88 CHAPTER 4 Start program. To this end, an indicator set including fifteen indicators was developed in a Delphi study with experts in 2019 (16) and reported annually in order to monitor the implementation of the nationwide program and to identify whether health outcomes improve. The indicator set reflects both processes (e.g. percentage of municipalities in which youth healthcare offers prenatal home visits) and outcomes (e.g. percentage of children born prematurely or with a low birth weight). In addition, the RIVM conducted a process evaluation to collect the experiences of those involved in the Solid Start program in order to provide further insight into factors that promote and hinder the implementation. The Ministry of Health uses the results of the monitor in combination with other data sources and expert opinions to determine whether goals are being achieved and to timely adjust policies. The results of the national Solid Start monitor showed that local coalitions evolve and formalize and that the majority of them also plan to monitor their local program, or have started to do so (17-19). However, the local coalitions generally experienced a lack of insight into which indicators to include in their local setting, where to find the data for their municipality and how to make optimal use of it. Because the national indicator set was considered less suitable for monitoring on a local level, they expressed a need for a uniform indicator set to use within their local coalition. In 2021, the RIVM started a support program that is focused on monitoring Solid Start on a local level (for additional information about the support program and its relation with the Solid Start program and national monitor see Appendix 1). Key elements of this support program include learning from and with other stakeholders (both within and between local coalitions) and sharing best practices within learning communities. The local coalitions that participated in the monitoring support program considered the development of a suitable indicator set the essential first step to stimulate monitoring on a local level. In this paper, we describe our approach in developing an indicator set to monitor the Solid Start program in Dutch local coalitions and we present this indicator set. The indicator set can be used by local coalitions to enhance the conversation between policymakers, managers, professionals and other stakeholders about the local situation and developments in order to prioritize interventions and policies. This can help to strengthen and promote integrated service delivery. METHODS Design and procedure Within this mixed-methods study, we used a modified Delphi technique as a structured method to reach consensus on an indicator set to monitor Solid Start on a local level (20). This commonly used approach in health research is suitable to synthesize knowledge from various experts with a different background or geographical location (21). Our study had several iterative rounds of self-administered questionnaires and expert meetings (Figure 1). The study was conducted between March and June 2021.
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