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

Causal loop diagram
The CLD as presented in Fig. 3 shows the system that shapes a healthy and sustainable food environment in healthcare institutions, formed by 30 factors, connections and mechanisms that influence the system. The arrows symbolize the connections between factors. An arrow with a plus symbol indicates that the relationship between the factors is positive (if the variable increases or decreases, the connected variable also increases or decreases correspondingly). An arrow with a minus symbol indicates that the relationship between the factors is negative (if the variables increases, the connected variable decreases, or if the variable decreases, the connected variable increases). Each colour represents a subsystem, in which factors are clustered. The following four connected subsystems were identified: (1) the healthcare organization, (2) the patient, (3) purchasing, procurement and budget and (4) national governance and policy. A total of six reinforcing feedback loops were identified, indicated by ‘R’ in the diagram. The identified leverage points are numbered and underlined.

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
Subsystem healthcare organization
Factors related to the healthcare organization are displayed in the light blue subsystem in Fig. 4. Most of the identified factors centre around support for a healthy and sustainable food environment within the entire organization. As illustrated by a participant: “I think support within the organization is very important, that is where it starts”. Another participant noted: “what really strikes me, is that the complexity [of the map] is within the healthcare organization part”. Three reinforcing feedback loops were identified within this subsystem. Feedback loop 1 indicates that broad support for healthy and sustainable food environments in the entire organization leads to the integration of healthy and sustainable foods in (preventive) care plans. This, in turn, increases nutritional knowledge and skills of staff, that positively shapes their norms and beliefs regarding healthy and sustainable eating, which fosters further support within the healthcare organization (R1, Fig. 4). Feedback loop 2 shows that if healthy and sustainable food is part of a (preventive) care plan for patients, this will enhance interdisciplinary working around food within the organization. Interdisciplinarity can also broaden the support for the creation of a healthy and sustainable food environment within the entire healthcare organization and that will increase the likelihood that healthy and sustainable food will become part of a (preventive) care plan for patients (R2, Fig. 4). Feedback loop 3 shows that having a ‘forerunner’ who initiates or leads change in the transition towards a healthy and sustainable food environment, is beneficial for creating support towards a healthy and sustainable food environment in the entire organization. For example, a person on management or board level who disseminates the importance of healthy and sustainable food and the role of the food environment can increase support, which can accelerate the implementation of food environment policies. An implemented food environment policy is again helpful in attracting and guiding forerunners, the beginning of feedback loop 3 (R3, Fig. 4).

Causal loop diagram subsystem healthcare organization
Subsystem the patient
Factors related to the role of the patient are displayed in the green subsystem (Fig. 5). No feedback loops were identified here. Most factors in this subsystem had a direct influence on the patient’s demand for healthy and sustainable food, including nutritional knowledge and skills, (clinical) dietary restrictions, patient’s autonomy, healthy and sustainable dietary habits and a more distal factor, namely the influence of (digital) food marketing. The patients’ demand for healthy and sustainable foods influenced the food purchases of staff and patients, e.g. patients asking staff to prepare or buy healthy and sustainable foods. Indirect factors that influenced patients’ demand for healthy and sustainable foods were the social network of patients, which in turn influenced the eating norms and beliefs of patients. The (clinical) diagnostics of patients and related (clinical) dietary restrictions affect the patients’ demand for food within the healthcare institution. Participants discussed the influence of patients’ autonomy and the influence of associated regulations on the demand for healthy and sustainable food. The autonomy and rights of individuals with intellectual disabilities or psychogeriatric conditions receiving involuntary care are protected and regulated in the Netherlands by the Care and Coercion Act (in Dutch: Wet Zorg en Dwang or Wzd 2020) [30], to ensure these individuals receive adequate care. Since diet and prevention are not part of this Act, it was indicated that patients often have full autonomy over their food choices, and the right to choose an unhealthy diet, illustrated by a participant: “it is not allowed that a health care receiver crosses the road [e.g. a busy roadway], but that someone [figural] eats him or herself to death is allowed, as this does not happen overnight”.

Causal loop diagram subsystem the patient
Subsystem purchasing, procurement and budget
Factors related to food purchasing, procurement and budget available for healthy and sustainable food are displayed in the orange subsystem (Fig. 6). In many healthcare institutions, staff members are tasked with procuring the food that patients consume, yet in some healthcare institutions (e.g. mental healthcare, institutions for people with intellectual disabilities) patients take on the responsibility of obtaining their own meals. Reinforcing feedback loop 4 shows that an allocated food budget would increase the purchases of healthy and sustainable food by staff and patients, which will enhance the (external) suppliers’ and caterers’ offerings of healthy and sustainable foods (supply and demand), which, in turn, will lower the costs of healthy and sustainable foods. As a result, more budget can be allocated to healthy and sustainable foods which in turn leads to an increase of healthy and sustainable food purchases by staff and patients (reinforcing loop R4, Fig. 6). A participant elaborated on this: “in theory there is budget, but in practice it is often not clear for what that budget is, for example, it is also for household products and then there is no budget left anymore for foods” and another participant said “there is no budget for healthy food, because it is more expensive than unhealthy food”. Feedback loop 4 can be extended to feedback loop 5, adding that more budget allocated to healthy and sustainable foods can increase the likelihood that healthy and sustainable food is part of a (preventive) care plan, which in turn can enhance the nutritional knowledge and skills of staff (subsystem the healthcare organization) and with that increases the purchases of healthy and sustainable foods by staff/patients (reinforcing loop R5, Fig. 6).

Causal loop diagram subsystem purchasing, procurement and budget
Subsystem national governance and policy
The final subsystem, displayed in dark blue, illustrated how factors related to national governance and policy shape the healthcare institutions’ food environment (Fig. 7). Reinforcing feedback loop 6 shows that lobby and agenda setting by e.g. civil society organizations can contribute to higher political priority and more (national) policy to create healthy and sustainable food environments, which in turn can enforce healthcare institutions to formulate and implement policies. Having a food environment policy within healthcare institutions can impose monitoring or evaluation of the food environment and this can help to empower the role of lobby and agenda setting, the start of feedback loop 6 (R6, Fig. 7). Illustrated by a participant: “Lobbying is important and trade associations have large influence, not only trade associations but also health insurers have an important position in this”. Participants further discussed that the government is more focused on economic interests than health interests, which restricts budget allocated to healthy and sustainable foods, illustrated by: “think of Value Added Taxes, the economic interests outweigh the health interests”. Furthermore, participants mentioned that the lack of prioritisation on the healthcare setting by the national government increases staff shortage and lowers available time staff has for health care receivers, which in the end negatively influences the support for realizing a healthy and sustainable food environment.

Causal loop diagram subsystem national governance and policy
Changeability and impact of leverage points
Twelve leverage points were identified (all leverage points are underlined and numbered in the causal loop diagram, Fig. 3). On the 10-point scale the three leverage points that received the highest score combination of impact and changeability are: (2) nutritional knowledge and skills of staff (impact = 7.0, changeability = 6.1), (12) lobby and agenda setting (impact = 7.3, changeability = 5.7), and (6) healthy and sustainable food is part of (preventive) care plan (impact = 7.4, changeability = 5.4). The impact and changeability scores for all leverage points are plotted and available via Additional file 3.
Actions for transition of the food environment
During session 2, participants formulated 40 actions based on the leverage points in the CLD, of which 10 actions were appraised on the events level of the ASM model, 22 actions on the structures level, 3 actions corresponded to the goals level and 5 actions to the beliefs level. The actions can be found in Additional file 4.
Evaluation of both GMB sessions
Overall, the results of the questionnaires showed that participants felt involved in both sessions with a mean score of 4.4 (SD = 0.5). Participants indicated that they were encouraged in systems thinking after the first session (M = 4.1, SD = 0.6) and obtained action awareness after the second session (M = 4.1, SD = 0.6). The open-end questions predominantly elucidated that participants wanted to share the outcomes of the sessions within their organization and that they required support from management level to implement the identified actions.
Follow-up summary: interviews after six, twelve months and time-line wall
Determining the accomplishments over the follow-up year through the interviews and time-line wall, participants highlighted various, small advancements towards improvement of the food environment, facilitated by the GMB sessions. Participants noted that the GMB sessions and outcomes played a role in raising awareness on the importance of a healthy and sustainable food environment, agenda setting, and the formulation of concrete plans to start improving the food environment. In one healthcare institution the sessions helped to (re)start the conversation on this topic with the management level: “But it helps to start the conversation with the management – and I do notice that after the conversation we had, they seem to think that it is all well-founded – then it seems like we are being taken more seriously – so that’s also very nice.” (P14). Another participant highlighted that the study trajectory served as an important motivator for improving the food environment, acting as a catalyst for staying proactive. Some participants mentioned that the study activities emphasized the collaborative effort in improving the food environment, fostering a sense of unity rather than isolation, illustrated by: “We do not act alone; there are several other healthcare institutions in the region who share similar intentions to undertake such endeavours.” (P6).
However, participants also mentioned that the study activities did not directly contribute to the initiation of concrete actions or improvements in the food environment, illustrated by “we have not done much in the meantime” (P1) or participants did not link or recall any changes to the study activities. Four healthcare institutions already started to improve their food environments before the sessions began (for example writing a new vision or outsourcing patient food service to in-house management) and the GMB sessions and outcomes served as a complementary effort, as illustrated by participants: “We are moving in a certain direction and we will also take the knowledge and information of the sessions with us” (P19) and “we already had the intention to make improvements when it comes to nutrition” (P6).
The main barriers for implementation of actions for improving the food environment that were mentioned by participants were: lack of time, lack of adequate budget or finances (e.g. because of inflation), no priority, no integration into daily tasks or daily health care, personnel changes (instable team), high workload, lack of communication and lack of support from management level or the entire organization or lack of having a forerunner to change the food environment As illustrated by a participant: “It is so important that you have support, because then you also have the resources and manpower” (P14) and “Because we have a staff shortage and there are a lot of flexible workers at this moment nutrition is not the first thing to tackle” (P11).
When participants were asked what they need in terms of resources to realize a healthy and sustainable food environment most participants indicated that they need (financial) support, people, forerunners, guidance (e.g. project leaders, tools for realizing a healthy and sustainable food environment, rules and policies within the healthcare institution but also from the government), peer support through learning from other healthcare institutions (e.g. by sharing best practices), and monitoring (e.g. by evaluation moments to assess the extent of change). Participants remarked the need of multidisciplinary collaboration and making integral decisions for the transition to a healthy and sustainable food environment. Also, having a vision and how to translate the vision to a plan were mentioned. One participant said: “Besides policy at national level, there are also opportunities for policy at municipal level” (P13). Another participant suggested that the role of the government in creating a healthy and sustainable food environment in healthcare institutions should be the same role the government takes in quitting smoking. Another participant stressed the importance of handling autonomy, especially when individuals may not fully grasp the consequences of unhealthy foods. In such cases, maintaining autonomy is crucial, accompanied by the ability to provide guidance in decision-making, for instance providing a patient two healthy food options.
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