Evaluating community-based health promotion: The application of a holistic evaluation approach to the Healthy Youth, Healthy Future programme

Public health challenges such as obesity, and health disparities are recognized as "wicked problems" due to their complexity and the numerous social and environmental factors that contribute to them. One approach to tackling wicked public health problems is community-based health promotion programmes. These programmes engage stakeholders from various sectors, including local governments, schools, and businesses, to transform community systems rather than solely focusing on individual behaviour change. This involves altering policies, stakeholder practices, community structures, and norms to support healthier lifestyles. This thesis evaluates the Healthy Youth, Healthy Future (JOGG) approach, a widely implemented community-based health promotion programme in the Netherlands. JOGG targets children and youth (0–18 years) by creating an environment that encourages healthy dietary habits and physical activity to prevent obesity. The program is locally implemented by coordinators who mobilize community stakeholders and provide them with resources and support to take collective action. Initiatives include water-drinking policies in childcare and strengthened intersectoral collaboration. Despite their potential, community-based programs face challenges in evaluation due to their complex and adaptive nature. Challenges include: 1) effects vary across different community contexts, 2) focusing on individual health outcomes while overlooking systemic community changes, 3) limited insight into the mechanisms driving community change. The main aim of this thesis was to gain insight into the implementation, working mechanisms, outcomes and impact of the JOGG approach. To consider the complex nature of JOGG and address evaluation challenges, we adopted a holistic evaluation approach. Findings Through case studies in nine JOGG municipalities we identified key events influencing programme implementation, including national policy developments, staff turnover, and the coordination teams’ experiences and actions. Through interviews we gained deeper insight into the critical role of JOGG coordinators. They appeared to take on a variety of roles throughout the implementation process. To initially engage stakeholders and facilitate collaboration, coordinators took on roles as implementers, project managers, networkers and matchmakers. As implementation progressed, the coordinators became linchpins within the network, politicians and programme managers to mobilise the network of stakeholders. Their competencies vary depending on available resources, organizational positioning, and professional backgrounds. Using the Ripple Effects Mapping method in five case studies, we found that JOGG contributed to increased stakeholder ownership, strengthened health policies, improved intersectoral collaboration, and shifts in social norms toward healthier lifestyles in the community. Five key mechanisms enabled these changes: 1) establishing a positive connotation with JOGG, 2) mobilising stakeholders, 3) facilitating projects, 4) connecting stakeholders to encourage collaboration, 5) sharing successes to normalize health promotion efforts. We found no significant association between JOGG exposure and changes in BMIz, physical activity, or dietary habits in national health survey data. Results did show a potential increase in fruit and vegetable consumption among youth. Conclusions While we found no evidence for the contribution of the JOGG approach to individual health outcomes, the programme contributed to sustainable community changes that support health promotion. The programme’s scope may be too narrow to address the broader system of interconnected factors contributing to childhood obesity. To maximize impact, community-based programs like JOGG must be supplemented by comprehensive national and international policy actions. However, policymakers often assess the success of such programmes based on individual health outcomes. Instead of focussing on the unrealistic expectation that a single programme can fully solve a wicked health problem, evaluations should focus on programme’s contributions as part of a broader strategy. Recommendations for evaluating community-based health promotion programmes include to combine diverse research methods, support local monitoring and evaluation and use intermediate outcomes to track progress towards sustainable changes to the community system.