Flexibility or Fidelity? The Implementation Dilemma in Community-Based Health Promotion

Flexibility or Fidelity? 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The Implementation Dilemma in Community-Based Health Promotion Calina Leonhardt, Sigurd Lauridsen, Dina Danielsen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8670170/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background: Childhood overweight and obesity are major public health challenges, linked to social inequality. Community-based and system-oriented interventions have been promoted as alternatives to individually focused approaches, yet their implementation remains poorly understood. This study examines the implementation of a flexible and locally anchored community-based health promotion programme targeting children aged 0–10 years in socioeconomically disadvantaged areas in Danish municipalities. Methods: The study draws on data from a process evaluation conducted from 2020 to 2024. The data includes 37 semi-structured interviews with practitioners, heads of institutions, and programme coordinators; 34 days of participant observation; annual implementation logs; and programme materials. Data were analysed using cross-thematic analysis. Results The programme’s broad, non-prescriptive framing created shared language, legitimacy and coordination, and it enabled staff to recognise and strengthen ongoing efforts. It also meant that implementation often centred on selecting and amplifying existing practices, whereas more demanding activities were downscaled or postponed, with substantial local variation shaped by capacity. These dynamics illustrate an inherent tension in implementation: Relying on established practices supports uptake, yet it risks producing incremental adjustments that may reinforce existing advantages and insufficiently address social inequality. We conceptualise these outcomes as a mix of meaningful alignment and superficial change. Conclusion Flexible, locally anchored community-based programmes can foster ownership and legitimacy, but risk remaining largely symbolic when they rely heavily on existing practices and frontline discretion. To avoid reinforcing inequalities, such designs require clearer expectations, supportive governance structures and targeted resources that explicitly address structural conditions in children’s everyday environments. Community-based interventions health promotion child obesity implementation social inequality. Introduction Childhood overweight and obesity are some of the major public health concerns of the 21st century. These conditions are associated with a broad range of physical and psychosocial consequences in childhood and later life, including increased risk of chronic diseases, social stigmatisation, and reduced quality of life (De Pergola & Silvestris, 2013; Flint et al., 2025; Pereira et al., 2019; WHO, 2024). Although obesity prevention has long been a policy priority, progress has been limited. Traditional approaches have emphasised individual behaviour change and parental responsibility, yet these interventions have yielded modest and inconsistent effects (Barte et al., 2010; Hayba et al., 2021; Hodder et al., 2022; Ickes et al., 2014; Peckmezian & Hay, 2017; Spiga et al., 2024). Moreover, childhood obesity is closely linked to social inequality (Iguacel et al., 2021; The Danish Health Authority, 2018). Children from socioeconomically disadvantaged families are disproportionately affected, partly due to, for example, lower parental education, limited health literacy, economic constraints that restrict access to nutritious food, physical activity, and support services, as well as additional risk factors such as minority ethnic background, parental mental illness, and limited parental support networks (Iguacel et al., 2021; The Danish Health Authority, 2018). These challenges are further shaped by structural conditions within institutions. Processes of inequality in the education system are well-documented (Ellegaard, 2007; Munch, 2007; Palludan, 2005), and even when staff in schools and childcare settings are professionally equipped and committed, limited resources and systemic demands may hinder equitable implementation of health promotion initiatives. As a result, the structural conditions shaping children’s everyday lives both increase their risk of obesity and reduce the effectiveness of preventive interventions (Croizet et al., 2019; Iguacel et al., 2021). Over the past two decades, understandings of childhood obesity have slowly but increasingly recognised its complex social, institutional, and structural determinants. This has shifted the field from individually targeted interventions towards community- and system-oriented approaches that aim to reshape the broader environments in which children live (Kelleher et al., 2017; O’Mara-Eves et al., 2013; Wolfenden et al., 2014). Community-based health promotion initiatives, in particular, seek to engage multiple stakeholders (such as preschools, schools, community organisations, and municipal services) in developing healthier everyday environments for children (Nickel & von dem Knesebeck, 2020a; O’Mara-Eves et al., 2013). Introducing The Child life in healthy balance programme – a community-based approach to childhood obesity The Child life in healthy balance programme is a community-based health promotion initiative developed by Local Government Denmark, the national association representing Danish municipalities (LGD, 2022). It ran from 2020 to 2024 in three municipalities with a high prevalence of childhood overweight and obesity and was followed by a five-year municipal commitment period, during which municipalities pledged to sustain the programme’s principles and activities. In total, the programme targeted approximately 6,500 children aged 0–10 years living in ten selected local areas characterised by socioeconomic disadvantage and higher rates of overweight and obesity among children. The programme was grounded in research on community-based health promotion and system-oriented interventions and structured around three overarching themes: 1. Healthy eating and drinking; 2. Play and physical activity; 3. A shared responsibility for promoting healthy communities for children. It did not provide a prescriptive definition of ‘healthy eating’ or ‘healthy weight development’. Instead, its goals were deliberately broad and open to interpretation by local actors. While the underlying outcome focus was on children’s weight trajectories and well-being, as measured through national health registers maintained by school and home health nurses, the practical orientation of activities emphasised creating supportive everyday environments. In practice, this has involved initiatives such as encouraging children to try new foods, incorporating opportunities for physically active play, fostering stronger connections within local communities, and strengthening families’ access to consistent, health-promoting routines, including regular mealtimes, sleep schedules, and opportunities for active play, beginning in infancy. Implementation of community-based initiatives Although the limitations of interventions focused solely on individual responsibility have prompted a turn toward more whole systems- and community approaches and interventions, these types of interventions continue to encounter substantial implementation challenges. Resistance to change, unclear responsibilities, professional boundary concerns, and cumulative burdens from overlapping initiatives are well-documented barriers in implementation science and in whole systems community interventions. These barriers may be even more pronounced in community-based approaches, where interventions must span organisational boundaries and engage diverse professional groups in cross-sectoral collaboration (Breitenstein et al., 2010; Cordova-Pozo, 2022; Kelleher et al., 2017; Khatri et al., 2024; Paulsen et al., 2023). Systematic reviews further suggest that evidence of effectiveness of these approaches remains inconclusive, particularly when implementation quality is poor or uneven (Breitenstein et al., 2010; Nickel & von dem Knesebeck, 2020a, 2020b; O’Mara-Eves et al., 2013; Wolfenden et al., 2014). In response, public health researchers have increasingly recommended intervention designs and implementation strategies that align closely with local practices, build on existing infrastructures, and allow for contextual adaptation rather than imposing rigid, externally defined programmes (Grunewald & Foley-Nicpon, 2023; Hawe, 2015; Hawkes C. et. al, 2017; Nobles et al., 2022), so-called ‘add-in’ approaches (Bentsen et al., 2020). While such designs are often presented as solutions to long-documented barriers, they also raise critical questions about intervention coherence and the preservation of mechanisms of change. The debate typically centres on the persistent tension between fidelity, which involves delivering an intervention as intended by its developers, and adaptation, which involves modifying components to better suit local contexts (Breitenstein et al., 2010; Durlak & DuPre, 2008; Fixsen, 2025). However, in whole systems- and community-based programmes, fidelity is rarely the point. These interventions are explicitly designed to be flexible and to embed themselves within existing practices rather than deliver a uniform package (Bentsen et al., 2020). In this article, we use the Child life in healthy balance programme as a case to examine and illustrate a persistent and foundational dilemma in the implementation of community-based health interventions, namely that implementation strategies which seek to integrate new initiatives by building upon existing practices may inadvertently undermine transformative potential in two critical ways: Risk of superficial change : When new interventions are aligned too closely with existing routines, there is a risk that no substantive change occurs. The initiative may be perceived as a continuation of current practice, resulting in either no change at all or, at best, an incremental increase in activities already being undertaken. Reinforcement of structural inequalities : By relying on and amplifying existing practices, implementation may reproduce the very social structures and processes that contribute to health inequities. In doing so, interventions risk perpetuating unequal outcomes, rather than challenging or disrupting the mechanisms that sustain them. The article seeks to advance understanding of how community-based health promotion initiatives unfold during implementation. In particular, it explores what such processes reveal about the promises and limitations of flexible, context-sensitive intervention designs as a strategy for preventing childhood obesity and reducing inequality in health among children. Methodology This study draws on qualitative data collected as part of the qualitative process evaluation of the implementation of the Child life in healthy balance programme, put into practice by Local Government Denmark, the national association representing Danish municipalities, in three Danish municipalities. Rather than assessing outcomes, the evaluation was designed to trace implementation processes in a community-based intervention, focusing on how broad, cross-sectoral goals were interpreted, developed, coordinated, and enacted across organisational boundaries over time. Unlike many traditional public health interventions, the Child life in healthy balance programme did not provide designated funding for intervention components, prescriptive activities, or detailed manuals for participating institutions. Rather, it relied on a local municipal coordinator in each municipality (two full-time and one part-time) to facilitate dialogue across institutions and encouraged local discretion in the participating institutions so that each setting could embed the programme’s goals within existing practices. Broad programme interventions and subgoals were co-created with local stakeholders and distributed across several key community actors, each with specific responsibilities within the three overarching themes: Home nursing. Home health nurses play a central role in the Danish welfare system, supporting families from infancy and through childhood via home and school visits. Within the programme, the nurses were tasked with expanding their support to families statistically at risk of childhood overweight, based on indicators such as parental education and weight. Their intervention components were the most prescriptive in the programme and included additional home visits, proactive phone calls to families with infants aged 0–6 months to support breastfeeding or healthy bottle-feeding habits, and follow-up calls with selected families to encourage early health-promoting routines. They were also expected to provide resources – such as pamphlets or simple tools for play and movement – ensuring families were better equipped to establish healthy lifestyles. Daycare facilities (nurseries and kindergartens). In Denmark, most children aged 0–6 attend daycare facilities, making these settings pivotal for shaping everyday routines. The programme encouraged daycare educators to work with themes of healthy eating, active play, and shared experiences in the local community. Rather than introducing new activities and specified intervention components, the programme sought to support staff in integrating health-promoting practices into existing pedagogical routines. Goals were co-created with selected institutions and included enhancing food acceptance, stimulating curiosity about local surroundings, and embedding movement and play into daily schedules in feasible, adaptable ways tailored to each institution’s resources. Schools and after-school programmes. Teachers, educators and school nurses were tasked with reinforcing health promotion in primary school contexts. After-school programmes in Denmark serve children in the four first years of primary school (ages 6–9), focusing on social development and structured recreation. In schools and after-school programmes, teachers and educators were asked to develop their own action plans detailing how they would integrate the programme’s broad goals, such healthier food practices, physical activity, and well-being promotion into both school and after-school environments. The purpose was to normalise health-promoting habits within institutions that play a daily role in children’s lives and to extend support beyond early childhood settings. Community organisations and associations . As the programme included an overall goal of shared responsibility in the community, unspecified local organisations and associations were envisaged as participants in the programme. This included organisations such as sports clubs, libraries, and cultural or voluntary associations. These actors were expected to collaborate with schools and daycare facilities to create coherent opportunities for children to engage in healthy activities beyond institutional settings. Local businesses . Shops and supermarkets were envisioned as partners in shaping healthier community environments, for example by increasing access to healthy foods. Although recruitment challenges meant that few business representatives participated directly, their potential contribution was addressed indirectly through municipal coordinators and institutional actors. By spanning across these diverse sectors, the programme aimed to foster a shared responsibility for child health across the community. The design allowed for considerable flexibility: Each institution was encouraged to adopt the programme’s principles in ways that were realistic and contextually appropriate, thereby reducing resistance to change, professional boundary conflicts, or the burden of overlapping initiatives. The Child life in healthy balance programme serves as a compelling example of a locally driven, contextually responsive approach to health promotion. It combined broad, loosely formulated goals with substantial professional discretion and cross-sector collaboration. Its architecture was thus designed to build on existing infrastructures and routines, aiming to create sustainable, community-wide environments that support children’s well-being and healthy weight development. Participants and recruitment Participants in this study represented practitioners from the settings targeted by the programme: Home and school health nurses, educators from kindergartens and daycares, teachers and educators from schools and after-school programmes, municipal programme coordinators, and representatives from civil society organisations and community associations. Recruitment was coordinated through Local Government Denmark, municipal programme coordinators, and institutional managers, who identified professionals directly involved in day-to-day implementation. The sampling strategy sought coverage of all programme settings, inclusion of both managerial staff and frontline practitioners, and a roughly even distribution across municipalities. Due to recruitment challenges, uneven implementation of specific initiatives, and limited access to particular settings, no local businesses and only a small number of voluntary associations and schoolteachers were interviewed directly. Their role was instead addressed indirectly through the perspectives of other actors. Data collection and sources To investigate the practical enactment of the intervention activities, we combined methods that capture both accounts (what actors say they do and why) and situated practice (what happens in context), and we integrated programme-level documentation to recover the coordination layer. Data collection was longitudinal (2020–2024) and multi-sited, enabling observation of development and adaptations as they unfolded in routine practice. Semi-structured interviews We conducted 37 semi-structured interviews with practitioners and heads of institutions across the three municipalities. Interviews included individual and small-group formats (typically 2–3 participants where relevant) and followed guides structured around the following: experiences with the programme – from development of concrete activities to ownership and local anchoring processes; local interpretation of its principles; concrete implementation activities; coordination across sectors; and perceived effects. Interviews began with open prompts and moved to more specific probes (Brinkmann, 2014). Most lasted approximately 60 minutes and were conducted in situ or held online (Microsoft Teams) to accommodate resource-constrained settings. Interviews were conducted by the last author (XX), with additional contributions from research assistants and students. All interviews were audio-recorded with consent and transcribed verbatim. A subset of participants was interviewed more than once, providing a longitudinal lens on implementation. Observations A total of 34 days of participant observation were conducted during the implementation period, covering workshops, planning meetings, thematic events, and everyday health-promotion practices. Observations followed a participant-observer stance with low interference (Tjørnhøj-Thomsen & Whyte, 2008). Fieldnotes were taken contemporaneously and expanded afterwards. Observational attention centred on how programme goals were translated and embedded in routines, interprofessional collaboration, discretionary work at the frontline and the local interpretation of programme goals and activities. Implementation logs To recover the trajectory and scope of implementation efforts, we analysed annual implementation logs prepared by municipal programme coordinators between 2021 and 2024. Logs summarised local activities, collaborations, adaptations, and reflections on contextual enablers/barriers across daycare and school settings. These documents provided a structured, longitudinal overview of coordination work and system-level adjustments that are not always visible in interviews or brief observations. Programme materials We additionally reviewed programme materials (e.g. agendas and minutes, communication artefacts, presentations, guidance documents) generated across the programme cycle. These materials offered insight into framing, decision processes, and the evolving articulation of goals and responsibilities across sectors, complementing practitioner accounts and observations. Table 1: Overview of data sources and material from included municipalities Home nurses Daycare facilities Schools and after-school programmes Programme employees Interviews Municipality 1 4 4 2 2 Municipality 2 4 6 4 2 Municipality 3 3 4 6 2 Cross-municipality interviews 0 0 0 3 Total 11 14 12 9 Participant observations Municipality 1 0 0 0 0 Municipality 2 0 4 7 0 Municipality 3 0 0 1 0 Cross-municipality events 8 12 2 8 Total 8 16 10 8 Implementation logs Municipality 1 4 4 4 4 Municipality 2 4 4 4 4 Municipality 3 4 4 4 4 Total 12 12 12 12 Additional programme materials Cross-municipality materials 11 1 6 5 Total 11 1 6 5 Analytical Approach All data sources (interviews, fieldnotes from observations, implementation logs, and programme materials) were imported into the qualitative software programme NVivo for systematic coding and analysis. We applied cross-thematic analysis (Terry et al., 2017), combining deductive and inductive strategies. Deductive codes were based on the interview guides and the study’s overall focus on implementation processes, while inductive coding allowed new and unanticipated themes to emerge from the material. The analysis aimed to identify common patterns as well as variations across different settings and actor groups, with particular attention to how the programme’s broad goals were interpreted, negotiated, and enacted in practice. Themes were iteratively refined through discussion within the author group to ensure analytical consistency and depth. Findings A Broad, Flexible, and Indistinct Programme As described, the principles of Child Life in Healthy Balance were framed as broad, high-level goals rather than specified activities. At launch events and thematic days, the programme developers explicitly emphasised that local institutions were responsible for interpreting the goals themselves (school observation at a teacher implementation workshop ). Across arenas and professional groups, participants portrayed the initiative as open and flexible. As one daycare manager put it: ‘And now [ Child Life in Healthy Balance ], it is so easy to lean on, because you can’t really disagree with those principles’ (Daycare manager 3 ). Several participants contrasted the programme’s breadth with earlier, more prescriptive top-down initiatives. They emphasised this openness as an advantage, not least because it did not entail additional resources or workload: ‘I don’t think [the programme activities] take time, and I also don’t think there are any financial costs in it, because [the effort] has more to do with a mindset than with time and economy. [The Child Life in Healthy Balance -programme] is really, what we make of it.’ (Pedagogical leader 1 ) A manager explained how the programme encouraged reflective work that qualified existing practice rather than adding tasks, noting that reflecting on the programme made her “more qualified when I go out to support my staff in their work with the children.” (Daycare manager 3). This openness was often described positively, especially in comparison with past experiences of top-down initiatives. Yet some also voiced concerns that the broad framing risked being ‘unambitious’ (quote from an observation in a daycare) and ‘unlikely to generate real change’ (quote from a school observation at an implementation workshop ). A municipal programme coordinator further noted that some participants found the lack of specificity difficult to operationalise: ‘That which is a bit vague also makes it a bit more… well, unmanageable. They can’t really picture it, what are they supposed to do, and what is their role?’ (Municipal programme coordinator 1). Selecting and Amplifying Existing Practices Because the programme placed few binding demands and left interpretation to local actors, institutions could decide for themselves how to implement it. A consistent pattern across arenas, management levels, and professions was to select and frame actions so that they extended what was already being done. One daycare manager recalled how an initial sense of overload quickly turned into a strategy of amplification: ‘Right at the beginning I thought ‘oh okay, this is a lot’ […]. Should we do something new, or should we try to look at what we are already doing and that makes sense within this project? We added a bit and increased our attention to some things that we probably needed to focus on a bit more. But there are also many things that we were already doing, where I think ‘well, that just goes hand in hand with this project […]’. That has made the project a bit more digestible and slightly less overwhelming.’ (Daycare manager 4 ) She elaborated that their approach was one of fit rather than overlay: ‘We haven’t taken [ Child Life in Healthy Balance ] and forced it on the institution. We have looked at the institution and how it complements [ Child Life in Healthy Balance ] […]. The things we already do are amplified.’ (Daycare manager 4 ). Other managers framed the programme as already largely implemented from the outset: ‘Well, I actually think we already did most of it. […] In fact, much of it is implemented, because we have already focused on it. and I think… well, we call it Child Life in Healthy Balance , but it was something we were already doing.’ (Daycare manager 1 ) During a themed day for the schools, workshop tasks that invited participants to decide whether they would implement new actions (e.g. adding movement to lessons) elicited the response that such activities were already habitual (school observation at an implementation workshop ). Home nurses framed programme materials, such as additional questions focusing on meals, similarly as a nudge to existing conversations: ‘But we have had them laminated, so we can bring them to the family home visits […] and it is something we already talk about anyway, but I just think you get that little bit of extra attention on it, right?’ (Home nurse 6) . Where new components were discussed, the different actors and institutions reverted to what was feasible within current constraints. For instance, collaboration with local associations was deprioritised where infrastructure was lacking. Likewise, ambitions to teach all children how to ride bicycles were moderated by children’s uneven access to bikes. At a themed day for schools, staff initially discussed ambitious changes such as reforming the canteen to promote healthier food in line with the programme goals. Yet managers encouraged them to focus instead on simpler activities more closely aligned with existing routines. Ultimately, action plans described practices already in place, according to the staff (school observation at an implementation workshop ). Recognition, Visibility, and a Shared Language Participants repeatedly described the programme as a way to notice, value, and articulate what they were already doing. As one kindergarten educator put it, ‘It is kind of a gentle push to keep on doing what we are doing’ (Educator from a daycare 3). Managers stressed that this recognition was intentional and motivating: ‘This shouldn’t require any additional work. That is what is so wonderful about something like this […]’ (Daycare manager 2). Another manager emphasised the importance of acknowledgement as a way to sustain morale: ‘It is also about clearly acknowledging what they do, so they become aware of the good they are doing. Because everyone contributes something positive.” (Daycare manager 3). This recognition was operationalised discursively in everyday forums: ‘[We have] group meetings and staff meetings, and we also have pedagogical days. Whenever something comes up, I mention [ Child Life in Healthy Balance ] and say, ‘See, this falls under that. This is what you are already doing. We just need to do more of it.’ (Daycare manager 3) In short, implementation largely took the form of reframing and making visible, with high acceptance and little overt resistance. This was evident across settings and professional groups. Shifting Responsibility, Conflicts, and Pragmatic Pacing Despite broad consensus on the value of the programme, tensions emerged once principles had to be enacted in practice. One after-school manager described this gap between agreement and action: ‘Fundamentally, everyone thinks [the ambitions behind Child Life in Healthy Balance ] are super great. Yes, I mean everyone […] But who is supposed to carry it out? Yes, well, no one can say we think that sounds bloody stupid. We are in favour of obesity and isolation? But it is about the execution; that is, the transition from thought to action. That is really what is the issue here.’ (Manager from an after-school programme) A municipal programme coordinator similarly noted that professionals did not object to the content or the aims of the programme as such. Instead, tensions arose when they were confronted with how these aims should be realised in practice: “[No one disagrees] about the content and the purpose and such. They have, of course, had reservations in relation to – both in daycare and school – the question of how far one can go. But it is more ethical considerations […]. So there have been some reservations, but it is more in terms of how to approach it. There haven’t really been reservations about the content. I have not experienced that.’ (Municipal programme coordinator 2) She described how conflicts emerged surrounding the execution, when staff had to engage in potentially uncomfortable tasks such as initiating dialogue with parents about unhealthy lunchboxes or addressing the behaviour of children who were less physically active. These issues were echoed in schools and after-school programmes, where staff reported discomfort in intervening in children’s habits and routines: ‘In in our after-school programme, we’ve decided to spend time outdoors with the children. But there’s actually quite a large group – especially of girls – who really just want to draw or to sit and tinker with something. So, the challenge is constantly figuring out how to really also reach those children who, in reality, just want to draw with a friend or play with dolls. And how much should we force them?’ (Manager from an after-school programme) Across arenas, actors consistently shifted responsibility for children’s health behaviours onto others. Daycare managers tended to point to schools and parents as the settings where problems concerning children’s health practices arose, while school staff shifted responsibility back to daycare and after-school programmes. In turn, after-school staff highlighted both schools and families as those ultimately responsible. In this way, responsibility circulated between arenas without being firmly anchored anywhere. As one daycare manager explained: ‘We serve food at the institution, so it is not a problem here. It becomes a problem when they start school [and start bringing lunchboxes]. […] Yes, so that is really where [the problem] lies. There is simply a shift.’ (Daycare manager 4) This account illustrates how responsibility for change was externalised: The daycare was positioned as unproblematic, while the onset of school was framed as the point at which unhealthy practices emerged. Similar reasoning was found across settings, with each arena acknowledging the importance of the programme’s goals while emphasising that decisive action needed to be taken elsewhere. Thus, even though there was broad consensus about the value of the principles, there was no shared agreement about who should actually modify practices in order to achieve them. In effect, the responsibility for change was displaced from one institutional site to another, leaving the programme’s objectives widely endorsed in principle but weakly enacted in practice. Finally, the absence of clearly defined success criteria meant that avoidance of resistance often took precedence over adherence to specific principles. Local managers described how municipal programme coordinators encouraged them to downscale or delay expectations when necessary: ‘She [the municipal programme coordinator] has great respect and listens when we say ‘no, it is too much’. [Then she says] ‘You are welcome to cut it down a bit.’’ (Daycare manager 2). Another manager added: ‘[The municipal programme coordinator] is actually really good at saying that maybe [that specific programme goal should] not [be implemented] right now, and we will revisit it at another time’ (Daycare manager 4) . Inspired by this approach from the municipal programme coordinators, local managers adopted similar strategies with their own staff. One explained how she adjusted expectations and simplified the programme to make it more manageable: ‘It is about translating [the material] to make it digestible and then controlling the pace. If I roll it out too quickly, I can immediately see their reaction, so I just have to pull back a little […]. If I asked for the wrong [principle or activity], then I need to find something else and sell that instead.’ (Daycare manager 4) This mindset was also visible among frontline staff, who framed success in relative and flexible terms. As one home nurse argued: ‘Well, I think in some way that you have to try to set the bar where it is realistic. If they only do it 30% of the time, then it is actually okay. Then we have come a really long way […]. It is better to have 30% that is good than 50% that is mediocre. So, in a way, it is about trying to have an awareness of where our success criteria actually lie, so we don’t set the bar somewhere completely utopian. I actually think that is one of the most important things to focus on, where we set the bar”. (Home nurse 5) To sum up, the findings point to two overarching outcomes. First, the programme’s broad and flexible goals worked well to generate a shared language, legitimacy, and coordination across participating institutions. Professionals valued the absence of prescriptive demands and the opportunity to align goals with their existing practices, which facilitated acceptance and limited overt resistance. Second, however, the same openness made it less effective in committing partners to concrete tasks or providing guidance on how such tasks should be carried out. As a result, implementation often took the form of selecting and amplifying existing activities, legitimising ongoing practices, and offering visibility rather than driving substantial new change. Ambitious elements were frequently downscaled, delayed, or reframed, and responsibilities shifted across arenas, occasionally creating tensions around sensitive practices such as addressing individual parents or children directly. Discussion This discussion interprets the implementation processes observed in Child Life in Healthy Balance , situating them within implementation and policy theory to explain why locally flexible, community-based designs can generate legitimacy yet struggle to produce structural change. We use Matland’s Ambiguity–Conflict framework and Lipsky’s street-level bureaucracy to illuminate how ambiguity, discretion, and frontline-coping strategies shape outcomes, and we consider the equity implications of privileging adaptation over specification. Finally, we draw out practical implications for programme design and implementation and identify priorities and recommendations for future interventions and research. Superficial Change and Symbolic Implementation The programme’s flexible goals and absence of clearly specified intervention components make it difficult to analyse its implementation using conventional implementation science frameworks, which typically assume evidence-based, standardised components and a corresponding expectation of fidelity. Both the intervention design and our findings expose the limits of applying fidelity-oriented logics to open-ended, locally anchored initiatives such as Child Life in Healthy Balance . Programmes of this nature resemble public policies more than clinical interventions: They articulate broad goals that resemble overarching ambitions rather than specific programme aims, and their outcomes hinge on how actors at multiple levels interpret, negotiate, and implement them. Viewed through a policy implementation lens, our two overarching implementation findings (the programme’s success in generating shared legitimacy and language, and its limited capacity to produce concrete behavioural change) become more intelligible. Matland’s Ambiguity–Conflict Model (1995) helps explain why the programme was readily accepted yet limited in its transformative potential. The intervention was deliberately designed with high ambiguity in mind: Its goals were framed broadly (healthy eating, physical activity, shared responsibility), and its means were left undefined and open to local interpretation. At the same time, conflicts were few and far between. Practitioners and managers across settings endorsed the aims in principle, since few could oppose ‘healthier food’, ‘more play’, or ‘shared responsibility’. In Matland’s terms, the implementation thus falls in part into the category of experimental implementation, where outcomes depend on local sense-making and integration into existing routines rather than adherence to a central blueprint (Matland, 1995 ). This helps explain why the programme was perceived as legitimate, feasible, and motivating: It generated little resistance because actors were able to frame it as an extension of what they were already doing. Yet Matland also emphasises the consequences of such processes: Results are typically uneven and highly dependent on local capacity and initiative (Matland, 1995 ). Our findings support this concern: The settings consistently selected practices they were already able to deliver, while more demanding components were sidelined. At the same time, moments of conflict did arise, particularly around sensitive practices (e.g. addressing parents about lunchboxes), pushing the programme towards symbolic implementation , where broad principles are endorsed discursively but concrete behavioural change is avoided. Seen through this lens, the implementation of Child Life in Healthy Balance oscillated between experimental and symbolic modes. The programme secured wide legitimacy and embedded itself across local settings, but largely by being absorbed into existing routines, producing visible consensus rather than structural change. While Matland’s model highlights the role of ambiguity and conflict, it says less about how frontline actors manage such conditions in practice. Here, Lipsky’s ( 2010 ) theory of street-level bureaucracy offers a complementary perspective. According to Lipsky, public policies, which are often broadly defined and ambiguously formulated, are ultimately shaped by the discretionary actions of frontline professionals such as teachers, nurses, and social workers. Working under resource constraints and competing demands, these actors develop coping strategies to make policy operational. These include routinisation, selective implementation, shifting responsibility, and redefining goals – strategies that allow policies to appear implemented, even when their more ambitious aims are scaled back or left unaddressed. The implementation of the Child Life in Healthy Balance programme illustrates these mechanisms in practice. Faced with broad, non-prescriptive aims and no additional resources, practitioners responded by embedding programme goals into existing routines; a clear example of routinisation. Selective implementation was also evident, with actors prioritising familiar and feasible activities while sidelining more demanding components. For instance, collaboration with local associations was deprioritised in areas lacking infrastructure, and ambitions around diet or physical activity were scaled back to fit local capacities (e.g. cycling initiatives curtailed due to lack of bicycles). Responsibility shifting emerged as a recurring strategy across sectors, with daycares, schools, and after-school programmes each positioning themselves as already contributing sufficiently, while redirecting responsibility for children’s health behaviours to parents, other institutions, or external actors. In Lipsky’s ( 2010 ) terms, these practices reflect how frontline professionals manage the burden of implementation without overt resistance, thus maintaining the appearance of policy enactment while attenuating its more ambitious aims. Finally, managers and staff adopted pragmatic pacing and redefined goals. Expectations were lowered; implementation was slowed to avoid staff resistance, and success was reframed in relative terms (e.g. achieving 30% compliance deemed satisfactory). These strategies sustained morale and legitimacy but reduced the programme’s transformative potential. Situating Our Findings in Relation to Other Studies The following compares our findings with key studies on whole systems- and community-based programmes, highlighting how different design choices influence flexibility, coherence, and implementation outcomes. Breitenstein et al. ( 2010 ) emphasise the importance of fidelity (adherence, dosage, and delivery quality) for achieving outcomes in community interventions. This presupposes that there is a clearly defined intervention to be delivered. In the Child Life in Healthy Balance programme, however, no such prescriptive content existed. Instead, participating institutions were presented with broad goals to interpret locally. From this perspective, fidelity is not only difficult to measure but also conceptually misplaced. The programme’s design explicitly abandoned the fidelity paradigm, privileging flexibility and local discretion. The Amsterdam Healthy Weight Programme provides a useful comparison, as Child Life in Healthy Balance was partly inspired by its design. Like its Danish counterpart, the Amsterdam programme adopted a whole-systems framing, prioritised partnerships, and cultivated a collective sense of responsibility. Yet Amsterdam coupled this flexibility with a clearer governance scaffold: Key components included neighbourhood managers, formalised ‘Healthy Weight Pacts’, targeted professional training, and more specific outcome targets (Professionals Sociaal Domein, 2019 ). These mechanisms seemed to reduce ambiguity and sustained pressure on concrete practice change, thereby limiting drift into symbolic implementation. Both programme models valued flexibility and local adaptation, but Amsterdam’s design added specifications and enabling resources that appeared to translate shared narratives into more consistent operational change. Taken together, these comparisons highlight a central paradox. Community-based programmes with flexible, locally anchored designs, such as Child Life in Healthy Balance , are valuable for accommodating known implementation barriers and fostering legitimacy. At the same time, they often place considerable demands on frontline actors, who are expected to enact broad ambitions with limited support. This is not to suggest that such efforts should not be pursued, but rather that their equity implications must be taken more seriously. Without specified components or supportive governance structures, such as those employed in Amsterdam, these foundations risk remaining symbolic rather than transformative. Implications for Practice and Research Our findings highlight both the potential and the constraints of highly flexible, locally led implementation approaches. The openness of Child Life in Healthy Balance fostered engagement and limited resistance, yet it also meant that more demanding or transformative elements were frequently downscaled or postponed. The trade-off between flexibility and direction is therefore central: Aligning interventions with existing practices can support ownership and legitimacy, but extensive reliance on local discretion risks preserving the status quo and producing symbolic rather than substantive implementation. A key concern is the equity dimension. When interventions are embedded into routine activities without critical attention to the social dynamics these routines reproduce, they may unintentionally reinforce existing inequalities (Hansen et al., 2025). For example, initiatives promoting cycling offer limited benefit in areas lacking safe infrastructure or access to bicycles. Instead of addressing these disparities, the programme adapts downward to existing constraints, thereby normalising unequal conditions. In this way, flexibility can become a mechanism through which structural inequities are reproduced, particularly when constraints are treated as immutable rather than as targets for change. Conversely, more directive approaches – that emphasise fidelity to defined components or mechanisms – may generate resistance but are more likely to ensure that transformative elements are enacted in practice (Breitenstein et al., 2010 ; Durlak & DuPre, 2008 ; Fixsen, 2025 ). Importantly, implementing health promotion is demanding, and intervention developers often place considerable expectations on frontline professionals, typically without providing sufficient resources or support. This reality must be acknowledged more explicitly in programme design. Moreover, our findings do not suggest that community-based health promotion should be abandoned. Rather, they point to the need for more deliberate strategies to address inequality within these frameworks, for instance, in terms of discovering and recognising existing practices that produce and reproduce social inequality. When the goal is to reduce entrenched disparities, flexible designs must be complemented by targeted resources, clearer expectations, and accountability mechanisms that ensure equity is not left to chance. Finally, our study is also an example of how dominant frameworks and concepts from implementation science are ill-suited to capture the dynamics of open, community- and goal-oriented programmes. Policy implementation theory offers valuable concepts for understanding such programmes, highlighting how legitimacy, discretion, and coping strategies shape outcomes. Future research should continue to bridge insights from both fields to adequately conceptualise and assess the implementation of complex, community-based interventions. Strengths and Limitations This study has several strengths. First, the longitudinal design, covering the entire implementation period from 2020 to 2024, provides a strong basis for analysing how the programme unfolded over time and how practices evolved in response to changing conditions. Second, the inclusion of diverse professional groups – such as home and school health nurses, educators, teachers, heads of institutions, and municipal programme coordinators – enabled the study to capture perspectives from those directly engaged in implementing Child Life in Healthy Balance in everyday practice. Third, the use of multiple data sources, including semi-structured interviews, participant observations, implementation logs, and programme materials, enhanced methodological rigour. The triangulation of these materials not only strengthened validity but also offered a nuanced, multi-layered understanding of how the programme was interpreted and enacted across settings. However, some limitations should be noted. Recruitment of participants was mediated through gatekeepers such as programme developers, municipal programme coordinators and heads of institutions. This process may have influenced who was invited to participate, introducing the risk of selection bias towards more engaged or supportive staff. Recruitment challenges also meant that the distribution of participants across settings was uneven: Compared to daycare staff and home health nurses, fewer representatives from schools and after-school programmes were included, which may have limited the breadth of perspectives from those arenas. Access to certain groups was further constrained. Despite the programme’s ambition to involve community associations and local businesses, only a few representatives from voluntary organisations and no business actors were interviewed directly. Their roles were instead addressed indirectly through the accounts of other participants, which means that the analysis may underrepresent the perspectives of these stakeholders. Finally, periods of reduced access due to the COVID-19 pandemic created practical challenges for data collection, particularly in the early phases of the programme, and may have affected the depth of material obtained from certain settings. Despite these limitations, the study sought to mitigate them by ensuring coverage across all three participating municipalities, including participants from all key institutional arenas, and by collecting data at multiple time points in the project lifecycle. Taken together, the dataset provides a comprehensive and credible basis for analysing the implementation processes of a complex, community-based health promotion programme. Conclusion The implementation of Child Life in Healthy Balance reveals a central paradox in community-based health promotion: Flexibility and contextual sensitivity can foster legitimacy while constraining transformative change. The programme’s open goals enabled coordination and shared language across institutions but also encouraged routinisation and selective uptake, resulting in symbolic rather than substantive change. By embedding ambitions within existing routines, implementation risks reinforcing structural inequalities and perpetuating the very disparities interventions such as Child Life in Healthy Balance aim to reduce. Viewed through policy implementation theory, these dynamics reflect how high ambiguity and low conflict – combined with resource constraints and discretionary coping strategies among frontline actors – favour acceptance over transformation. However, the findings underscore that flexibility alone is insufficient for addressing complex challenges such as childhood obesity. Future designs must balance adaptability with mechanisms that safeguard equity and transformative intent. Declarations Competing interests The authors declare that they have no conflicts of interest related to this study. There are no financial, personal, or professional affiliations that could be perceived as influencing the content or outcomes presented in this manuscript. This study was conducted with full transparency and adherence to ethical standards, and the authors have no competing interests to disclose. Funding Data collection for the broader evaluation was supported by XXX. No specific funding was received for the preparation of this article. Author Contribution CL contributed to data acquisition, conducted the analysis, interpreted the findings and drafted the main manuscript. SL contributed to interpretation of findings and critically revised the manuscript for important intellectual content. DD contributed to data acquisition and conceptualisation, contributed to interpretation of findings, and critically revised the manuscript for important intellectual content. All authors reviewed and approved the final manuscript. Acknowledgements We sincerely thank the participants for their time and engagement, which provided valuable insights to this study. We also acknowledge the many individuals whose contributions and engagement made this research possible. References Barte, J., Ter Bogt, N., Bogers, R., Teixeira, P., Blissmer, B., Mori, T., & Bemelmans, W. (2010). Maintenance of weight loss after lifestyle interventions for overweight and obesity, a systematic review. Obesity reviews , 11 (12), 899–906. Bentsen, P., Bonde, A. H., Schneller, M. B., Danielsen, D., Bruselius-Jensen, M., & Aagaard-Hansen, J. (2020). Danish ‘add-in’school-based health promotion: integrating health in curriculum time. Health promotion international , 35 (1), e70–e77. Breitenstein, S. M., Gross, D., Garvey, C. A., Hill, C., Fogg, L., & Resnick, B. (2010). Implementation fidelity in community-based interventions. 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Danmarks Pædagogiske Universitetsforlag. Paulsen, L., Benz, L., Müller, C., Wallmann-Sperlich, B., & Bucksch, J. (2023). Personal determinants of change agents' decision-making behavior in community health promotion: a qualitative study. Bmc Public Health , 23 (1), 1731. https://doi.org/10.1186/s12889-023-16590-y Peckmezian, T., & Hay, P. (2017). A systematic review and narrative synthesis of interventions for uncomplicated obesity: weight loss, well-being and impact on eating disorders. Journal of eating disorders , 5 , 1–15. Pereira, M., Padez, C. M. P., & Nogueira, H. (2019). Describing studies on childhood obesity determinants by Socio-Ecological Model level: a scoping review to identify gaps and provide guidance for future research. Int J Obes (Lond) , 43 (10), 1883–1890. https://doi.org/10.1038/s41366-019-0411-3 Professionals Sociaal Domein (2019). Amsterdam will become the Healthiest City for Children! - Review 2012–2017 pt. 2. Spiga, F., Davies, A. L., Tomlinson, E., Moore, T. H., Dawson, S., Breheny, K., Savović, J., Gao, Y., Phillips, S. M., & Hillier-Brown, F. (2024). Interventions to prevent obesity in children aged 5 to 11 years old. Cochrane Database of Systematic Reviews(5). Terry, G., Hayfield, N., Clarke, V., & Braun, V. (2017). Thematic analysis. The SAGE handbook of qualitative research in psychology, 2(17–37), 25. The Danish Health Authority (2018). Forebyggelsespakke - Overvægt. T. D. H. Authority. https://www.sst.dk/-/media/Udgivelser/2018/Forebyggelsespakker/Overv%C3%A6gt.ashx?la=da&hash=F191DE073B818B27B87236507E3B4011B95580DA The Danish Ministry of Justice (2018). LOV nr 502 af 23/05/2018 - Databeskyttelsesloven. The Danish Ministry of Justice. Retrieved 14-09-2024 from https://www.retsinformation.dk/eli/lta/2018/502 Tjørnhøj-Thomsen, T., & Whyte, S. (2008). Fieldwork and participant observation. research methods in public health . In: Gyldendal Akademisk København. WHO (2024). Obesity and overweight. Retrieved 20-09-2024 from https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight Wolfenden, L., Wyse, R., Nichols, M., Allender, S., Millar, L., & McElduff, P. (2014). A systematic review and meta-analysis of whole of community interventions to prevent excessive population weight gain. Preventive Medicine , 62 , 193–200. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 23 Jan, 2026 Editor assigned by journal 23 Jan, 2026 Submission checks completed at journal 23 Jan, 2026 First submitted to journal 22 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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The Implementation Dilemma in Community-Based Health Promotion","fulltext":[{"header":"Introduction","content":"\u003cp\u003eChildhood overweight and obesity are some of the major public health concerns of the 21st century. These conditions are associated with a broad range of physical and psychosocial consequences in childhood and later life, including increased risk of chronic diseases, social stigmatisation, and reduced quality of life (De Pergola \u0026amp; Silvestris, 2013; Flint et al., 2025; Pereira et al., 2019; WHO, 2024). Although obesity prevention has long been a policy priority, progress has been limited. Traditional approaches have emphasised individual behaviour change and parental responsibility, yet these interventions have yielded modest and inconsistent effects (Barte et al., 2010; Hayba et al., 2021; Hodder et al., 2022; Ickes et al., 2014; Peckmezian \u0026amp; Hay, 2017; Spiga et al., 2024).\u003c/p\u003e\n\u003cp\u003eMoreover, childhood obesity is closely linked to social inequality (Iguacel et al., 2021; The Danish Health Authority, 2018). Children from socioeconomically disadvantaged families are disproportionately affected, partly due to, for example, lower parental education, limited health literacy, economic constraints that restrict access to nutritious food, physical activity, and support services, as well as additional risk factors such as minority ethnic background, parental mental illness, and limited parental support networks (Iguacel et al., 2021; The Danish Health Authority, 2018). These challenges are further shaped by structural conditions within institutions. Processes of inequality in the education system are well-documented (Ellegaard, 2007; Munch, 2007; Palludan, 2005), and even when staff in schools and childcare settings are professionally equipped and committed, limited resources and systemic demands may hinder equitable implementation of health promotion initiatives. As a result, the structural conditions shaping children’s everyday lives both increase their risk of obesity and reduce the effectiveness of preventive interventions (Croizet et al., 2019; Iguacel et al., 2021).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOver the past two decades, understandings of childhood obesity have slowly but increasingly recognised its complex social, institutional, and structural determinants. This has shifted the field from individually targeted interventions towards community- and system-oriented approaches that aim to reshape the broader environments in which children live (Kelleher et al., 2017; O’Mara-Eves et al., 2013; Wolfenden et al., 2014). Community-based health promotion initiatives, in particular, seek to engage multiple stakeholders (such as preschools, schools, community organisations, and municipal services) in developing healthier everyday environments for children (Nickel \u0026amp; von dem Knesebeck, 2020a; O’Mara-Eves et al., 2013).\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eIntroducing \u003cem\u003eThe Child life in healthy balance\u003c/em\u003e programme – a community-based approach to childhood obesity\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe \u003cem\u003eChild life in healthy balance\u003c/em\u003e programme is a community-based health promotion initiative developed by Local Government Denmark, the national association representing Danish municipalities (LGD, 2022). It ran from 2020 to 2024 in three municipalities with a high prevalence of childhood overweight and obesity and was followed by a five-year municipal commitment period, during which municipalities pledged to sustain the programme’s principles and activities. In total, the programme targeted approximately 6,500 children aged 0–10 years living in ten selected local areas characterised by socioeconomic disadvantage and higher rates of overweight and obesity among children.\u003c/p\u003e\n\u003cp\u003eThe programme was grounded in research on community-based health promotion and system-oriented interventions and structured around three overarching themes: 1. Healthy eating and drinking; 2. Play and physical activity; 3. A shared responsibility for promoting healthy communities for children. It did not provide a prescriptive definition of ‘healthy eating’ or ‘healthy weight development’. Instead, its goals were deliberately broad and open to interpretation by local actors. While the underlying outcome focus was on children’s weight trajectories and well-being, as measured through national health registers maintained by school and home health nurses, the practical orientation of activities emphasised creating supportive everyday environments. In practice, this has involved initiatives such as encouraging children to try new foods, incorporating opportunities for physically active play, fostering stronger connections within local communities, and strengthening families’ access to consistent, health-promoting routines, including regular mealtimes, sleep schedules, and opportunities for active play, beginning in infancy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplementation of community-based initiatives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAlthough the limitations of interventions focused solely on individual responsibility have prompted a turn toward more whole systems- and community approaches and interventions, these types of interventions continue to encounter substantial implementation challenges. Resistance to change, unclear responsibilities, professional boundary concerns, and cumulative burdens from overlapping initiatives are well-documented barriers in implementation science and in whole systems community interventions. These barriers may be even more pronounced in community-based approaches, where interventions must span organisational boundaries and engage diverse professional groups in cross-sectoral collaboration (Breitenstein et al., 2010; Cordova-Pozo, 2022; Kelleher et al., 2017; Khatri et al., 2024; Paulsen et al., 2023). Systematic reviews further suggest that evidence of effectiveness of these approaches remains inconclusive, particularly when implementation quality is poor or uneven (Breitenstein et al., 2010; Nickel \u0026amp; von dem Knesebeck, 2020a, 2020b; O’Mara-Eves et al., 2013; Wolfenden et al., 2014).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn response, public health researchers have increasingly recommended intervention designs and implementation strategies that align closely with local practices, build on existing infrastructures, and allow for contextual adaptation rather than imposing rigid, externally defined programmes (Grunewald \u0026amp; Foley-Nicpon, 2023; Hawe, 2015; Hawkes C. et. al, 2017; Nobles et al., 2022), so-called ‘add-in’ approaches (Bentsen et al., 2020). While such designs are often presented as solutions to long-documented barriers, they also raise critical questions about intervention coherence and the preservation of mechanisms of change. The debate typically centres on the persistent tension between fidelity, which involves delivering an intervention as intended by its developers, and adaptation, which involves modifying components to better suit local contexts (Breitenstein et al., 2010; Durlak \u0026amp; DuPre, 2008; Fixsen, 2025). However, in whole systems- and community-based programmes, fidelity is rarely the point. These interventions are explicitly designed to be flexible and to embed themselves within existing practices rather than deliver a uniform package (Bentsen et al., 2020).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn this article, we use the \u003cem\u003eChild life in healthy balance\u003c/em\u003e programme as a case to examine and illustrate a persistent and foundational dilemma in the implementation of community-based health interventions, namely that implementation strategies which seek to integrate new initiatives by building upon existing practices may inadvertently undermine transformative potential in two critical ways:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\u003cstrong\u003eRisk of superficial change\u003c/strong\u003e: When new interventions are aligned too closely with existing routines, there is a risk that no substantive change occurs. The initiative may be perceived as a continuation of current practice, resulting in either no change at all or, at best, an incremental increase in activities already being undertaken.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eReinforcement of structural inequalities\u003c/strong\u003e: By relying on and amplifying existing practices, implementation may reproduce the very social structures and processes that contribute to health inequities. In doing so, interventions risk perpetuating unequal outcomes, rather than challenging or disrupting the mechanisms that sustain them.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe article seeks to advance understanding of how community-based health promotion initiatives unfold during implementation. In particular, it explores what such processes reveal about the promises and limitations of flexible, context-sensitive intervention designs as a strategy for preventing childhood obesity and reducing inequality in health among children.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003eThis study draws on qualitative data collected as part of the qualitative process evaluation of the implementation of the \u003cem\u003eChild life in healthy balance\u003c/em\u003e programme, put into practice by Local Government Denmark, the national association representing Danish municipalities, in three Danish municipalities. Rather than assessing outcomes, the evaluation was designed to trace implementation processes in a community-based intervention, focusing on how broad, cross-sectoral goals were interpreted, developed, coordinated, and enacted across organisational boundaries over time.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUnlike many traditional public health interventions, the \u003cem\u003eChild life in healthy balance\u003c/em\u003e programme did not provide designated funding for intervention components, prescriptive activities, or detailed manuals for participating institutions. Rather, it relied on a local municipal coordinator in each municipality (two full-time and one part-time) to facilitate dialogue across institutions and encouraged local discretion in the participating institutions so that each setting could embed the programme’s goals within existing practices. Broad programme interventions and subgoals were co-created with local stakeholders and distributed across several key community actors, each with specific responsibilities within the three overarching themes:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eHome nursing.\u003c/strong\u003e Home health nurses play a central role in the Danish welfare system, supporting families from infancy and through childhood via home and school visits. Within the programme, the nurses were tasked with expanding their support to families statistically at risk of childhood overweight, based on indicators such as parental education and weight. Their intervention components were the most prescriptive in the programme and included additional home visits, proactive phone calls to families with infants aged 0–6 months to support breastfeeding or healthy bottle-feeding habits, and follow-up calls with selected families to encourage early health-promoting routines. They were also expected to provide resources – such as pamphlets or simple tools for play and movement – ensuring families were better equipped to establish healthy lifestyles.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eDaycare facilities (nurseries and kindergartens).\u003c/strong\u003e In Denmark, most children aged 0–6 attend daycare facilities, making these settings pivotal for shaping everyday routines. The programme encouraged daycare educators to work with themes of healthy eating, active play, and shared experiences in the local community. Rather than introducing new activities and specified intervention components, the programme sought to support staff in integrating health-promoting practices into existing pedagogical routines. Goals were co-created with selected institutions and included enhancing food acceptance, stimulating curiosity about local surroundings, and embedding movement and play into daily schedules in feasible, adaptable ways tailored to each institution’s resources.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSchools and after-school programmes.\u003c/strong\u003e Teachers, educators and school nurses were tasked with reinforcing health promotion in primary school contexts. After-school programmes in Denmark serve\u0026nbsp;children in the four first years of primary school (ages 6–9), focusing on social development and structured recreation. In schools and after-school programmes, teachers and educators were asked to develop their own action plans detailing how they would integrate the programme’s broad goals, such healthier food practices, physical activity, and well-being promotion into both school and after-school environments. The purpose was to normalise health-promoting habits within institutions that play a daily role in children’s lives and to extend support beyond early childhood settings.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eCommunity organisations and associations\u003c/strong\u003e. As the programme included an overall goal of shared responsibility in the community, unspecified local organisations and associations were envisaged as participants in the programme. This included organisations such as sports clubs, libraries, and cultural or voluntary associations. These actors were expected to collaborate with schools and daycare facilities to create coherent opportunities for children to engage in healthy activities beyond institutional settings.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eLocal businesses\u003c/strong\u003e. Shops and supermarkets were envisioned as partners in shaping healthier community environments, for example by increasing access to healthy foods. Although recruitment challenges meant that few business representatives participated directly, their potential contribution was addressed indirectly through municipal coordinators and institutional actors.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eBy spanning across these diverse sectors, the programme aimed to foster a shared responsibility for child health across the community. The design allowed for considerable flexibility: Each institution was encouraged to adopt the programme’s principles in ways that were realistic and contextually appropriate, thereby reducing resistance to change, professional boundary conflicts, or the burden of overlapping initiatives.\u003c/p\u003e\n\u003cp\u003eThe \u003cem\u003eChild life in healthy balance\u003c/em\u003e programme serves as a compelling example of a locally driven, contextually responsive approach to health promotion. It combined broad, loosely formulated goals with substantial professional discretion and cross-sector collaboration. Its architecture was thus designed to build on existing infrastructures and routines, aiming to create sustainable, community-wide environments that support children’s well-being and healthy weight development.\u003c/p\u003e\n\u003ch2\u003eParticipants and recruitment\u003c/h2\u003e\n\u003cp\u003eParticipants in this study represented practitioners from the settings targeted by the programme: Home and school health nurses, educators from kindergartens and daycares, teachers and educators from schools and after-school programmes, municipal programme coordinators, and representatives from civil society organisations and community associations. Recruitment was coordinated through Local Government Denmark, municipal programme coordinators, and institutional managers, who identified professionals directly involved in day-to-day implementation. The sampling strategy sought coverage of all programme settings, inclusion of both managerial staff and frontline practitioners, and a roughly even distribution across municipalities.\u003c/p\u003e\n\u003cp\u003eDue to recruitment challenges, uneven implementation of specific initiatives, and limited access to particular settings, no local businesses and only a small number of voluntary associations and schoolteachers were interviewed directly. Their role was instead addressed indirectly through the perspectives of other actors.\u003c/p\u003e\n\u003ch2\u003eData collection and sources\u003c/h2\u003e\n\u003cp\u003eTo investigate the practical enactment of the intervention activities, we combined methods that capture both accounts (what actors say they do and why) and situated practice (what happens in context), and we integrated programme-level documentation to recover the coordination layer. Data collection was longitudinal (2020–2024) and multi-sited, enabling observation of development and adaptations as they unfolded in routine practice.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSemi-structured interviews\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted 37 semi-structured interviews with practitioners and heads of institutions across the three municipalities. Interviews included individual and small-group formats (typically 2–3 participants where relevant) and followed guides structured around the following: experiences with the programme – from development of concrete activities to ownership and local anchoring processes; local interpretation of its principles; concrete implementation activities; coordination across sectors; and perceived effects. Interviews began with open prompts and moved to more specific probes (Brinkmann, 2014). Most lasted approximately 60 minutes and were conducted in situ or held online (Microsoft Teams) to accommodate resource-constrained settings. Interviews were conducted by the last author (XX), with additional contributions from research assistants and students. All interviews were audio-recorded with consent and transcribed verbatim. A subset of participants was interviewed more than once, providing a longitudinal lens on implementation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObservations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 34 days of participant observation were conducted during the implementation period, covering workshops, planning meetings, thematic events, and everyday health-promotion practices. Observations followed a participant-observer stance with low interference (Tjørnhøj-Thomsen \u0026amp; Whyte, 2008). Fieldnotes were taken contemporaneously and expanded afterwards. Observational attention centred on how programme goals were translated and embedded in routines, interprofessional collaboration, discretionary work at the frontline and the local interpretation of programme goals and activities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplementation logs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo recover the trajectory and scope of implementation efforts, we analysed annual implementation logs prepared by municipal programme coordinators between 2021 and 2024. Logs summarised local activities, collaborations, adaptations, and reflections on contextual enablers/barriers across daycare and school settings. These documents provided a structured, longitudinal overview of coordination work and system-level adjustments that are not always visible in interviews or brief observations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProgramme materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe additionally reviewed programme materials (e.g. agendas and minutes, communication artefacts, presentations, guidance documents) generated across the programme cycle. These materials offered insight into framing, decision processes, and the evolving articulation of goals and responsibilities across sectors, complementing practitioner accounts and observations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Overview of data sources and material from included municipalities\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"623\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHome nurses\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDaycare facilities\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSchools and after-school programmes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eProgramme employees\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterviews\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMunicipality 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMunicipality 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMunicipality 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCross-municipality interviews\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e11\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e14\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e12\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e9\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipant observations\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMunicipality 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMunicipality 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMunicipality 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCross-municipality events\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e16\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e10\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eImplementation logs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMunicipality 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMunicipality 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMunicipality 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e12\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e12\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e12\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e12\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdditional programme materials\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCross-municipality materials\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e11\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003eAnalytical Approach\u003c/h2\u003e\n\u003cp\u003eAll data sources (interviews, fieldnotes from observations, implementation logs, and programme materials) were imported into the qualitative software programme NVivo for systematic coding and analysis. We applied cross-thematic analysis (Terry et al., 2017), combining deductive and inductive strategies. Deductive codes were based on the interview guides and the study’s overall focus on implementation processes, while inductive coding allowed new and unanticipated themes to emerge from the material.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe analysis aimed to identify common patterns as well as variations across different settings and actor groups, with particular attention to how the programme’s broad goals were interpreted, negotiated, and enacted in practice. Themes were iteratively refined through discussion within the author group to ensure analytical consistency and depth.\u003c/p\u003e"},{"header":"Findings","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eA Broad, Flexible, and Indistinct Programme\u003c/h2\u003e \u003cp\u003eAs described, the principles of \u003cem\u003eChild Life in Healthy Balance\u003c/em\u003e were framed as broad, high-level goals rather than specified activities. At launch events and thematic days, the programme developers explicitly emphasised that local institutions were responsible for interpreting the goals themselves \u003cem\u003e(school observation at a teacher implementation workshop\u003c/em\u003e). Across arenas and professional groups, participants portrayed the initiative as open and flexible. As one daycare manager put it: \u0026lsquo;And now [\u003cem\u003eChild Life in Healthy Balance\u003c/em\u003e], it is so easy to lean on, because you can\u0026rsquo;t really disagree with those principles\u0026rsquo; \u003cem\u003e(Daycare manager 3\u003c/em\u003e).\u003c/p\u003e \u003cp\u003eSeveral participants contrasted the programme\u0026rsquo;s breadth with earlier, more prescriptive top-down initiatives. They emphasised this openness as an advantage, not least because it did not entail additional resources or workload:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026lsquo;I don\u0026rsquo;t think [the programme activities] take time, and I also don\u0026rsquo;t think there are any financial costs in it, because [the effort] has more to do with a mindset than with time and economy. [The \u003cem\u003eChild Life in Healthy Balance\u003c/em\u003e -programme] is really, what we make of it.\u0026rsquo; \u003cem\u003e(Pedagogical leader 1\u003c/em\u003e)\u003c/p\u003e\u003cp\u003eA manager explained how the programme encouraged reflective work that qualified existing\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003epractice rather than adding tasks, noting that reflecting on the programme made her \u0026ldquo;more qualified when I go out to support my staff in their work with the children.\u0026rdquo; \u003cem\u003e(Daycare manager 3).\u003c/em\u003e This openness was often described positively, especially in comparison with past experiences of top-down initiatives. Yet some also voiced concerns that the broad framing risked being \u0026lsquo;unambitious\u0026rsquo; \u003cem\u003e(quote from an observation in a daycare)\u003c/em\u003e and \u0026lsquo;unlikely to generate real change\u0026rsquo; \u003cem\u003e(quote from a school observation at an implementation workshop\u003c/em\u003e). A municipal programme coordinator further noted that some participants found the lack of specificity difficult to operationalise: \u0026lsquo;That which is a bit vague also makes it a bit more\u0026hellip; well, unmanageable. They can\u0026rsquo;t really picture it, what are they supposed to do, and what is their role?\u0026rsquo; \u003cem\u003e(Municipal programme coordinator 1).\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eSelecting and Amplifying Existing Practices\u003c/h2\u003e \u003cp\u003eBecause the programme placed few binding demands and left interpretation to local actors, institutions could decide for themselves how to implement it. A consistent pattern across arenas, management levels, and professions was to select and frame actions so that they extended what was already being done. One daycare manager recalled how an initial sense of overload quickly turned into a strategy of amplification:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026lsquo;Right at the beginning I thought \u0026lsquo;oh okay, this is a lot\u0026rsquo; [\u0026hellip;]. Should we do something new, or should we try to look at what we are already doing and that makes sense within this project? We added a bit and increased our attention to some things that we probably needed to focus on a bit more. But there are also many things that we were already doing, where I think \u0026lsquo;well, that just goes hand in hand with this project [\u0026hellip;]\u0026rsquo;. That has made the project a bit more digestible and slightly less overwhelming.\u0026rsquo; \u003cem\u003e(Daycare manager 4\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eShe elaborated that their approach was one of \u003cem\u003efit\u003c/em\u003e rather than overlay: \u0026lsquo;We haven\u0026rsquo;t taken [\u003cem\u003eChild Life in Healthy Balance\u003c/em\u003e] and forced it on the institution. We have looked at the institution and how it complements [\u003cem\u003eChild Life in Healthy Balance\u003c/em\u003e] [\u0026hellip;]. The things we already do are amplified.\u0026rsquo; \u003cem\u003e(Daycare manager 4\u003c/em\u003e). Other managers framed the programme as already largely implemented from the outset: \u0026lsquo;Well, I actually think we already did most of it. [\u0026hellip;] In fact, much of it is implemented, because we have already focused on it. and I think\u0026hellip; well, we call it \u003cem\u003eChild Life in Healthy Balance\u003c/em\u003e, but it was something we were already doing.\u0026rsquo; \u003cem\u003e(Daycare manager 1\u003c/em\u003e)\u003c/p\u003e \u003cp\u003eDuring a themed day for the schools, workshop tasks that invited participants to decide whether they would implement new actions (e.g. adding movement to lessons) elicited the response that such activities were already habitual \u003cem\u003e(school observation at an implementation workshop\u003c/em\u003e). Home nurses framed programme materials, such as additional questions focusing on meals, similarly as a nudge to existing conversations: \u0026lsquo;But we have had them laminated, so we can bring them to the family home visits [\u0026hellip;] and it is something we already talk about anyway, but I just think you get that little bit of extra attention on it, right?\u0026rsquo; \u003cem\u003e(Home nurse 6)\u003c/em\u003e.\u003c/p\u003e \u003cp\u003eWhere new components were discussed, the different actors and institutions reverted to what was feasible within current constraints. For instance, collaboration with local associations was deprioritised where infrastructure was lacking. Likewise, ambitions to teach all children how to ride bicycles were moderated by children\u0026rsquo;s uneven access to bikes.\u003c/p\u003e \u003cp\u003eAt a themed day for schools, staff initially discussed ambitious changes such as reforming the canteen to promote healthier food in line with the programme goals. Yet managers encouraged them to focus instead on simpler activities more closely aligned with existing routines. Ultimately, action plans described practices already in place, according to the staff \u003cem\u003e(school observation at an implementation workshop\u003c/em\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eRecognition, Visibility, and a Shared Language\u003c/h2\u003e \u003cp\u003eParticipants repeatedly described the programme as a way to notice, value, and articulate what they were already doing. As one kindergarten educator put it, \u0026lsquo;It is kind of a gentle push to keep on doing what we are doing\u0026rsquo; \u003cem\u003e(Educator from a daycare 3).\u003c/em\u003e\u003c/p\u003e \u003cp\u003eManagers stressed that this recognition was intentional and motivating: \u0026lsquo;This shouldn\u0026rsquo;t require any additional work. That is what is so wonderful about something like this [\u0026hellip;]\u0026rsquo; \u003cem\u003e(Daycare manager 2).\u003c/em\u003e Another manager emphasised the importance of acknowledgement as a way to sustain morale: \u0026lsquo;It is also about clearly acknowledging what they do, so they become aware of the good they are doing. Because everyone contributes something positive.\u0026rdquo; \u003cem\u003e(Daycare manager 3).\u003c/em\u003e This recognition was operationalised discursively in everyday forums:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026lsquo;[We have] group meetings and staff meetings, and we also have pedagogical days. Whenever something comes up, I mention [\u003cem\u003eChild Life in Healthy Balance\u003c/em\u003e] and say, \u0026lsquo;See, this falls under that. This is what you are already doing. We just need to do more of it.\u0026rsquo; \u003cem\u003e(Daycare manager 3)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn short, implementation largely took the form of reframing and making visible, with high acceptance and little overt resistance. This was evident across settings and professional groups.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eShifting Responsibility, Conflicts, and Pragmatic Pacing\u003c/h2\u003e \u003cp\u003eDespite broad consensus on the value of the programme, tensions emerged once principles had to be enacted in practice. One after-school manager described this gap between agreement and action:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026lsquo;Fundamentally, everyone thinks [the ambitions behind \u003cem\u003eChild Life in Healthy Balance\u003c/em\u003e] are super great. Yes, I mean everyone [\u0026hellip;] But who is supposed to carry it out? Yes, well, no one can say we think that sounds bloody stupid. We are in favour of obesity and isolation? But it is about the execution; that is, the transition from thought to action. That is really what is the issue here.\u0026rsquo; \u003cem\u003e(Manager from an after-school programme)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eA municipal programme coordinator similarly noted that professionals did not object to the content or the aims of the programme as such. Instead, tensions arose when they were confronted with how these aims should be realised in practice:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;[No one disagrees] about the content and the purpose and such. They have, of course, had reservations in relation to \u0026ndash; both in daycare and school \u0026ndash; the question of how far one can go. But it is more ethical considerations [\u0026hellip;]. So there have been some reservations, but it is more in terms of how to approach it. There haven\u0026rsquo;t really been reservations about the content. I have not experienced that.\u0026rsquo; \u003cem\u003e(Municipal programme coordinator 2)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eShe described how conflicts emerged surrounding the execution, when staff had to engage in potentially uncomfortable tasks such as initiating dialogue with parents about unhealthy lunchboxes or addressing the behaviour of children who were less physically active. These issues were echoed in schools and after-school programmes, where staff reported discomfort in intervening in children\u0026rsquo;s habits and routines:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026lsquo;In in our after-school programme, we\u0026rsquo;ve decided to spend time outdoors with the children. But there\u0026rsquo;s actually quite a large group \u0026ndash; especially of girls \u0026ndash; who really just want to draw or to sit and tinker with something. So, the challenge is constantly figuring out how to really also reach those children who, in reality, just want to draw with a friend or play with dolls. And how much should we force them?\u0026rsquo; \u003cem\u003e(Manager from an after-school programme)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAcross arenas, actors consistently shifted responsibility for children\u0026rsquo;s health behaviours onto others. Daycare managers tended to point to schools and parents as the settings where problems concerning children\u0026rsquo;s health practices arose, while school staff shifted responsibility back to daycare and after-school programmes. In turn, after-school staff highlighted both schools and families as those ultimately responsible. In this way, responsibility circulated between arenas without being firmly anchored anywhere. As one daycare manager explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026lsquo;We serve food at the institution, so it is not a problem here. It becomes a problem when they start school [and start bringing lunchboxes]. [\u0026hellip;] Yes, so that is really where [the problem] lies. There is simply a shift.\u0026rsquo; \u003cem\u003e(Daycare manager 4)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis account illustrates how responsibility for change was externalised: The daycare was positioned as unproblematic, while the onset of school was framed as the point at which unhealthy practices emerged. Similar reasoning was found across settings, with each arena acknowledging the importance of the programme\u0026rsquo;s goals while emphasising that decisive action needed to be taken elsewhere. Thus, even though there was broad consensus about the value of the principles, there was no shared agreement about who should actually modify practices in order to achieve them. In effect, the responsibility for change was displaced from one institutional site to another, leaving the programme\u0026rsquo;s objectives widely endorsed in principle but weakly enacted in practice.\u003c/p\u003e \u003cp\u003eFinally, the absence of clearly defined success criteria meant that avoidance of resistance often took precedence over adherence to specific principles. Local managers described how municipal programme coordinators encouraged them to downscale or delay expectations when necessary: \u0026lsquo;She [the municipal programme coordinator] has great respect and listens when we say \u0026lsquo;no, it is too much\u0026rsquo;. [Then she says] \u0026lsquo;You are welcome to cut it down a bit.\u0026rsquo;\u0026rsquo; \u003cem\u003e(Daycare manager 2).\u003c/em\u003e Another manager added: \u0026lsquo;[The municipal programme coordinator] is actually really good at saying that maybe [that specific programme goal should] not [be implemented] right now, and we will revisit it at another time\u0026rsquo; \u003cem\u003e(Daycare manager 4)\u003c/em\u003e.\u003c/p\u003e \u003cp\u003eInspired by this approach from the municipal programme coordinators, local managers adopted similar strategies with their own staff. One explained how she adjusted expectations and simplified the programme to make it more manageable:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026lsquo;It is about translating [the material] to make it digestible and then controlling the pace. If I roll it out too quickly, I can immediately see their reaction, so I just have to pull back a little [\u0026hellip;]. If I asked for the wrong [principle or activity], then I need to find something else and sell that instead.\u0026rsquo; \u003cem\u003e(Daycare manager 4)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis mindset was also visible among frontline staff, who framed success in relative and flexible terms. As one home nurse argued:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026lsquo;Well, I think in some way that you have to try to set the bar where it is realistic. If they only do it 30% of the time, then it is actually okay. Then we have come a really long way [\u0026hellip;]. It is better to have 30% that is good than 50% that is mediocre. So, in a way, it is about trying to have an awareness of where our success criteria actually lie, so we don\u0026rsquo;t set the bar somewhere completely utopian. I actually think that is one of the most important things to focus on, where we set the bar\u0026rdquo;. \u003cem\u003e(Home nurse 5)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eTo sum up, the findings point to two overarching outcomes. First, the programme\u0026rsquo;s broad and flexible goals worked well to generate a shared language, legitimacy, and coordination across participating institutions. Professionals valued the absence of prescriptive demands and the opportunity to align goals with their existing practices, which facilitated acceptance and limited overt resistance. Second, however, the same openness made it less effective in committing partners to concrete tasks or providing guidance on how such tasks should be carried out. As a result, implementation often took the form of selecting and amplifying existing activities, legitimising ongoing practices, and offering visibility rather than driving substantial new change. Ambitious elements were frequently downscaled, delayed, or reframed, and responsibilities shifted across arenas, occasionally creating tensions around sensitive practices such as addressing individual parents or children directly.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis discussion interprets the implementation processes observed in \u003cem\u003eChild Life in Healthy Balance\u003c/em\u003e, situating them within implementation and policy theory to explain why locally flexible, community-based designs can generate legitimacy yet struggle to produce structural change. We use Matland\u0026rsquo;s Ambiguity\u0026ndash;Conflict framework and Lipsky\u0026rsquo;s street-level bureaucracy to illuminate how ambiguity, discretion, and frontline-coping strategies shape outcomes, and we consider the equity implications of privileging adaptation over specification. Finally, we draw out practical implications for programme design and implementation and identify priorities and recommendations for future interventions and research.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eSuperficial Change and Symbolic Implementation\u003c/h2\u003e \u003cp\u003eThe programme\u0026rsquo;s flexible goals and absence of clearly specified intervention components make it difficult to analyse its implementation using conventional implementation science frameworks, which typically assume evidence-based, standardised components and a corresponding expectation of fidelity. Both the intervention design and our findings expose the limits of applying fidelity-oriented logics to open-ended, locally anchored initiatives such as \u003cem\u003eChild Life in Healthy Balance\u003c/em\u003e. Programmes of this nature resemble public policies more than clinical interventions: They articulate broad goals that resemble overarching ambitions rather than specific programme aims, and their outcomes hinge on how actors at multiple levels interpret, negotiate, and implement them.\u003c/p\u003e \u003cp\u003eViewed through a policy implementation lens, our two overarching implementation findings (the programme\u0026rsquo;s success in generating shared legitimacy and language, and its limited capacity to produce concrete behavioural change) become more intelligible.\u003c/p\u003e \u003cp\u003eMatland\u0026rsquo;s Ambiguity\u0026ndash;Conflict Model (1995) helps explain why the programme was readily accepted yet limited in its transformative potential. The intervention was deliberately designed with high ambiguity in mind: Its goals were framed broadly (healthy eating, physical activity, shared responsibility), and its means were left undefined and open to local interpretation. At the same time, conflicts were few and far between. Practitioners and managers across settings endorsed the aims in principle, since few could oppose \u0026lsquo;healthier food\u0026rsquo;, \u0026lsquo;more play\u0026rsquo;, or \u0026lsquo;shared responsibility\u0026rsquo;. In Matland\u0026rsquo;s terms, the implementation thus falls in part into the category of experimental implementation, where outcomes depend on local sense-making and integration into existing routines rather than adherence to a central blueprint (Matland, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e1995\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis helps explain why the programme was perceived as legitimate, feasible, and motivating: It generated little resistance because actors were able to frame it as an extension of what they were already doing. Yet Matland also emphasises the consequences of such processes: Results are typically uneven and highly dependent on local capacity and initiative (Matland, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e1995\u003c/span\u003e). Our findings support this concern: The settings consistently selected practices they were already able to deliver, while more demanding components were sidelined. At the same time, moments of conflict did arise, particularly around sensitive practices (e.g. addressing parents about lunchboxes), pushing the programme towards \u003cem\u003esymbolic implementation\u003c/em\u003e, where broad principles are endorsed discursively but concrete behavioural change is avoided.\u003c/p\u003e \u003cp\u003eSeen through this lens, the implementation of \u003cem\u003eChild Life in Healthy Balance\u003c/em\u003e oscillated between experimental and symbolic modes. The programme secured wide legitimacy and embedded itself across local settings, but largely by being absorbed into existing routines, producing visible consensus rather than structural change.\u003c/p\u003e \u003cp\u003eWhile Matland\u0026rsquo;s model highlights the role of ambiguity and conflict, it says less about how frontline actors manage such conditions in practice. Here, Lipsky\u0026rsquo;s (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2010\u003c/span\u003e) theory of street-level bureaucracy offers a complementary perspective. According to Lipsky, public policies, which are often broadly defined and ambiguously formulated, are ultimately shaped by the discretionary actions of frontline professionals such as teachers, nurses, and social workers. Working under resource constraints and competing demands, these actors develop coping strategies to make policy operational. These include routinisation, selective implementation, shifting responsibility, and redefining goals \u0026ndash; strategies that allow policies to appear implemented, even when their more ambitious aims are scaled back or left unaddressed.\u003c/p\u003e \u003cp\u003eThe implementation of the \u003cem\u003eChild Life in Healthy Balance\u003c/em\u003e programme illustrates these mechanisms in practice. Faced with broad, non-prescriptive aims and no additional resources, practitioners responded by embedding programme goals into existing routines; a clear example of routinisation. Selective implementation was also evident, with actors prioritising familiar and feasible activities while sidelining more demanding components. For instance, collaboration with local associations was deprioritised in areas lacking infrastructure, and ambitions around diet or physical activity were scaled back to fit local capacities (e.g. cycling initiatives curtailed due to lack of bicycles). Responsibility shifting emerged as a recurring strategy across sectors, with daycares, schools, and after-school programmes each positioning themselves as already contributing sufficiently, while redirecting responsibility for children\u0026rsquo;s health behaviours to parents, other institutions, or external actors. In Lipsky\u0026rsquo;s (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2010\u003c/span\u003e) terms, these practices reflect how frontline professionals manage the burden of implementation without overt resistance, thus maintaining the appearance of policy enactment while attenuating its more ambitious aims.\u003c/p\u003e \u003cp\u003eFinally, managers and staff adopted pragmatic pacing and redefined goals. Expectations were lowered; implementation was slowed to avoid staff resistance, and success was reframed in relative terms (e.g. achieving 30% compliance deemed satisfactory). These strategies sustained morale and legitimacy but reduced the programme\u0026rsquo;s transformative potential.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eSituating Our Findings in Relation to Other Studies\u003c/h2\u003e \u003cp\u003eThe following compares our findings with key studies on whole systems- and community-based programmes, highlighting how different design choices influence flexibility, coherence, and implementation outcomes. Breitenstein et al. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2010\u003c/span\u003e) emphasise the importance of fidelity (adherence, dosage, and delivery quality) for achieving outcomes in community interventions. This presupposes that there is a clearly defined intervention to be delivered. In the \u003cem\u003eChild Life in Healthy Balance\u003c/em\u003e programme, however, no such prescriptive content existed. Instead, participating institutions were presented with broad goals to interpret locally. From this perspective, fidelity is not only difficult to measure but also conceptually misplaced. The programme\u0026rsquo;s design explicitly abandoned the fidelity paradigm, privileging flexibility and local discretion.\u003c/p\u003e \u003cp\u003eThe Amsterdam Healthy Weight Programme provides a useful comparison, as \u003cem\u003eChild Life in Healthy Balance\u003c/em\u003e was partly inspired by its design. Like its Danish counterpart, the Amsterdam programme adopted a whole-systems framing, prioritised partnerships, and cultivated a collective sense of responsibility. Yet Amsterdam coupled this flexibility with a clearer governance scaffold: Key components included neighbourhood managers, formalised \u0026lsquo;Healthy Weight Pacts\u0026rsquo;, targeted professional training, and more specific outcome targets (Professionals Sociaal Domein, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). These mechanisms seemed to reduce ambiguity and sustained pressure on concrete practice change, thereby limiting drift into symbolic implementation. Both programme models valued flexibility and local adaptation, but Amsterdam\u0026rsquo;s design added specifications and enabling resources that appeared to translate shared narratives into more consistent operational change.\u003c/p\u003e \u003cp\u003eTaken together, these comparisons highlight a central paradox. Community-based programmes with flexible, locally anchored designs, such as \u003cem\u003eChild Life in Healthy Balance\u003c/em\u003e, are valuable for accommodating known implementation barriers and fostering legitimacy. At the same time, they often place considerable demands on frontline actors, who are expected to enact broad ambitions with limited support. This is not to suggest that such efforts should not be pursued, but rather that their equity implications must be taken more seriously. Without specified components or supportive governance structures, such as those employed in Amsterdam, these foundations risk remaining symbolic rather than transformative.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eImplications for Practice and Research\u003c/h2\u003e \u003cp\u003e Our findings highlight both the potential and the constraints of highly flexible, locally led implementation approaches. The openness of \u003cem\u003eChild Life in Healthy Balance\u003c/em\u003e fostered engagement and limited resistance, yet it also meant that more demanding or transformative elements were frequently downscaled or postponed. The trade-off between flexibility and direction is therefore central: Aligning interventions with existing practices can support ownership and legitimacy, but extensive reliance on local discretion risks preserving the status quo and producing symbolic rather than substantive implementation.\u003c/p\u003e \u003cp\u003eA key concern is the equity dimension. When interventions are embedded into routine activities without critical attention to the social dynamics these routines reproduce, they may unintentionally reinforce existing inequalities (Hansen et al., 2025). For example, initiatives promoting cycling offer limited benefit in areas lacking safe infrastructure or access to bicycles. Instead of addressing these disparities, the programme adapts downward to existing constraints, thereby normalising unequal conditions. In this way, flexibility can become a mechanism through which structural inequities are reproduced, particularly when constraints are treated as immutable rather than as targets for change. Conversely, more directive approaches \u0026ndash; that emphasise fidelity to defined components or mechanisms \u0026ndash; may generate resistance but are more likely to ensure that transformative elements are enacted in practice (Breitenstein et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Durlak \u0026amp; DuPre, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2008\u003c/span\u003e; Fixsen, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eImportantly, implementing health promotion is demanding, and intervention developers often place considerable expectations on frontline professionals, typically without providing sufficient resources or support. This reality must be acknowledged more explicitly in programme design. Moreover, our findings do not suggest that community-based health promotion should be abandoned. Rather, they point to the need for more deliberate strategies to address inequality within these frameworks, for instance, in terms of discovering and recognising existing practices that produce and reproduce social inequality. When the goal is to reduce entrenched disparities, flexible designs must be complemented by targeted resources, clearer expectations, and accountability mechanisms that ensure equity is not left to chance.\u003c/p\u003e \u003cp\u003eFinally, our study is also an example of how dominant frameworks and concepts from implementation science are ill-suited to capture the dynamics of open, community- and goal-oriented programmes. Policy implementation theory offers valuable concepts for understanding such programmes, highlighting how legitimacy, discretion, and coping strategies shape outcomes. Future research should continue to bridge insights from both fields to adequately conceptualise and assess the implementation of complex, community-based interventions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eThis study has several strengths. First, the longitudinal design, covering the entire implementation period from 2020 to 2024, provides a strong basis for analysing how the programme unfolded over time and how practices evolved in response to changing conditions. Second, the inclusion of diverse professional groups \u0026ndash; such as home and school health nurses, educators, teachers, heads of institutions, and municipal programme coordinators \u0026ndash; enabled the study to capture perspectives from those directly engaged in implementing \u003cem\u003eChild Life in Healthy Balance\u003c/em\u003e in everyday practice. Third, the use of multiple data sources, including semi-structured interviews, participant observations, implementation logs, and programme materials, enhanced methodological rigour. The triangulation of these materials not only strengthened validity but also offered a nuanced, multi-layered understanding of how the programme was interpreted and enacted across settings.\u003c/p\u003e \u003cp\u003eHowever, some limitations should be noted. Recruitment of participants was mediated through gatekeepers such as programme developers, municipal programme coordinators and heads of institutions. This process may have influenced who was invited to participate, introducing the risk of selection bias towards more engaged or supportive staff. Recruitment challenges also meant that the distribution of participants across settings was uneven: Compared to daycare staff and home health nurses, fewer representatives from schools and after-school programmes were included, which may have limited the breadth of perspectives from those arenas. Access to certain groups was further constrained. Despite the programme\u0026rsquo;s ambition to involve community associations and local businesses, only a few representatives from voluntary organisations and no business actors were interviewed directly. Their roles were instead addressed indirectly through the accounts of other participants, which means that the analysis may underrepresent the perspectives of these stakeholders. Finally, periods of reduced access due to the COVID-19 pandemic created practical challenges for data collection, particularly in the early phases of the programme, and may have affected the depth of material obtained from certain settings.\u003c/p\u003e \u003cp\u003eDespite these limitations, the study sought to mitigate them by ensuring coverage across all three participating municipalities, including participants from all key institutional arenas, and by collecting data at multiple time points in the project lifecycle. Taken together, the dataset provides a comprehensive and credible basis for analysing the implementation processes of a complex, community-based health promotion programme.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe implementation of \u003cem\u003eChild Life in Healthy Balance\u003c/em\u003e reveals a central paradox in community-based health promotion: Flexibility and contextual sensitivity can foster legitimacy while constraining transformative change. The programme\u0026rsquo;s open goals enabled coordination and shared language across institutions but also encouraged routinisation and selective uptake, resulting in symbolic rather than substantive change. By embedding ambitions within existing routines, implementation risks reinforcing structural inequalities and perpetuating the very disparities interventions such as \u003cem\u003eChild Life in Healthy Balance\u003c/em\u003e aim to reduce.\u003c/p\u003e \u003cp\u003eViewed through policy implementation theory, these dynamics reflect how high ambiguity and low conflict \u0026ndash; combined with resource constraints and discretionary coping strategies among frontline actors \u0026ndash; favour acceptance over transformation. However, the findings underscore that flexibility alone is insufficient for addressing complex challenges such as childhood obesity. Future designs must balance adaptability with mechanisms that safeguard equity and transformative intent.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no conflicts of interest related to this study. There are no financial, personal, or professional affiliations that could be perceived as influencing the content or outcomes presented in this manuscript. This study was conducted with full transparency and adherence to ethical standards, and the authors have no competing interests to disclose.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eData collection for the broader evaluation was supported by XXX. No specific funding was received for the preparation of this article.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eCL contributed to data acquisition, conducted the analysis, interpreted the findings and drafted the main manuscript. SL contributed to interpretation of findings and critically revised the manuscript for important intellectual content. DD contributed to data acquisition and conceptualisation, contributed to interpretation of findings, and critically revised the manuscript for important intellectual content. All authors reviewed and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eWe sincerely thank the participants for their time and engagement, which provided valuable insights to this study. We also acknowledge the many individuals whose contributions and engagement made this research possible.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBarte, J., Ter Bogt, N., Bogers, R., Teixeira, P., Blissmer, B., Mori, T., \u0026amp; Bemelmans, W. (2010). Maintenance of weight loss after lifestyle interventions for overweight and obesity, a systematic review. \u003cem\u003eObesity reviews\u003c/em\u003e, \u003cem\u003e11\u003c/em\u003e(12), 899\u0026ndash;906.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBentsen, P., Bonde, A. H., Schneller, M. B., Danielsen, D., Bruselius-Jensen, M., \u0026amp; Aagaard-Hansen, J. (2020). 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A systematic review and meta-analysis of whole of community interventions to prevent excessive population weight gain. \u003cem\u003ePreventive Medicine\u003c/em\u003e, \u003cem\u003e62\u003c/em\u003e, 193\u0026ndash;200.\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":"global-implementation-research-and-applications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"gira","sideBox":"Learn more about [Global Implementation Research and Applications](http://link.springer.com/journal/43477)","snPcode":"43477","submissionUrl":"https://submission.springernature.com/new-submission/43477/3","title":"Global Implementation Research and Applications","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Community-based interventions, health promotion, child obesity, implementation, social inequality.","lastPublishedDoi":"10.21203/rs.3.rs-8670170/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8670170/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eChildhood overweight and obesity are major public health challenges, linked to social inequality. Community-based and system-oriented interventions have been promoted as alternatives to individually focused approaches, yet their implementation remains poorly understood. This study examines the implementation of a flexible and locally anchored community-based health promotion programme targeting children aged 0\u0026ndash;10 years in socioeconomically disadvantaged areas in Danish municipalities.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eThe study draws on data from a process evaluation conducted from 2020 to 2024. The data includes 37 semi-structured interviews with practitioners, heads of institutions, and programme coordinators; 34 days of participant observation; annual implementation logs; and programme materials. Data were analysed using cross-thematic analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe programme\u0026rsquo;s broad, non-prescriptive framing created shared language, legitimacy and coordination, and it enabled staff to recognise and strengthen ongoing efforts. It also meant that implementation often centred on selecting and amplifying existing practices, whereas more demanding activities were downscaled or postponed, with substantial local variation shaped by capacity. These dynamics illustrate an inherent tension in implementation: Relying on established practices supports uptake, yet it risks producing incremental adjustments that may reinforce existing advantages and insufficiently address social inequality. We conceptualise these outcomes as a mix of meaningful alignment and superficial change.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eFlexible, locally anchored community-based programmes can foster ownership and legitimacy, but risk remaining largely symbolic when they rely heavily on existing practices and frontline discretion. To avoid reinforcing inequalities, such designs require clearer expectations, supportive governance structures and targeted resources that explicitly address structural conditions in children\u0026rsquo;s everyday environments.\u003c/p\u003e","manuscriptTitle":"Flexibility or Fidelity? The Implementation Dilemma in Community-Based Health Promotion","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-02 10:58:43","doi":"10.21203/rs.3.rs-8670170/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-23T19:17:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-23T10:32:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-23T10:31:09+00:00","index":"","fulltext":""},{"type":"submitted","content":"Global Implementation Research and Applications","date":"2026-01-22T12:47:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"global-implementation-research-and-applications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"gira","sideBox":"Learn more about [Global Implementation Research and Applications](http://link.springer.com/journal/43477)","snPcode":"43477","submissionUrl":"https://submission.springernature.com/new-submission/43477/3","title":"Global Implementation Research and Applications","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"f7bf107a-f780-47ed-aa54-e635fcab31e7","owner":[],"postedDate":"March 2nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-02T10:58:43+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-02 10:58:43","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8670170","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8670170","identity":"rs-8670170","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}