167 General discussion The reasons range from overestimating the effects of collaboration in the first place, to difficulties in measuring the effects, especially when the effects are diverse, long-term and influenced by other factors. In the case of the action program Solid Start, an absence of immediate improvements in health outcomes would not necessarily imply a lack of impact, and conversely, any potential improvement in outcomes cannot unequivocally be attributed to the program. Alderwick and colleagues (77) suggest that while collaboration may not directly improve health, it may facilitate other developments and contribute to improvements as part of broader strategies to improve health. Moreover, especially programs focusing on early life and intergenerational aspects may not yield immediate measurable effects on health outcomes or equity. Nonetheless, investing in preventive programs for a good start in life, with the potential for positive impact across generations, remains justifiable even without conclusive evidence of immediate effects. Consequently, the scientific literature supports our understanding that it is valuable to monitor long-term through varied methods, and, rather than concentrating on outcomes, consider the context and processes in collaboration as well (30, 77). This entails a deeper exploration of the connection between these processes and outcomes within certain contexts, aiming to illuminate the causal pathways that contribute to successful collaboration. Starting from this objective, the previously mentioned systematic review of Such et al. (30) adopted a realist-informed perspective to outline the components and dynamics of collaboration in a causal loop diagram. Based on these insights and our finding that context matters in coalition development for Solid Start, we recommend applying a realist approach in monitoring the action program Solid Start for more insights into what works, for whom, in which context and for which outcomes (53, 79). Such an approach further stimulates learning and facilitates adaptations in daily practice and policy. Moreover, a realist approach also holds promise for studying specific interventions for (future) parents in greater depth (80, 81). It is well-documented that preventive interventions designed to improve overall health inadvertently can widen existing inequities in the population, as individuals in more vulnerable situations participate, respond and benefit less (82, 83). Recent Dutch studies also found that the implementation of early life interventions for parents in vulnerable populations are influenced by many factors (84, 85). Taking a realist approach in studying interventions may further help to identify potential improvements of interventions in a given context, particularly for the benefit of individuals in vulnerable situations. In this line of thought, it may also be beneficial to focus on coalitions that achieve better outcomes despite facing comparable challenges, and to seek understanding of what is working well and why, similar to a positive deviance approach (86). For the longitudinal monitoring of the action program Solid Start, we also propose that stakeholders from policy, practice, research and experts-by-experience together deepen their understanding on the objectives and theories of change of the program. This can be achieved by addressing questions such as: what does ‘a solid start for every child’ entail? What matters to whom? How is success defined for the action program Solid Start? What short-term developments and proxy measures are anticipated? Which indicators 6
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