Understanding the system dynamics of obesity-related behaviours in 10- to 14-year-old adolescents in Amsterdam from a multi-actor perspective

Determinants, behaviour change techniques and pedagogical approaches used in secondary school-based food and nutrition programmes: a qualitative study of the SWITCH project

BACKGROUND

Food and nutrition programmes at secondary schools have the potential to improve public and planetary health, as they target a wide range of adolescents. Nevertheless, it is currently unclear what mechanisms are underlying such educational interventions in order to aim for behaviour change. This qualitative study therefore aims to identify determinants and behaviour change techniques (BCTs) incorporated in secondary school-based food and nutrition programmes. Better understanding of determinants and BCTs can identify points of improvements to facilitate long-term dietary behaviour change.

METHODS

Fifteen online semi-structured interviews were conducted between November 2021 and January 2022 with representatives of 14 Dutch programmes, supplemented by a document analysis of scientific and grey literature related to the included programmes (e.g., evaluation reports, teacher manuals). Transcripts and literature were analysed deductively, using the terminology of Mechanisms of Action (MOAs) and the BCT Taxonomy v1, followed by an inductive coding phase.

RESULTS

Determinants knowledge (n = 13), skills (n = 12), awareness (n = 9), and beliefs about consequences (n = 7) were identified most, as well as BCTs Knowledge transfer (n = 13), Natural consequences (n = 7) and Goals and planning (n = 5). Inductive coding led to the identification of pedagogical approaches that were considered important for successful delivery of programmes, such as the use of activating learning methods.

CONCLUSIONS

It seems promising for food and nutrition programmes at secondary schools to expand their current focus beyond knowledge and skills, to also target environmental, social and other essential individual determinants during adolescence which are now under-reported, such as identity. Moreover, our study revealed the importance for programmes to be tailored to adolescents' worldviews and to stimulate adolescents to be actively involved.

Monitoring and adaptation of a system dynamics approach to prevent childhood overweight and obesity: findings from the LIKE programme

BACKGROUND

There are few examples of public health programmes rooted in system dynamics methodology. The aim of this paper was to broaden the evidence-base on the implementation and evaluation of a system dynamics programme for obesity prevention, using the Lifestyle Innovations based on youth's Knowledge and Experience (LIKE) Programme as a case study. In LIKE, system dynamics principles were operationalized around three central pillars: the action programme is (1) rooted in a system-based understanding; (2) integrated in the local context and (3) dynamic.

METHODS

This study took place in an urban setting in Amsterdam, the Netherlands, as part of the LIKE programme. The action programme consisted of establishing thematic action groups around previously identified leverage points within the system of overweight-related behaviours among adolescents. An action monitoring register was used to monitor action development and implementation, including the targeted system level. To track action implementation and adaptation over time, we conducted an in-depth evaluation using ripple effects mapping and additional interviews for three action groups. This data was analysed by performing a thematic content analysis.

RESULTS

During the 6-year course of LIKE, 63 action ideas were formulated by 12 action groups, and 22 of these actions were implemented. Most of these implemented actions targeted lower system levels. A total of 9 of the 22 implemented actions were incorporated in existing initiatives. We observed that operationalization of system dynamics principles influenced the form of the action programme. Action ideas were dynamic in the sense that they changed over time or were abandoned because of growing system insights and/or factors within the wider context. This required shifting the focus from individual actions to the programme as a whole and formulating action ideas in terms of their function in changing the system, instead of on its form.

CONCLUSIONS

Using LIKE as a case study, this study provides an example of the output of a system dynamics action programme. We show how leverage points can be used as a starting point to develop action ideas that target lower and higher system levels. This demands monitoring and evaluation that facilitates continuous customization of the programme.

Converging perspectives on the processes exacerbating adolescent obesity: An integrative systems approach

Adolescent obesity is a complex public health challenge with steadily increasing and variable prevalence among countries. This paper synthesises the driving feedback mechanisms of adolescent obesity studied in the CO-CREATE project, furthering our understanding of the complexity of this issue. Using systems thinking principles and causal loop diagramming, we integrated the following knowledge and perspectives derived from diverse sources into a causal loop diagram (CLD): a systems map generated by adolescents through participatory modelling workshops, a comprehensive literature review, and input from subject-matter experts during validation workshops. We used a structured and iterative approach to include drivers and to identify feedback loops exacerbating adolescent obesity. The CLD identified 27 key feedback loops across four themes: twelve related to the commercial food environment, six to the physical activity environment, four to mental wellbeing and five to social norms. These loops indicate not only diet and physical activity as drivers of obesity but also stress and other emotional and social pressures. Recognising the imperative need to integrate the perspectives and experiences of adolescents into our analysis, this work advocates for the synthesis of experiential insights with empirical research. The integrated CLD can be used as a visual tool that fosters collaboration among stakeholders and engenders a more comprehensive and inclusive system understanding that can provide holistic intervention considerations to tackle adolescent obesity. Additionally, the CLD lays a foundation for subsequent quantitative modelling works to further address this issue and develop context-based approaches to prevention and evaluation of adolescent obesity.

Involving national stakeholders in a systems approach to map drivers of childhood obesity and actions to prevent childhood obesity in Denmark: the Generation Healthy Kids Study

BACKGROUND

Childhood obesity is a preventable global public health challenge, increasingly recognized as a complex problem, stemming from complex drivers. Obesity is characterized by multiple interdependencies and diverse influences at different societal levels. Tackling childhood obesity calls for a holistic approach that engages with complexity and recognizes that there is no single "magic bullet" intervention to prevent obesity. To facilitate a shared understanding of the complex structures and relationships that determine children's weight development, systems approaches have shown promising potential. However, systems approaches require more development and research in public health.

AIM

This paper describes the processes of gathering national stakeholders to create a system map of childhood obesity drivers in Denmark to map existing obesity prevention initiatives and define real-world actions to prevent childhood obesity in local communities in Denmark. The system map and action ideas will inform the development of community-based activities in a large-scale national study, the Generation Healthy Kids Study.

METHODS

During two workshops in the autumn of 2022, national stakeholders (n = 45) were involved in generating and revising a system map. We used a scripted approach inspired by group model building and community-based systems dynamics methods to engage stakeholders, collect and visualize their knowledge on childhood obesity, create consensus on the drivers of childhood health, identify local and national intervention opportunities for prevention of childhood obesity and develop actions to create system changes.

RESULTS

The study identified the following six sub-systems of factors influencing childhood obesity: (1) family; (2) diet and dietary habits; (3) physical activity and active living; (4) mental health and wellbeing; (5) screen, media and sleep; and (6) competencies of professionals.

CONCLUSIONS

A systems approach to childhood obesity was useful to generate a shared understanding of the underlying drivers of childhood overweight and obesity and has potential for informing initiatives at local and national level in Denmark. However, challenges were experienced regarding the usefulness of the system mapping process, with a tension between the map as a step in a shared process towards actions and the map as means to gain a deeper understanding of the complex system of childhood overweight and obesity and how to change the system.

Understanding the dynamics driving obesity in socioeconomically deprived urban neighbourhoods: an expert-based systems map

BACKGROUND

Over the past decades, the prevalence of obesity among adults has rapidly increased, particularly in socioeconomically deprived urban neighbourhoods. To better understand the complex mechanisms behind this trend, we created a system map exposing the underlying system driving obesity prevalence in socioeconomically deprived urban neighbourhoods over the last three decades in the Netherlands.

METHODS

We conducted Group Model Building (GMB) sessions with a group of thirteen interdisciplinary experts to develop a Causal Loop Diagram (CLD) of the obesogenic system. Using system-based analysis, the underlying system dynamics were interpreted.

RESULTS

The CLD demonstrates the food environment, physical activity environment, socioeconomic environment and socio-political environment, and their interactions. We identified the following overarching reinforcing dynamics in the obesogenic system in socioeconomically deprived urban neighbourhoods: (1) adverse socioeconomic conditions and an unhealthy food environment reinforced each other, (2) increased social distance between social groups and adverse socioeconomic conditions reinforced each other and (3) increased social distance between institutions and communities and the normalisation of unhealthy behaviours reinforced each other. These deeper system dynamics further reinforced chronic stress, sedentary behaviour, sleeping problems, unhealthy diets and reduced physical activity over time. In turn, these dynamics led to the emergent result of rising obesity prevalence in socioeconomically deprived urban neighbourhoods over the past decades.

CONCLUSIONS

Our study sheds light on the system dynamics leading to neighbourhoods with an unhealthy food environment, challenging socioeconomic conditions, a widening distance between social groups and an infrastructure that discouraged physical activity while promoting sedentary behaviour. Our insights can form the basis for the development of an integrated approach aimed at reshaping the obesogenic system in socioeconomically deprived urban neighbourhoods.

A qualitative study on facilitators and barriers to adoption and implementation of nutrition interventions in higher education settings in Flanders

The transition from secondary school to college or university is a well-known and well-studied risk period for weight and/or fat gain and not meeting the dietary recommendations. Higher education acts as a promising setting to implement nutrition interventions. An important condition for intervention success is that interventions are implemented as intended by the protocol and integrated in the institutional policy. Unfortunately, to date, there is only little understanding of the factors influencing adoption and implementation of nutrition interventions in higher education settings. This study aimed to provide insight into stakeholders' perspectives on facilitators and barriers to adoption and implementation of nutrition interventions promoting healthy and sustainable diets among higher education students in Flanders. Eight online group interviews and three online individual interviews were conducted involving a total of 37 stakeholders (e.g., staff of student services and student restaurants) from ten Flemish higher education institutions with varying food policy quality scores, and one external catering company which provides catering in higher education institutions. A semi-structured interview guide based on the Consolidated Framework for Implementation Research (CFIR-framework) was used to facilitate the interviews. Afterwards, the data were analyzed using a combined inductive and deductive thematic approach led by the CFIR-framework. Most of the institutions' food policies focused on the provision and promotion of healthy and sustainable nutrition. Therefore, the reported factors in the present study consequently relate primarily to these two strategies. Stakeholders preferred to adopt low cost and institution-tailored interventions supported by experts and evidence, considering them easier and less resourceful to implement in the specific context of the institution. They stressed the importance of considering both students' and institution stakeholders' needs and perspectives in the development of nutrition interventions and implementation plans. Furthermore, interventions should be focused on a combination of different ecological levels and various strategies. Future interventions should be developed participatively and should be focused on a combination of both individual and environmental levels. Higher education institutions are encouraged to use opportunities such as creating win-win situations within the institution, working together with research groups and engaging students through student associations. The findings of this research add to the literature on implementation science and inform future development and implementation of nutrition interventions in higher education settings.

Hypothetical mechanisms driving physical activity levels in ethnic minority groups living in Europe: a systematically identified evidence-based conceptual systems model

BACKGROUND

In Europe, physical activity levels tend to be lower in ethnic minority groups than the general population. Interventions and policies based on research examining isolated determinants of physical activity have had limited success in increasing physical activity levels. This study used systems dynamics theory and the capability approach theoretical framework to develop a conceptual model of how individual characteristics, institutional and physical environments and the migration context may interact to promote or hinder physical activity in ethnic minority groups living in Europe.

METHODS

A systematic update of Langøien et al.'s 2017 review of the determinants of physical activity in ethnic minority groups living in Europe was conducted. Our target population included individuals of all ages who reported a familial migration background from any low- and middle-income countries or belonging to minority indigenous population in Europe. Outcomes pertaining to non-work related physical activity of light, moderate or vigorous intensity performed in any setting were included. Included studies provided an evidence base from which to derive the causal loop diagrams comprising our conceptual model. Sub-system causal loop diagrams were interpreted in co-author review sessions to explicate non-linear system mechanisms, such as reinforcing and balancing feedback loops.

RESULTS

Forty-one studies were identified, of which the majority was qualitative. The conceptual model consisted of 4 causal loop diagrams relating to psychosocial constructs; sociocultural constructs; health and health communication and social and material resources, in interaction with environmental/migration context. Four hypothetical mechanisms were identified, e.g. hypothesizing that participation in organised activities leads to increased self-efficacy, thereby enabling further participation.

CONCLUSIONS

This study contributes an evidence-based conceptual systems model which elucidates how low levels of physical activity in ethnic minority groups in Europe could be supported by reinforcing and balancing mechanisms involving factors relating to physical and institutional environments, migration context and individuals. A pluralistic approach to literature review, integrating complexity methods such as CLDs into more conventional systematic literature review, supports novel insights into how factors could interact to support persistently low levels of activity, moving beyond the identification of potential relationships between isolated factors to indicating the ways in which these relationships are sustained and could be modified by intervention or policy.

Mapping complex public health problems with causal loop diagrams

This paper presents causal loop diagrams (CLDs) as tools for studying complex public health problems like health inequality. These problems often involve feedback loops-a characteristic of complex systems not fully integrated into mainstream epidemiology. CLDs are conceptual models that visualize connections between system variables. They are commonly developed through literature reviews or participatory methods with stakeholder groups. These diagrams often uncover feedback loops among variables across scales (e.g. biological, psychological and social), facilitating cross-disciplinary insights. We illustrate their use through a case example involving the feedback loop between sleep problems and depressive symptoms. We outline a typical step-by-step process for developing CLDs in epidemiology. These steps are defining a specific problem, identifying the key system variables involved, mapping these variables and analysing the CLD to find new insights and possible intervention targets. Throughout this process, we suggest triangulating between diverse sources of evidence, including domain knowledge, scientific literature and empirical data. CLDs can also be evaluated to guide policy changes and future research by revealing knowledge gaps. Finally, CLDs may be iteratively refined as new evidence emerges. We advocate for more widespread use of complex systems tools, like CLDs, in epidemiology to better understand and address complex public health problems.

Development of an action programme tackling obesity-related behaviours in adolescents: a participatory system dynamics approach

System dynamics approaches are increasingly addressing the complexity of public health problems such as childhood overweight and obesity. These approaches often use system mapping methods, such as the construction of causal loop diagrams, to gain an understanding of the system of interest. However, there is limited practical guidance on how such a system understanding can inform the development of an action programme that can facilitate systems changes. The Lifestyle Innovations Based on Youth Knowledge and Experience (LIKE) programme combines system dynamics and participatory action research to improve obesity-related behaviours, including diet, physical activity, sleep and sedentary behaviour, in 10-14-year-old adolescents in Amsterdam, the Netherlands. This paper illustrates how we used a previously obtained understanding of the system of obesity-related behaviours in adolescents to develop an action programme to facilitate systems changes. A team of evaluation researchers guided interdisciplinary action-groups throughout the process of identifying mechanisms, applying the Intervention Level Framework to identify leverage points and arriving at action ideas with aligning theories of change. The LIKE action programme consisted of 8 mechanisms, 9 leverage points and 14 action ideas which targeted the system's structure and function within multiple subsystems. This illustrates the feasibility of developing actions targeting higher system levels within the confines of a research project timeframe when sufficient and dedicated effort in this process is invested. Furthermore, the system dynamics action programme presented in this study contributes towards the development and implementation of public health programmes that aim to facilitate systems changes in practice.