161 General discussion between the two approaches. Thus, a combined approach, where the top-down approach stimulates the bottom-up approach and vice versa, in an emergent way, is beneficial to implement integrated care. In our study, this combined approach may have promoted the continuation or strengthening of initiatives that existed since before the nationwide action program Solid Start, rather than resulting in stagnation or cessation. Applying a local focus avoids the pitfall of a one-size-fits-all strategy and allows for variation, local leadership, and continuous learning within an enabling policy environment (32). Lessons learned in monitoring In this thesis, we share our findings on monitoring the action program Solid Start at both national and local level. Our research has provided more insights into the operationalization of vulnerability (Chapter 2 and 3) and increased our understanding of useful indicators and data to monitor the action program Solid Start (Chapter 4). We share two lessons learned in monitoring based on these findings. 3. Considering both risk and protective factors is important for a comprehensive perspective The findings from several of our studies highlighted the significance of considering both risk and protective factors to vulnerability. In Chapter 2, we found that a unidimensional perspective to vulnerability, being focused on (single) risk factors in one domain, may be insufficient to correctly predict adverse outcomes during pregnancy and childbirth. The importance of considering protective factors as well was further supported in Chapter 4, in which we learned that a local indicator set to monitor the action program Solid Start should cover both risk and protective factors. The interrelatedness between risk and protective factors and viewing health from a broader perspective has become more common. This trend is also evident in other fields like elderly care (34), GP-care and hospital-care, and accompanied by the emergence of more comprehensive concepts and methods (35) in the Netherlands and abroad, such as Positive Health (36) and Salutogenesis (37, 38). These concepts emphasize people’s strengths, opportunities and positive experiences, rather than focusing (merely) on weaknesses or risks. Additionally, they adopt a more holistic perspective in health and well-being as they consider physical, social and emotional aspects. This broad perspective encourages cross-sector collaborations and preventive strategies by acknowledging the relevance of multiple sectors to gain insight and create solutions. Academic literature in early life is also shifting its focus from adversity and risks towards emphasizing the importance of resilience and protective factors (39, 40). Traditionally, studies have primarily concentrated on risk factors in predicting adverse early life outcomes. There is still much to learn about the co-occurrence and interplay of risk and protective factors to improve the health and wellbeing of future generations. Those protective factors are not merely the absence of risks, but additional elements that increase well-being or guard against unfavourable outcomes (41). Hence, research into resilience and protective factors is emerging, with social support being most frequently studied and best supported in the social sciences (39, 40, 42, 43). Additionally, an increasing 6
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