collaboration, suggesting that perceptions of coherence are influenced by processes and structures during collaboration that contribute to form actor\u0026rsquo;s experiences and perceptions. Perceptions of comprehensibility were linked to awareness of shared goals, disciplinary and contextual knowledge as well as clearly defined roles and responsibilities. Manageability was described as matters of perceiving challenges as resolve-able in the local context; being able to identify, activate and adapt resources, as well as supportive structures and personal competence. Meaningfulness was experienced through being able to define processes; perceptions of goal-attainment; visibility of contributions and impact, as well as experiences of learning and social cohesion. Implications of findings for practice and theory are discussed.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e \u003cp\u003eApplying Salutogenesis unto municipal collaboration processes yielded valid insights into how coherence can be understood and assessed beyond individual experiences. A shared vision about the common aims; the anchoring goals and procedures; the structure and content of collaboration activities (inclusive joined and mutual learning sessions) as well as the presence of feed-back loops emerge as important assets and valid entry points to facilitate for coherent experiences and processes in municipalities. The novel application of the theoretical framework can contribute to develop Salutogenesis as a sound theory for settings-based approaches within Health Promotion.\u003c/p\u003e","manuscriptTitle":"Perceptions of coherence during planning for local Public Health Work: building capacity and developing theory through collaborative action research","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-12 06:20:11","doi":"10.21203/rs.3.rs-8395684/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-27T15:12:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-16T13:25:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"159625160685287143088473644214457325804","date":"2026-04-13T07:45:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"28200787680329839999661103088744720979","date":"2026-04-10T10:53:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"318443965165618756026537779220830099963","date":"2026-04-09T07:15:13+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-07T15:15:17+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-07T15:10:53+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-07T12:55:34+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-07T10:11:02+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-01-07T10:01:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8c26f35b-df8a-4cc0-8e53-3c58bface92e","owner":[],"postedDate":"January 12th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-12T06:20:11+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-12 06:20:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8395684","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8395684","identity":"rs-8395684","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}