Biljana Meshkovska

• Sarah, Forberger,; Meshkovska, Biljana; A., Reisch, Lucia; Aleksandra, Luszczynska, & Hajo, Zeeb, (2026). Bridging policy and implementation science: operationalising political and structural determinants for health policy implementation evaluation | Implementation Science Communications | Springer Nature Link. Implementation Science Communications. doi: 10.1186/s43058-026-01137-0. Full text in Research Archive Show summary

  Despite their critical role in shaping public health policy implementation, key political and structural determinants within implementation frameworks are often poorly defined, underreported, or treated as background rather than as core implementation variables. Existing implementation science frameworks acknowledge these determinants, they lack systematic, operationalised guidance for reporting them, resulting in limited explanatory power, poor comparability, and an overemphasis on individual-level factors. This paper aims to improve reporting standards in public health policy implementation evaluation by defining key political and structural determinants and proposing their operationalisation within established implementation frameworks. The synthesis drew on seven systematic and scoping reviews and three in-depth case studies from the PEN, ASTRA, and STOP projects, covering nutrition, physical activity, and tobacco control. We consolidated predefined, theory-informed extraction categories from the underlying reviews, together with recurring reporting gaps, into overarching reporting dimensions. We then contextualised and refined these dimensions using evidence from the three case studies across diverse governance levels and socio-political settings. We consolidated and operationalised eight core reporting dimensions: (1) policy objectives and scope, (2) actors, power, and competence, (3) legal status and jurisdiction, (4) policy instruments (regulatory, economic, communicative, behavioural), (5) implementation strategies (centralised vs. decentralised, coordination mechanisms), (6) resources (financial, human, material, and implementation costs), (7) equity impact and (8) policy lifecycle. The dimensions specify political and structural information relevant to policy implementation evaluation and provide a structured basis for more systematic and transparent reporting across diverse policy contexts. The operationalisation is designed to complement and to be integrated into established implementation frameworks. Systematic and transparent reporting of political and structural determinants is essential for understanding the success or failure of policy implementation. The proposed operationalisation offers researchers and evaluators a practical approach to strengthen public health policy implementation evaluations. Designed for integration into frameworks such as CFIR and CICI, it may help identify leverage points, support adaptive policy design, and contribute to more effective, equitable, and sustainable public health interventions.

• Siwa, Maria; Banik, Anna; Cereijo, Luis; Herstad, Sondre Haugsbø; Lakerveld, Jeroen & Lien, Nanna [Show all 9 contributors for this article] (2026). Implementation Strategies Used in Effective Policies to Combat Obesity in Socioeconomically Disadvantaged Communities: Systematic Review. Obesity Reviews. ISSN 1467-7881. doi: 10.1111/obr.70183. Full text in Research Archive Show summary

  ABSTRACT Introduction The effectiveness of obesity prevention or obesity reduction policies is co‐determined by policy content, the implementation process, and contextual factors. This systematic review provides insight into implementation strategies used in whole‐of‐community obesity prevention policies aimed at changes in two types of outcomes: (1) a reduction in obesity/overweight prevalence, body mass index–related outcomes, and other weight‐related outcomes, or (2) a change in nutrition behaviors, physical activity, and sedentary behaviors or screen time. We specifically examined implementation strategies using the Expert Recommendations for Implementing Change (ERIC) framework, focusing on policies implemented in low socioeconomic status communities. Methods Following Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines, eight databases were searched. Risk of bias was assessed using the Joanna Briggs Institute (JBI) critical appraisal tool. The efficacy of implementation strategies was considered supported if at least 66% of the studies that applied respective strategies reported significant improvements for a given outcome type across at least three studies. Results A total of 29 original studies were included. Fifteen implementation strategies from the ERIC framework were consistently associated with favorable outcomes. These strategies included altering incentive structures, assessing community readiness, and using data warehousing techniques. Six additional non–ERIC strategies (e.g., cultural adaptation and grassroots mobilization) received support across different outcome domains. Most studies (72%) had a low risk of bias. Conclusion Findings may help prioritize implementation strategies that may drive the success of whole‐of‐community obesity policies targeting disadvantaged populations. The results suggest a need to expand existing implementation taxonomies to include community‐driven strategies.

• Meshkovska, Biljana; Zolfaghari, Mahshid; Brandvik, Caroline Løvik; Klepp, Knut-Inge; Kopainsky, Birgit & Lie, Hanne Cathrine [Show all 7 contributors for this article] (2026). Adoption of the Norwegian School Fruit Program: A Qualitative Study on Barriers and Facilitators. Global Implementation Research and Applications. doi: 10.1007/s43477-026-00238-1. Full text in Research Archive Show summary

  The Norwegian School Fruit Program is financed by parents or local municipalities. The aim of this study was to explore contextual barriers and facilitators that influence the adoption of the program by schools using the Context and Implementation of Complex Interventions (CICI) framework. We conducted semi-structured interviews with 21 participants (mainly principals) from 20 lower secondary schools (classes 8–10). We analyzed the data using a deductive qualitative approach based on the CICI framework. We compared findings across schools offering the program (1) with no-parental-payment, (2) by parental subscription, and schools that (3) discontinued or (4) never offered the program. Economic costs were perceived as the main barrier to adoption across all schools. Although most schools recognized the need for such a program, some preferred to make their own arrangements. Except for schools offering the parental subscription option, many schools perceived asking parents to pay for the program as unfair, not in line with Norwegian values, and unlikely to allow the program to reach those who need it the most. Further barriers were the lack of legislation making the program obligatory and potential political changes causing uncertainty regarding the programme’s continuation from one year to the next. Social aspects of eating together were recognized as a facilitator. Food provision programs should be compatible with school priorities such as academic performance and mental health. Context and setting are dynamic and should be continuously evaluated to ensure they are in line with evolving school priorities and needs.

• Zolfaghari, Mahshid; Lien, Nanna; Brandvik, Caroline Løvik; Klepp, Knut-Inge; Kopainsky, Birgit & Lie, Hanne Cathrine [Show all 7 contributors for this article] (2025). Understanding the dynamics of implementing the Norwegian School Fruit Programme: integrating implementation science and system dynamics | Implementation Science Communications. Implementation Science Communications. p. 1–48. doi: 10.1186/s43058-025-00834-6. Full text in Research Archive Show summary

  Many implementation determinants of school nutritional interventions have been identified, but a deeper understanding of their interplay within a system is needed. The present study aimed to investigate how the Norwegian School Fruit Programme, particularly the No Parental Payment Programme (NPPP), is being implemented in schools and how it interacts with the school system structure and dynamics as perceived by school personnel and pupils. Moreover, it aimed to understand the dynamic interplay between the determinants of the Consolidated Framework for Implementation Research (CFIR) in the NPPP’s context. The overarching methodology was qualitative system dynamics modelling, with data collected through a series of group model building (GMB) workshops at four schools offering the NPPP. Using GMB scripts, facilitated discussions between school personnel and pupils were held for a better understanding of the NPPP’s implementation dynamics and to create diagrams illustrating how implementation determinants interact with each other and each school’s unique context. The individual school diagrams were compiled into a single diagram. The CFIR was subsequently mapped on to this diagram. Lack of communication with pupils, the food stores outside schools, and the NPPP’s design weakened the reinforcing mechanism that fostered pupils’ eating of fruit. Not eating enough of the fruit increased implementation costs because schools had to deal with leftover fruit and littering issues. Implementation costs caused schools to adopt implementation processes, like reflecting, engaging, and adapting to reduce the costs, although some of these did not work or counterintuitively decreased pupils’ eating of fruit. The success of these processes was contested by the design of the NPPP and mechanisms that were shaped by the goals and priorities of the schools. This research employed qualitative system dynamics to investigate NPPP implementation dynamics. Recommendations for improving implementation include aligning NPPP’s design with pupils’ preferences, monitoring eating of fruit, and involving internal stakeholders (pupils and school personnel) for gathering feedback, and external stakeholders (municipalities) for monitoring.

• Meshkovska, Biljana; Bos, Arjan ER & Siegel, Melissa (2025). Sex work in a post-trafficking context: A qualitative study from the viewpoint of survivors and service providers in Europe. International Review of Victimology. ISSN 0269-7580. doi: 10.1177/02697580251369521. Full text in Research Archive Show summary

  Sex work and trafficking for the purpose of sexual exploitation have been linked since the origins of human trafficking. Nonetheless, deeper insights into the role sex work plays in the life of trafficking survivors, following a trafficking experience are lacking. This research explores how sex work is approached in the context of (re) integration of persons trafficked, how service providers view sex work, and what the implications are for the survivors and their recovery. A total of 52 qualitative interviews were conducted in Europe (Southeastern Europe, the Netherlands, and Italy) with service providers who have been in direct contact with survivors of human trafficking, as well as survivors of trafficking for the purpose of sexual exploitation. Themes were derived based on how sex work was conceptualised by both service providers and survivors. Findings show that return to sex work following a trafficking experience is considered to be an undesirable outcome of the (re) integration process. Sex work is stigmatised by both service providers and victims, openly and subtly, in the context of trafficking and generally. It is seen as ‘not normal’ by all groups interviewed, and trafficking victims in particular seek to distance themselves from the experience, whether they entered it knowingly or not. Long-term recovery and (re) integration of victims of trafficking may be difficult if stigmatisation in regard to involvement in sex work persists, both from the perspective of survivors as well as service providers.

• Lam, Thao Minh; Aarestrup, Julie; Akker, Erica L. T. van den; Baker, Jennifer L.; Banik, Anna & Berntzen, Bram J. [Show all 56 contributors for this article] (2025). Advancing knowledge, maps and tools to address obesity and related socio-economic disparities in Europe: the OBCT project. Global health action. ISSN 1654-9716. 18(1). doi: 10.1080/16549716.2025.2517492. Full text in Research Archive Show summary

  The steady rise in overweight and obesity in Europe disproportionately affects people and communities with a lower socio-economic position (SEP). Many obesity prevention approaches exist, but these have had limited reach and unsatisfactory effects thus far, especially in low-SEP populations. In this context, there is a need for implementation of effective individual-level and population-based preventive strategies that also tackle health inequalities. Effective strategies require consideration of the complex and cross-domain obesity risk factors across the life course. Feasible and acceptable strategies require multisectoral collaborations and innovative approaches, including a whole-of community and systems perspective. With the Horizon Europe-funded OBCT project, we aim to quantify the relative contribution of biological, socio-cultural and built environment factors to obesity and the interactions of these risks within and across various life course stages; and translate the resulting knowledge into practical, equitable, and effective tools for action. These tools will include: a comprehensive obesity risk screener; a map of the obesogenicity of neighbourhood environments as well as trends in obesity prevalence of each European country; recommendations for lifestyle behaviours (diet, physical activity, sedentary behaviours) to prevent obesity during key life transition stages; a decision support dashboard for policy makers; and co-developed toolboxes to support implementation of policy recommendations in low-SEP communities. OBCT’s outputs will highlight the areas and domains in which obesity should be targeted and will empower the research community, policymakers, health professionals and residents in Europe to adapt and implement strategies to effectively reduce obesity risk, particularly in low-SEP communities.

• Zolfaghari, Mahshid; Meshkovska, Biljana; Brandvik, Caroline Løvik; Kopainsky, Birgit; Klepp, Knut-Inge & Lie, Hanne Cathrine [Show all 7 contributors for this article] (2025). A Systems Perspective on the Drivers of Adoption of the Norwegian School Fruit Scheme. Global Implementation Research and Applications. 5, p. 336–348. doi: 10.1007/s43477-025-00173-7. Full text in Research Archive Show summary

  Successful adoption of evidence-based primary prevention interventions by schools is important for public health but relies on multiple factors. Using a systems perspective enables the identification of the interconnectivity and feedback loops among these factors, which can facilitate or hinder adoption. This study aimed to conceptualize a system structure showing how adoption factors are interrelated, and which feedback loops influence schools’ decisions to adopt interventions, using the parent-paid Norwegian school fruit scheme (the parent-paid scheme) as a case. We interviewed principals and personnel (n = 7) from schools that adopted, de-adopted, or never adopted the parent-paid scheme. These interviews were analyzed using qualitative system dynamics modeling. The analysis resulted in a causal loop diagram representing a system structure driving schools’ adoption decisions. The preliminary results were validated during a workshop with new participants who hold decision-making roles in schools (n = 5). Due to previous experiences with a free scheme, some schools perceived the parent-paid scheme’s relative advantages as low, which, in synergy with schools’ preference to offer it for free to pupils, resulted in the parent-paid scheme never being adopted. Nevertheless, there were schools that adopted the parent-paid scheme, driven by feedback loops like perceived need and relative advantages. These feedback loops, however, weakened over time as de-adoption resulted from a lack of demand from parents and pupils. Taking a systems perspective offered a temporal view of adoption processes, revealing how past decisions, like de-adopting a free scheme, influence future decisions. It highlighted how reinforcing feedback loops, like perceived need, set schools on adoption paths. Finally, it identified gaps in information flow, including those necessary for adaptation, as potential missing feedback loops to continuous adoption. As such, the schools’ decision to adopt the parent-paid scheme is a dynamic process with systemic characteristics that should be considered when developing strategies to ensure adoption.

• Meshkovska, Biljana; Moerman, Gerben; Baillergeau, Evelyne; Bröer, Christian; Lien, Nanna & Luszczynska, Aleksandra [Show all 9 contributors for this article] (2025). Voices of youth: youth participation in the CO-CREATE project. BMC Public Health. 25, p. 1–12. doi: 10.1186/s12889-025-23097-1. Full text in Research Archive Show summary

  Introduction Applying youth participatory action research (YPAR) has become common practice in public health. However, there are challenges in applying YPAR and there is a need for improving the process by learning from youth that has participated in such projects. This study explores youth involvement in the CO-CREATE project which focused on developing overweight and obesity prevention policies. Methods This is a qualitative study, based on three data sources: 1) fieldnotes taken by project staff during observation of youth (approximately 150 observations) 2) semi-structured interviews with project staff (n = 12) 3) direct feedback from participating youth through feedback forms (n = 51). Data was analyzed in NVivo, following the principles of reflexive thematic analysis. Results Five themes were generated which showcase youth involvement in CO-CREATE: 1) an inspired and engaged youth; 2) insights through respectful interactions; 3) a strength of voice and call to action; 4) challenges in understanding project and disengagement; and 5) interpersonal conflict and pressure to participate. Conclusion Taking the time to build trust and create a feeling of equality is important. It is also important to allow youth to take the lead when they wish so and have clear ideas of how to do so. Voices of rebelliousness can be a show of strength and help reach the goals of the project. Participation in CO-CREATE may have contributed toward individual empowerment of youth.

• Brandvik, Caroline Løvik; Meshkovska, Biljana; Schultz, Gry Irene Granli & Garnweidner-Holme, Lisa (2024). Implementing a nutrition education intervention in Eastern Norwegian Kindergartens: barriers and facilitators. BMC Nutrition. 10(1). doi: 10.1186/s40795-024-00908-z. Full text in Research Archive Show summary

  Background Implementations to improve healthy eating in kindergartens may play a pivotal role in shaping children’s dietary behaviors. There is limited research on the implementation and key implementation determinants (barriers and facilitators) of interventions in kindergarten settings. The aim of this study was to explore kindergarten staff members’ experiences with the implementation of a nutrition education intervention to identify implementation barriers and facilitators. Methods We interviewed 12 employees from five different kindergartens in an Eastern Norwegian municipality between 2019 until 2020. The individual interviews were guided by the consolidated framework for implementation research. The interviews were recorded, transcribed verbatim, and analyzed inductively, inspired by Braun and Clarke’s reflexive thematic analysis. Results Implementation facilitators were satisfactory planning and presentation execution, including tailoring to kindergarten and staff needs, food and meals being a kindergarten/staff priority, and confidence-building of staff. Barriers included unsatisfactory planning and presentation execution, the presentation as a one-time event, non-tailoring to kindergarten and staff needs, and kindergartens/staff not prioritizing food and meals. Conclusions When developing and implementing similar kindergarten interventions, the following should be considered: a participatory approach, active engagement of staff, the physical learning environment, and the frequency of opportunities to revisit topics.

• Meshkovska, Biljana; Gebremariam, Mekdes; Atukunda, Prudence; Iversen, Per Ole; Wandel, Margareta & Lien, Nanna (2023). Barriers and facilitators to implementation of nutrition-related actions in school settings in low- and middle-income countries (LMICs): a qualitative systematic review using the Consolidated Framework for Implementation Research (CFIR). Implementation Science Communications. 4(1). doi: 10.1186/s43058-023-00454-y. Full text in Research Archive Show summary

  Background Low- and middle-income countries (LMICs) are particularly vulnerable to the double burden of malnutrition: co-existence of underweight, overweight, obesity, and/or diet-related non-communicable diseases. Nutrition-related double-duty actions in school settings have been identified as one of the ways to address this challenge. However, to be able to take full advantage of the potential impact, it is important to understand their implementation as well. The aim of this paper is to systematically review qualitative research on barriers and facilitators to the implementation of nutrition-related actions in the school settings in LMICs. Methods The following databases were searched: EMBASE, ERIC, MEDLINE, Global Health and PsycInfo (all on Ovid), Scopus (Elsevier), the Web of Science Social Sciences Citation Index, and Global Index Medicus from the World Health Organization. Of the 4253 identified records, 4030 were excluded after the abstract and title screen, leaving 223 for the full-text screen. A final 36 papers were included in this review. The consolidated framework for implementation research (CFIR) was used in the analysis. Results We identified barriers and facilitators to implementation linked to the following CFIR constructs/sub-constructs: design quality and packaging, cost (intervention characteristics); target group needs and resources, cosmopolitanism, external policy and incentives (outer setting); structural characteristics, readiness for implementation (inner setting); knowledge and beliefs (characteristics of individuals) and engaging, executing (process). All identified constructs apart from target group needs and resources, knowledge and beliefs, and engaging were predominantly barriers. Available resources were the most prevalent barriers across studies. Conclusion This review identified barriers and facilitators to the implementation of nutrition-related actions based on qualitative articles in the school setting in LMICs, using the CFIR. Schools face continuous challenges in regard to funding and the government sector may have a role to play not only by offering financial assistance, but also through policy-making that would support healthy eating practices on school grounds.

• Vitali, Veronica; Tiboldo, Giulia; Castellari, Elena & Meshkovska, Biljana (2023). Teachers’ perspectives on the EU Fruit and Vegetable Scheme implementation in Italy. Health Education Journal. ISSN 0017-8969. 82(8), p. 907–921. doi: 10.1177/00178969231210933. Full text in Research Archive Show summary

  Objective: School-based fruit and vegetable provision programmes can improve children’s eating patterns and health by ensuring access to fruit and vegetables and providing nutrition education. However, the effectiveness of these programmes may be significantly affected by the implementation quality. The objective of this study was to identify barriers and facilitators to the implementation of the EU School Fruit and Vegetables Scheme according to Italian teachers’ perspective. Design, Setting, and Method: We carried out semi-structured interviews with teachers in two elementary schools in Italy that had participated in the EU School Fruit and Vegetables Scheme for several years. The interview protocol was based on domains, constructs and sub-constructs from the Consolidated Framework for Implementation Research (CFIR). Qualitative data from the interviews were coded deductively using the CFIR to identify the main barriers and facilitators to implementing the EU School Fruit and Vegetables Scheme. Results: Among the main facilitators of implementation of the EU School Fruit and Vegetables Scheme were the quality and variety of the products, as well as the educational intentions behind the scheme, and teachers’ overall level of engagement. Barriers were to be found in lack of teacher training, an absence of accompanying measures, limited knowledge about a healthy diet, the low involvement of parents, and finally, problems with product delivery. Conclusions: Providing more comprehensive teacher education and training and extending access to accompanying measures may improve the EU School Fruit and Vegetables Scheme’s implementation quality and effectiveness. Moreover, allowing greater flexibility in between suppliers and accounting for each geographic area’s unique character are crucial to overcoming the delivery problems that currently act as barriers to the implementation of the scheme.

• Meshkovska, Biljana; Forberger, Sarah; Wendt, Janine; Scheller, Daniel A.; Castellari, Elena & Tiboldo, Giulia [Show all 8 contributors for this article] (2023). Barriers and Facilitators to Implementation of the EU School Fruit and Vegetables Scheme: Cross Country Study. Global Implementation Research and Applications. doi: 10.1007/s43477-023-00100-8. Full text in Research Archive Show summary

  Abstract The European Union (EU) School Fruit and Vegetables Scheme is a nutrition policy program. It has three actions: delivery of fruit and vegetables in schools, accompanying educational and information measures. The aim of this study is to identify barriers and facilitators to the implementation of the Scheme as perceived by implementers at government level. This work is a qualitative, exploratory study using the Consolidated Framework for Implementation Research (CFIR) to guide data collection and analysis. Twenty-three semi-structured interviews were conducted with representatives ( n  = 29) from agriculture, health and education, across 10 EU member states and the EU. Qualitative data were coded inductively. Themes were mapped to constructs of the CFIR. We found content in regard to 19 out of 26 constructs of the CFIR. Some example constructs are: adaptability, external policy and incentives, networks and communications, knowledge and beliefs and executing. Flexibility in how the scheme is designed and implemented and newly established cooperation between implementing ministries are facilitators. However, the timing of the yearly budget allocation is a barrier. Taking EU funding for granted is a potential disincentive to improvement, although the EU funding facilitates sustainability. Despite agreement on what the overall goals of the Scheme are, there is ambiguity as to what the perceived primary goal is, which may be a barrier. Some goal ambiguity may be useful at the supranational level, enabling politically acceptable framing and continuation of the financing of the Scheme, but this translates into a potential barrier to design and implementation at country and school level.

• Wendt, Janine; Scheller, Daniel A.; Flechtner-Mors, Marion; Meshkovska, Biljana; Luszczynska, Aleksandra & Lien, Nanna [Show all 10 contributors for this article] (2023). Barriers and facilitators to the adoption of physical activity policies in elementary schools from the perspective of principals: An application of the consolidated framework for implementation research–A cross-sectional study. Frontiers in Public Health. 11. doi: 10.3389/fpubh.2023.935292. Full text in Research Archive Show summary

  Background Studies have shown that policies to promote physical activity in schools can have a positive impact on children's physical activity behavior. However, a large research gap exists as to what determinants may influence the adoption of such policies. Applying the Consolidated Framework for Implementation Research (CFIR), we investigated barriers and facilitators to the adoption of physical activity policies in elementary schools in Baden-Wuerttemberg, Germany, from the perspective of school principals. Methods A cross-sectional study was conducted between May and June 2021. School principals from elementary and special needs schools ( n = 2,838) were invited to participate in the study. The online questionnaire used was developed based on the CFIR and included questions on school characteristics and constructs of the CFIR domains inner setting, characteristics of individuals, and process. Logistic regression analyses were performed to examine associations between policy adoption and school characteristics as well as CFIR determinants. Results In total, 121 schools (4%) participated in the survey, of which 49 (40.5%) reported having adopted a policy to promote physical activity. Positive associations with policy adoption were found for general willingness among teaching staff [odds ratio (OR): 5.37, 95% confidence interval (CI): 1.92–15.05], available resources (OR: 2.15, 95% CI: 1.18–3.91), access to knowledge and information (OR: 2.11, 95% CI: 1.09–4.09), and stakeholder engagement (OR: 3.47, 95% CI: 1.24–9.75). Conclusions This study provides a first insight into potential barriers and facilitators at the organizational level of schools that may be relevant to the adoption of physical activity policies, from the perspective of school principals. However, due to a low response rate, the results must be interpreted with caution. A strength of this study includes theoretical foundation through the use of the CFIR. The CFIR could be well-adapted to the school setting and provided valuable support for developing the questionnaire and interpreting the study results.

• Meshkovska, Biljana; Bos, Arjan E.R. & Siegel, Melissa (2023). How (re) integration success and (re) integration failure is conceptualised in different contexts for women trafficked for the purpose of sexual exploitation. International Review of Victimology. ISSN 0269-7580. doi: 10.1177/026975802311512. Full text in Research Archive
• Wendt, Janine; Scheller, Daniel A.; Banik, Anna; Luszczynska, Aleksandra; Forberger, Sarah & Zeeb, Hajo [Show all 16 contributors for this article] (2023). Good practice recommendations on implementation evaluation for policies targeting diet, physical activity, and sedentary behaviour. BMC Public Health. 23(1). doi: 10.1186/s12889-023-15775-9. Full text in Research Archive Show summary

  Health policies aim to achieve specific health goals through system-level changes, unlike common health interventions that focus on promoting specific health behaviors on individual level. However, reliable data on the feasibility and implementation of policy actions across Europe are lacking. Moreover, no practice-oriented guidance exists for policy makers and implementers on how to evaluate policy implementation. As part of the Policy Evaluation Network, we aimed to synthesise knowledge on how to evaluate the implementation of policies promoting healthy diets, physical activity, and reducing sedentary behaviours. The multidisciplinary working group comprised 16 researchers and conducted two scoping reviews, three systematic reviews, two meta-reviews, two qualitative case studies and one quantitative case study over three years. The target populations included the general population, those at risk for obesity, and school children. Based on these reviews and case studies, this article summarises and presents the findings and lessons learned regarding the implementation evaluation of policies in nine case reports. Drawing on these experiences, three critical requirements for policy implementation evaluation were set: 1) conduct a comprehensive policy implementation evaluation from a multi-level perspective, 2) use implementation frameworks to address processes, determinants, and outcomes, and 3) engage relevant stakeholders in policy implementation evaluation. Finally, the consensus process resulted in 10 steps for the implementation evaluation of policies to promote physical activity and a healthy diet and to reduce sedentary behaviours, which adhere to the requirements and resources of the targeted policy. The findings of an implementation evaluation can lead to a better understanding of why policies work or not and can serve as a basis for developing solutions. This practice-oriented guidance outlines factors that should be considered in policy implementation evaluation to address its complexity. In this way, involved researchers and practitioners are empowered to engage in the evaluation process to close the knowledge gap regarding policy implementation.

• Scheidmeir, Marie; Kubiak, Thomas; Luszczynska, Aleksandra; Wendt, Janine; Scheller, Daniel A. & Meshkovska, Biljana [Show all 15 contributors for this article] (2022). Acceptability of policies targeting dietary behaviours and physical activity: a systematic review of tools and outcomes. European Journal of Public Health. ISSN 1101-1262. 32(4 S), p. iv32–iv49. doi: 10.1093/eurpub/ckac053. Full text in Research Archive Show summary

  Abstract Background Successful implementation of health policies require acceptance from the public and policy-makers. This review aimed to identify tools used to assess the acceptability of policies targeting physical activity and dietary behaviour, and examine if acceptability differs depending on characteristics of the policy and of the respondents. Methods A systematic review (PROSPERO: CRD42021232326) was conducted using three databases (Science Direct, PubMed and Web of Science). Results Of the initial 7780 hits, we included 48 eligible studies (n = 32 on dietary behaviour, n = 11 on physical activity and n = 5 on both), using qualitative and quantitative designs (n = 25 cross-sectional, quantitative; n = 15 qualitative; n = 5 randomized controlled trials; n = 3 mixed-methods design). Acceptability was analysed through online surveys (n = 24), interviews (n = 10), focus groups (n = 10), retrospective textual analysis (n = 3) and a taste-test experiment (n = 1). Notably, only 3 (out of 48) studies applied a theoretical foundation for their assessment. Less intrusive policies such as food labels and policies in a later stage of the implementation process received higher levels of acceptability. Women, older participants and respondents who rated policies as appropriate and effective showed the highest levels of acceptability. Conclusion Highly intrusive policies such as taxations or restrictions are the least accepted when first implemented, but respondents’ confidence in the relevance and effectiveness of the policy may boost acceptability over the course of implementation. Studies using validated tools and a theoretical foundation are needed to further examine opportunities to increase acceptability.

• Forberger, Sarah; Reisch, Lucia; Meshkovska, Biljana; Lobczowska, Karolina; Scheller, Daniel Alexander & Wendt, Janine [Show all 11 contributors for this article] (2022). Sugar-sweetened beverage tax implementation processes: results of a scoping review. Health Research Policy and Systems. 20(33). doi: 10.1186/s12961-022-00832-3. Full text in Research Archive Show summary

  Taxing sugar-sweetened beverages (SSB) is seen as a win–win situation for governments. It is argued that SSB taxes are relatively easy to implement from a practical perspective compared to for example other nutrition policies. However, the implementation of SSB taxation laws does not happen by itself. Therefore, this work examines implementation processes for SSB taxation in terms of (1) pre-implementation context, (2) taxation instruments used and (3) interactions in the implementation process. Ten databases and grey literature were systematically searched for studies reporting on SSB taxation implementation processes up to February 2020. All studies (N = 1248) were screened independently by two reviewers according to predefined criteria. The selection of variables to be extracted was based on the policy cycle heuristic and informed by intervention implementation research. Information on the process of implementing SSB taxation is limited. Only six cases based on three publications were identified, indicating a gap in this research area. SSB taxation implementation was accomplished by hiring a subcontractor for the implementation or using pre-existing tax collection structures. Political and public support within the implementation process seems to be supportive for the city of Berkeley and for Portugal but was not reported for the Pacific Islands. However, the existing data are very limited, and further research on SSB taxation implementation processes is needed to determine whether the aim of the policy and the envisaged outcome are linked in practice. Registration The protocol was registered with the Open Science Framework (OSF) (osf.io/7w84q/)

• Forberger, Sarah; Reisch, Lucia A.; Meshkovska, Biljana; Lobczowska, Karolina; Scheller, Daniel A. & Wendt, Janine [Show all 12 contributors for this article] (2022). What we know about the actual implementation process of public physical activity policies: results from a scoping review. European Journal of Public Health. ISSN 1101-1262. 32(4 S), p. iv59–iv65. doi: 10.1093/eurpub/ckac089. Full text in Research Archive Show summary

  Abstract Background Physical inactivity rates have remained high worldwide since 2001. Public policies are an essential upstream lever to target individual physical activity (PA) behaviour. However, implementers have different strategies and face implementation challenges that are poorly understood. The present study analyzes the implementation processes of public policies to promote PA in terms of: (i) the policies covered and their legal quality, (ii) the actors and stakeholders involved in the implementation process and (iii) the used implementation strategies (vertical, horizontal or a mix). Methods A scoping review was systematically conducted (registered Open Science Framework: osf.io/7w84q/), searching 10 databases and grey literature until March 2022. Of the 7741 titles and abstracts identified initially, 10 studies were included. Results The current evidence includes high-income countries (USA, n = 7; UK, New Zealand and Oman, n = 1 each). Policy areas covered are education (school sector) and PA promotion in general (national PA plans or city-wide approaches). The legal classification ranges from laws (school sector) to coordination and budgeting to non-legally binding recommendations. The jurisdictions covered were federal (n = 4), state (n = 1), county (n = 1), school district (n = 1) and city (n = 3). Implementation strategies for city-wide approaches are characterized by a coordinated approach with vertical and horizontal integration; federal PA policies by a mix of implementation strategies; and the school sector by a strict horizontal top-down integration without the involvement of other actors. Conclusion Implementation strategies differ by policy field. Therefore, continuous evaluation of the implementation process is necessary to align policy implementation with policy goals to promote individual PA behaviour.

• Kelly, Liam; Twohig, Cliona; Woods, Cathrine B.; Luszczynska, Aleksandra; Murrin, Celine M. & Lien, Nanna [Show all 14 contributors for this article] (2022). Reaching consensus on definitions for food and physical activity policies: experience from the Policy Evaluation Network. European Journal of Public Health. ISSN 1101-1262. 32(4). doi: 10.1093/eurpub/ckac147. Full text in Research Archive Show summary

  <p><i>Background -</i> An upsurge in policy evaluation research within public health sciences has led to multi-disciplinary research networks like the ‘Policy Evaluation Network’ (PEN). This multi-disciplinary collaboration highlighted the need for consensus on clear, common terminology and definitions to facilitate the multi-disciplinary research. This article outlines the development process of the PEN definitions glossary tool, with a focus on the key domains of policy design, implementation and outcomes as they apply to physical activity, sedentary behaviour and dietary behaviours. <p><i>Methods -</i> A project specific participatory process was undertaken, involving PEN researchers (n = 48) from seven European countries across various disciplinary backgrounds. All involved researchers were invited to identify and collate definitions that were commonly used in their research field. Terms and definitions were discussed and debated during three online workshops. Subsequently, the definitions were discussed and refined until consensus was reached. <p><i>Results -</i> Consensus definitions for 93 terms related to the evaluation of policy design, implementation and outcomes are provided. Consensus was reached on a range of terms where the terms were understood and used differently across represented disciplines (e.g. ‘Outcome’ and ‘Impact’). A conceptual ‘Inter-relations in policy-related concepts’ diagram was developed to enable navigation through an online database with key terms. <p><i>Conclusions -</i>The definitions resulting from this participatory process has supported PEN researchers and practitioners across disciplines to reach a shared understanding of different terms related to policy evaluation. Thus, providing a platform for avoiding conflicting use of the same terms in differing contexts over the course of the PEN work programme, facilitating clear and consistent communication, and allowing for clarity within collaborative multi-disciplinary projects and in public-facing messages.

• Zolfaghari, Mahshid; Meshkovska, Biljana; Banik, Anna; Kamphuis, Carlijn B.M.; Kopainsky, Birgit & Luszczynska, Aleksandra [Show all 8 contributors for this article] (2022). Applying a systems perspective to understand the mechanisms of the European School Fruit and Vegetable Scheme. European Journal of Public Health. ISSN 1101-1262. 32(4), p. iv107–iv113. doi: 10.1093/eurpub/ckac054. Full text in Research Archive Show summary

  Background For the past two decades, the percentage of European children who consume fruit daily has remained at around 40%, despite numerous school-based policy efforts and interventions. This study aimed to apply a systems approach to provide an integrated perspective of the mechanisms of the European School Fruit and Vegetable Scheme (the Scheme) to understand better how to increase its long-term impact on children’s fruit and vegetable consumption. Methods We developed a causal loop diagram by synthesizing peer-reviewed articles and national government documents related to the Scheme, following the conceptualization steps of system dynamics. The initial causal loop diagrams were then validated in three stages by consulting with experts (two individuals and a group) in school-based fruit and vegetable programmes, children's fruit and vegetable consumption and the Scheme, using disconfirmatory interview guidelines. Results The findings suggest that a central self-reinforcing mechanism through which children socialize during fruit and vegetable consumption is critical in the habituation process. Additionally, the initial increase in children’s fruit and vegetable consumption following the Scheme implementation is due to growth in three self-reinforcing loops related to motivation and capability mechanisms; however, this trend gradually slows and stops due to four balancing feedback loops with alternative goals related to opportunity mechanisms that reach their limits. Conclusions The scheme's design should incorporate activities that align the objectives of the implementers and recipients of the Scheme at all levels. This alignment should provide children with ongoing opportunities to consume fruits and vegetables and strengthen the motivation and capability mechanisms.

• Lobczowska, Karolina; Banik, Anna; Romaniuk, Piotr; Forberger, Sarah; Kubiak, Thomas & Meshkovska, Biljana [Show all 15 contributors for this article] (2022). Frameworks for implementation of policies promoting healthy nutrition and physically active lifestyle: systematic review. International Journal of Behavioral Nutrition and Physical Activity. 19(16). doi: 10.1186/s12966-021-01242-4. Full text in Research Archive Show summary

  Background Policy frameworks focusing on policy implementation may vary in terms of their scope, included constructs, relationships between the constructs, and context factors. Although multiple policy implementation frameworks exist, the overarching synthesis characterizing differences between the frameworks is missing. This study investigated frameworks guiding implementation of policies aiming at healthy nutrition, physical activity promotion, and a reduction of sedentary behavior. In particular, we aimed at examining the scope of the frameworks and the content of included constructs (e.g., referring to implementation processes, determinants, or implementation evaluation), the level at which these constructs operate (e.g., the individual level, the organizational/community level), relationships between the constructs, and the inclusion of equity factors. Methods A systematic review (the PROSPERO registration no. CRD42019133251) was conducted using 9 databases and 8 stakeholder websites. The content of 38 policy implementation frameworks was coded and analyzed. Results Across the frameworks, 47.4% (18 in 38) addressed three aims: description of the process, determinants, and the evaluation of implementation. The majority of frameworks (65.8%; 25 in 38) accounted for constructs from three levels: individual, organizational/community, and the system level. System-level constructs were included less often (76.3%; 29 in 38) than individual-level or organizational/community-level constructs (86.8% [33 in 38 frameworks] and 94.7% [36 in 38 frameworks] respectively). The majority of frameworks (84.2%, 32 in 38) included at least some sections that were solely of descriptive character (a list of unassociated constructs); 50.0% (19 in 38) included sections of prescriptive character (general steps of implementation); 60.5% (23 in 38) accounted for explanatory sections (assuming bi- or uni-directorial associations). The complex system approach was accounted for only in 21.1% (8 in 38) of frameworks. More than half (55.3%; 21 in 38) of frameworks did not account for any equity constructs (e.g., socioeconomic status, culture). Conclusions The majority of policy implementation frameworks have two or three aims (combining processes, determinants and/or the evaluation of implementation), include multi-level constructs (although the system-level determinants are less frequently included than those from the individual- or organizational/community-level), combine sections of purely descriptive character with sections accounting for prescriptive and/or explanatory associations, and are likely to include a little or no equity constructs. Registration PROSPERO, #CRD42019133251.

• Meshkovska, Biljana; Scheller, Daniel A.; Wendt, Janine; Jilani, Hannah; Scheidmeir, Marie & Stratil, Jan M. [Show all 7 contributors for this article] (2022). Barriers and facilitators to implementation of direct fruit and vegetables provision interventions in kindergartens and schools: a qualitative systematic review applying the consolidated framework for implementation research (CFIR). International Journal of Behavioral Nutrition and Physical Activity. 19(11). doi: 10.1186/s12966-022-01246-8. Full text in Research Archive Show summary

  Background Although children’s intake of fruit and vegetables has seen a recent rise, almost half of adolescents do not eat even one piece of fruit or vegetables per day. One way to address this problem is through interventions that provide fruit and vegetables directly to children in kindergartens and schools. For such interventions to meet their intended goals, what is important to consider in addition to impact is implementation. Our objective is to systematically review qualitative results reporting on the determinants (barriers and facilitators) to implementation of interventions that entail direct provision of fruit and vegetables in kindergarten and school settings and conduct a framework analysis of those results using the Consolidated Framework for Implementation Research (CFIR). Methods A systematic search was designed and run in November 2019 for: MEDLINE (Ovid), Embase (Ovid), PsychINFO (Ovid), ERIC (Ovid), Cochrane Library Reviews and Cochrane Library Trials. A keyword search of the journal Implementation Science was completed. Screening of titles and abstracts (n = 5427) and full texts (n = 227), led to 14 included articles. Coding and analysis were done using the framework method and CFIR. Results The following CFIR constructs were found relevant: 1) intervention characteristics domain: ‘design quality and packaging’, ‘adaptability’ ‘cost’; 2) outer setting: ‘cosmopolitanism’, ‘external policy and incentives’ ‘patients’ needs and resources’; 3) inner setting: ‘implementation climate’, ‘readiness for implementation’ and ‘structural characteristics’; 4) characteristics of individuals: ‘individual stage of change’, ‘knowledge and beliefs about the intervention’ 5) process: ‘engaging’, ‘executing’ and ‘reflecting and evaluating’. The review stresses the dual role of parents as both supporting the implementation and targets of the intervention, which could have implications for the design and implementation of future fruit and vegetables interventions. Positive child perceptions of the value of the intervention and perceived behavior change due to the intervention were reported as relevant facilitators to implementation across several studies, and should be taken into consideration in future design efforts. Conclusions CFIR offers a systematic way to identify and organize barriers and facilitators to implementation of interventions in the kindergarten and school setting. Revisions are encouraged to allow adequate space for perceptions of various implementation actors and the target group. PROSPERO registration CRD42020167697.

• Randby, Jorunn Sofie; Meshkovska, Biljana; Holbæk, Helene & Lien, Nanna (2021). An Exploration of Implementation Enablers and Barriers for Norwegian School Meal Guidelines. Global Implementation Research and Applications. 1, p. 122–134. doi: 10.1007/s43477-021-00010-7. Full text in Research Archive Show summary

  Abstract School meal guidelines can be important tools to promote children’s diets, but their implementation depends on several influencing factors. Understanding these is important for designing effective interventions to increase implementation. The aim of this study was to examine barriers to and enablers of implementation of the Norwegian national guideline on food and meals in schools by applying a school-based implementation framework to data collection and analysis. The Multi-level Quality Implementation Framework (MQIF) was used to develop semi-structured interview guides. At four schools, principals and after-school leaders were interviewed individually, whereas teachers ( n  = 27) and children ( n  = 26) participated in separate focus group interviews. The interviews were recorded, transcribed verbatim, and analyzed deductively according to predefined constructs in the MQIF. Most implementation barriers and enablers were identified at the school level and barriers dominated. Important barriers included a weak mandate to prioritize work on school meals; weak administrative leadership; the lack of a school culture around meal practices; a noisy classroom climate undermining social meals; limited facilities; and difficulties with the teacher–parent collaboration around packed lunches. Important enablers were engagement by the education authorities; coordinated action at a municipal level; whole-school discussions on meal practices; and teachers’ facilitation for social meals. The MQIF successfully guided us in identifying factors that influence school meal guideline implementation. Low priority of school meals and low implementation authority appeared as underlying reasons for some implementation barriers. The study indicates that, to overcome these barriers, schools need support for implementation.

• Meshkovska, Biljana; Bos, Arjan & Siegel, Melissa (2021). Long-term (re)integration of persons trafficked for the purpose of sexual exploitation. International Review of Victimology. ISSN 0269-7580. 27(3), p. 245–271. doi: 10.1177/02697580211011445. Full text in Research Archive
• Meshkovska, Biljana; Mickovski, Nikola; Bos, Arjan E.R. & Siegel, Melissa (2016). Trafficking of Women for Sexual Exploitation in Europe: Prosecution, trials and their impact. Anti-Trafficking Review. ISSN 2287-0113. doi: 10.14197/atr.20121665. Full text in Research Archive
• Meshkovska, Biljana; Siegel, Melissa; Stutterheim, Sarah E. & Bos, Arjan E.R. (2015). Female Sex Trafficking: Conceptual Issues, Current Debates, and Future Directions. Journal of Sex Research. ISSN 0022-4499. doi: 10.1080/00224499.2014.1002126. Full text in Research Archive

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• Dahlgren, Monica Linnea; Kværner, Ane Sørlie; Berstad, Paula Marianna; Hjartåker, Anette & Meshkovska, Biljana (2026). Acceptability of a digital diet- and lifestyle intervention in the Norwegian colorectal cancer screening program – A qualitative interview study. Full text in Research Archive

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