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. 2025 Jan 29;25(1):372.
doi: 10.1186/s12889-024-21124-1.

Identifying mechanisms that shape the food environment in long-term healthcare facilities in the Netherlands: a participatory system dynamics approach

Joline J Wierda  1 , S Coosje Dijkstra  2   3 , Tamika M Wopereis  4 , Sanne K Djojosoeparto  4 , Maartje P Poelman  4
Affiliations

Identifying mechanisms that shape the food environment in long-term healthcare facilities in the Netherlands: a participatory system dynamics approach

Joline J Wierda et al. BMC Public Health. .

Abstract

Background: Creating healthy and sustainable food environments within long-term healthcare facilities asks for a systemic approach. This study aimed to: (1) identify system dynamics underlying the food environment of long-term healthcare facilities, (2) formulate actions for changing the system to promote a healthy and sustainable food environment and (3) evaluate stakeholder perspectives about the process and progress towards action implementation up to one-year follow-up.

Methods: A group model building (GMB) approach was used during two workshops with stakeholders of five different long-term healthcare facilities in the Netherlands. Stakeholders created a causal loop diagram (CLD) and formulated actions for change. Interviews were conducted at six- and twelve months to evaluate perspectives on the GMB process and progress towards action implementation.

Results: The developed CLD consisted of 30 factors influencing the food environment in long-term healthcare facilities and four interrelated subsystems (patient; healthcare organization; national governance and policy; purchasing, procurement and budget). Stakeholders formulated 40 corresponding actions. After one year follow-up, small steps towards action implementation were observed (e.g., agenda setting, raising internal awareness, formulating plans), with several barriers hindering implementation being noted (e.g., lack of time, budget, priority).

Conclusions: This study gained a comprehensive, collectively acknowledged understanding of the system dynamics underlying the food environment in Dutch long-term healthcare institutions. The results underscore the importance of crafting a coherent set of actions that addresses various factors and underlying mechanisms to initiate systemic change. However, achieving actual system changes in long-term healthcare facilities requires prolonged efforts and overcoming barriers towards implementation.

Keywords: Causal loop diagram; Food environment; Group model building; Healthcare institution; Long-term care; System dynamics.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: The study was approved by the Social Sciences Ethics Committee of Wageningen University & Research (ethical approval number: 2021-38-Wierda) and the study complies with the Netherlands Code of Conduct for Research Integrity. All participants provided informed consent to participate. The study followed all procedures in accordance with the relevant guidelines and regulations of the Declaration of Helsinki [52]. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
One-year study trajectory: activities for participating healthcare institutions, outputs and measures
Fig. 2
Fig. 2
Time-line wall input during the closing session
Fig. 3
Fig. 3
Causal loop diagram shows the system that shapes the food environment in healthcare institutions. Each colour represents a subsystem; feedback loops are indicated by an ‘R’ followed by a number; leverage points are underlined
Fig. 4
Fig. 4
Causal loop diagram subsystem healthcare organization
Fig. 5
Fig. 5
Causal loop diagram subsystem the patient
Fig. 6
Fig. 6
Causal loop diagram subsystem purchasing, procurement and budget
Fig. 7
Fig. 7
Causal loop diagram subsystem national governance and policy
See this image and copyright information in PMC

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