Grêaux K M, van Assema P, Bessems K M H H, de Vries N K, Harting J
Department of Health Promotion, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre+, PO Box 616, 6200 MD, Maastricht, the Netherlands.
Caphri School of Public Health and Primary Care, Department of Health Promotion, Maastricht University Medical Centre+, PO Box 616, Maastricht, 6200 MD, the Netherlands.
Arch Public Health. 2023 Oct 17;81(1):183. doi: 10.1186/s13690-023-01196-y.
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.
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.
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.
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.
从复杂系统的角度来看，实施应被理解为在一种环境中引入一项干预措施，该干预措施需要与这种环境相互作用，以便在改善健康方面发挥其功能。干预与环境的相互作用的存在可能意味着在实施过程中可能会出现关键互动点的特定模式。我们研究了这种“实施瓶颈”的存在情况及其规律，因为这可能为预测和干预潜在的实施问题创造机会。
我们在荷兰市政部门间政策制定的背景下进行了一项横断面观察性研究。我们要求健康促进干预措施的实施者通过对一系列干预系统中实施条件的存在情况和重要性进行评分来识别瓶颈。我们使用描述性统计来描述这些系统（根据其行为改变方法、健康主题和实施环境）以及作为瓶颈的条件。在按干预系统及其特征对瓶颈进行分层后，我们通过比较出现的瓶颈的数量和性质来检验我们的假设。
超过一半的可能条件被确定为实施瓶颈。瓶颈出现在所有类别的条件中，例如与实施者、干预措施以及政治和行政支持有关的条件，并且常常与部门间政策制定相关，例如与共同实施者及其组织有关的条件。我们的两个假设都得到了支持：（1）每个干预系统都遇到了一组独特的——数量有限的——阻碍实施的条件；（2）大多数瓶颈与它们出现的系统的特征相关，但在没有这种关联的情况下也会出现瓶颈，或者在存在这种关联的情况下也不会出现瓶颈。
我们得出结论，综合健康政策制定中的干预与环境相互作用可能导致实施瓶颈既有规律又有变化。规律可能部分由干预系统的功能预测，并可作为构建实现长期健康改善所需的结构变革能力的基础。变化可能表明需要灵活性，以便根据各个地点大多不可预测的问题进一步调整实施方法。
