When Flexibility Becomes Ambiguity: Implementation Dilemmas in a Danish Community-Based Health Promotion Programme

Abstract 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. This 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. 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. 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