Patterns in bottlenecks for implementation of health promotion interventions: a cross-sectional observational study on intervention-context interactions in the Netherlands.

BACKGROUND: From a complex systems perspective, implementation should be understood as the introduction of an intervention in a context with which it needs to interact in order to achieve its function in terms of improved health. The presence of intervention-context interactions could mean that during implementation particular patterns of crucial interaction points might arise. We examined the presence of - and regularities in - such 'bottlenecks for implementation', as this could create opportunities to predict and intervene in potential implementation problems. METHODS: We conducted a cross-sectional observational study against the background of municipal intersectoral policymaking in the Netherlands. We asked implementers of health promotion interventions to identify bottlenecks by rating the presence and importance of conditions for implementation in a range of intervention systems. We used descriptive statistics to characterize these systems (by their behaviour change method, health theme and implementation setting) and the conditions that acted as bottlenecks. After stratifying bottlenecks by intervention system and the system's characteristics, we tested our hypotheses by comparing the number and nature of the bottlenecks that emerged. RESULTS: More than half of the possible conditions were identified as a bottleneck for implementation. Bottlenecks occurred in all categories of conditions, e.g., relating to the implementer, the intervention, and political and administrative support, and often connected with intersectoral policymaking, e.g., relating to the co-implementer and the co-implementer's organization. Both our hypotheses were supported: (1) Each intervention system came across a unique set of - a limited number of - conditions hampering implementation; (2) Most bottlenecks were associated with the characteristics of the system in which they occurred, but bottlenecks also appeared in the absence of such an association, or remained absent in the presence thereof. CONCLUSIONS: We conclude that intervention-context interactions in integrated health policymaking may lead to both regularities and variations in bottlenecks for implementation. Regularities may partly be predicted by the function of an intervention system, and may serve as the basis for building the capacity needed for the structural changes that can bring about long-lasting health improvements. Variations may point at the need for flexibility in further tailoring the implementation approach to the - mostly unpredictable - problems at individual sites.

Does partnership diversity in intersectoral policymaking matter for health promoting intervention packages' composition? A multiple-case study in the Netherlands.

Intersectoral policymaking to improve public health includes integrated health promotion (HP) intervention packages that address a variety of health behavior determinants. The involvement of different partners is assumed to be necessary to implement such integrated packages. We examined how partnership diversity was associated with the composition of intervention packages implemented in Dutch municipalities. In a longitudinal multiple-case study (2012-14), we collected questionnaire data among 31 project leaders and 152 intervention implementers in 31 (alliances of) municipalities. Package composition was assessed in terms of intervention strategies, implementation settings and targeted behavioral determinants. Partnership diversity during the adoption and implementation phases was assessed in terms of the actors and sectors, as well as private partners and citizens involved. The association between partnership diversity and package composition was examined using crosstabs. Almost all packages integrated multiple strategies, but mostly education, facilitation and case finding, in multiple, but mostly health and public settings, such as schools. The packages targeted diverse behavioral determinants, although mainly personal and social environmental factors. A variety of partners from multiple sectors was involved, during both adoption and implementation of the packages. However, partners from the health, welfare and education sectors were mostly involved. More partnership diversity, especially during implementation, was associated with more integrated intervention packages. In intersectoral policymaking, investment in diversely composed partnerships seems worthwhile for implementing integrated intervention packages. However, investments in other conditions, like framing health issues and network management, are also needed to make environmental determinants of health behavior the object of HP.

Energy, saturated fat and fibre intakes among Dutch children and adolescents at breakfast and implications for educational messages.

The aim of this study was to assess energy, saturated fat and fibre intakes at breakfast among Dutch youngsters aged 10-19 years and the extent to which they meet nutritional value recommendations and the educational messages on food group intake by the Netherlands Nutrition Centre (NNC). A cross-sectional design was used and data were collected through an online questionnaire among 2380 students attending 71 Dutch schools for primary and secondary education. Energy intake at breakfast was, on average, 15.8% of daily recommended energy intake; mean saturated fat intake was 7.5 en% and mean fibre intake 1.0 g per 100 kcal. Of the participants, 67.2% met the saturated fat intake recommendation and 35.3% the fibre intake recommendation. In addition, 25.5% were assessed to have an adequate energy intake based on daily recommended, but not individually measured, age- and gender-specific energy intake. Most participants consumed products from the grains food group, in combination with products from one or two other food groups. Consumption from two or more food groups resulted in less favourable intake. Our study found generally inadequate fibre intake at breakfast as well as an indication of inadequate energy intake at breakfast among Dutch youngsters. The educational message of the NNC to consume at least (wholemeal) bread or another fibre-rich product (cereals) at breakfast seems realistic in terms of compliance and favourable in terms of the resulting nutritional value. The educational message to preferably eat from each of the five main food groups should be reconsidered.