Participants
13 community members participated in the first GMB workshop and 12 in the second one. A total of 18 community members attended the action-implementation meeting, of which 6 people had not attended prior GMB workshops but had colleagues who did (due to time restrictions or new jobs) (Table 2). A total of 13 policy stakeholders, including local policy advisors and regional programme managers, attended the external member-check meeting.
Causal loop diagram
Figure 1 shows the final CLD illustrating 46 factors and mechanisms that were perceived to shape a healthy and sustainable local food environment. The research team identified four interrelated subsystems that represent a common larger theme, which are represented by distinct colours in Fig. 1, including (1) societal factors; (2) individual/, socio-economic factors; (3) commercial factors; and (4) political factors. Nine key reinforcing feedback loops were identified within or across these subsystems (represented with an ‘R’ in Fig. 1, followed by a number).
Causal loop diagram (CLD) of the factors influencing a healthy and sustainable local food environment. Factors written in grey are already mentioned in the CLD but have been rewritten elsewhere to increase readability
Societal factors
The first identified subsystem addresses societal factors that were perceived to underlay the local food environment, including aspects such as globalization of the food chain, decreasing prevalence of traditional eating moments and digitalization (Fig. 1).
The participants noticed that modern consumers dedicate less time to preparing and eating meals and prefer convenient and ready-made meals: “Compared to 5 years ago, people are increasingly buying ready-made meals, and often opting for take-out options” (retailer) Participants discussed how the increased consumption of convenient and ready-made meals could be attributed to their greater availability, which allows people to spend less time to prepare and consume a meal: “You also fill up [your agenda] completely. If you knew that [food cannot be obtained so quickly, easily, and at any time] then you would not do that” (retailer).
Next, participants discussed that the increased consumption of convenient and ready-made meals can also be explained by a general lack of time, which has to do with a decrease in traditional working hours and society’s 24/7 economy. The 24/7 economy was also perceived as contributing to a decline in traditional eating moments, resulting in people spending less time on their meals. Consequently, there is a growing desire for meals that are easy to prepare and consume (R1, Fig. 1). Participants also discussed how the increased consumer demand for ready-made meals boosts the e-commerce and platform economy but the other way around: a larger e-commerce and platform economy boosts the demand for convenience and ready-made meals (R2, Fig. 1). Additionally, the increasing e-commerce and platform economy, feed back into the growing 24/7 economy, closing R1 (Fig. 1).
Individual, socio-economic factors
The second identified subsystem revolves around individual, socio-economic factors that, according to the participants, create consumer demand that shape local food environments, including factors such as culture, skills, affordability and social norms (Fig. 1).
Participants discussed the role of healthy/sustainable food in today’s society, with a focus on social norms and the affordability of food. They argued that eating unhealthy food is often the norm, especially during social gatherings. Participants also discussed how this norm could be reversed through increased knowledge and skills, or by talking more about healthy food to raise awareness: “It is quite hip to talk about food, and the extent to which people think about food also contributes to shaping the social norm” (retailer). The participants hypothesized that if healthy/sustainable food were to become the norm, consumers would be more conscious of their food, increase their food skills, hence, see it as a priority, and demand more healthy/sustainable food (R3, Fig. 1). However, participants discussed that consumer demand for healthy/sustainable food is also largely influenced by its relative affordability. They noted that having a healthy/sustainable diet is more challenging for people with a low income.
Commercial factors
The third identified subsystem focuses on the commercial factors, linked to the food industry, which were perceived to shape the local food environment. It includes factors such as marketing budget for healthy/sustainable food, lobbying from the food industry, and the food industry’s willingness to change (Fig. 1).
The participants discussed the widespread availability, constant advertising and low price of unhealthy food. One participant explained how the food industry is dependent on consumer demand: “As a company, you cannot simply change the supply without there being a demand” (retailer). Also, consumer demand for healthy/sustainable food impacts the food industry’s willingness to change, ultimately determining the allocation of staff and resources. The latter also influences production costs, which affect the affordability of food, and as mentioned above, the affordability of healthy/sustainable food impacts consumer demand for it (R5, Fig. 1).
Some participants mentioned the omnipresence of unhealthy food advertisements in the streets and discussed the industry’s predominant investment in unhealthy food marketing. A participant explained: “You prefer to advertise for things that you can sell” (retailer). Thus, the potential profit from (healthy/sustainable) food is a crucial factor in determining what will be advertised. Yet, the participants also discussed other factors influencing the choice of foods offered and promoted by retailers, such as the freshness of food and the number of staff and resources needed to be able to prepare and offer certain foods. They discussed how an increased marketing budget for (healthy/sustainable) food impacts the market share of producers of those foods. In turn, a larger market share leads to reduced production costs, thus yielding higher profits for the producers of (healthy/sustainable) food (R6, Fig. 1).
Participants also discussed how the food industry’s willingness to change is contingent upon the level of priority that is given to healthy/sustainable food. The participants agreed that the food industry often prioritizes economic interests over public health and sustainability, decreasing the likelihood that healthy/sustainable food takes precedence over unhealthy and less sustainable alternatives (R4, Fig. 1). Participants argued that as long as the food industry is not willing to shift towards more healthy/sustainable food, it will continue its lobbying efforts towards the government, which will reduce the chances that healthy/sustainable food become a governmental priority (R7, Fig. 1).
Political factors
The fourth and final subsystem identified illustrates how political factors, such as governmental priorities, food policies and a capitalist system were perceived to shape the local food environment (Fig. 1).
Participants observed that the current (Dutch) healthcare system concentrates on treating diseases, rather than prioritizing prevention efforts: “Our healthcare system is focused on curing instead of preventing” (lifestyle coach). Participants emphasized that this eventually results in a lack of budget for prevention and healthy and sustainable food environments (R8, Fig. 1).
Participants also observed that various governmental departments may hold divergent interests, which influences the extent to which healthy/sustainable food is a governmental priority. A participant (local policy advisor) explained that colleagues working on the job market would see the opening of a large fast-food chain as a significant asset. On the other hand, another colleague working in the public health domain would perceive this development as unfavourable due to negative health implications. Participants then discussed how the lack of prioritization of public health hampers the implementation of policies in favour of healthy and sustainable food environments: “We really only have few policy tools to keep food outlets out” (local policy advisor). This challenge also was linked to the broader political climate in the Netherlands. Participants further discussed how food policies could, in the long term, support shaping social norms around healthy/sustainable food, which in turn can pave the way for societal organizations to lobby the government to make healthy/sustainable food a governmental priority (R9, Fig. 1).
External member-check meeting
The external stakeholders found the CLD impressive and useful and deemed it applicable to their respective municipalities. Based on the discussions held, minor adaptations were made to the CLD (Fig. 1). Three factors were merged into one overarching factor (‘governmental food policies’), one factor was embedded in the CLD (‘climate crisis’) and one new perceived association was drawn (between ‘globalization of the food chain’ and ‘market share healthy/sustainable food producers’).
Leverage points and system-based actions for change
Eight leverage points were identified based on the first GMB workshop and in consultation with the participants during the second GMB workshop (Fig. 1). Based on these leverage points, participants formulated a total of 20 different actions. Most actions, 11 in total, corresponded to the ‘structures level’ of the ASM model, followed by 7 actions addressing the ‘events level’. The participants formulated one action corresponding to the ‘beliefs level’ and another one corresponding to the ‘goals level’ of the ASM (Table 3) [40].
Selection and implementation of actions
A total of 15 participants shared their top three actions most feasible and urgent to implement. Two of these participants were not able to attend the meeting, and four participants joined without sharing their top three actions. Based on this list of the top three actions, the stakeholders and the ASM levels of all actions, the researchers selected the eight most relevant actions for the action implementation meeting (Table 3).
Due to a lack of time and preferences of participants, implementation plans were developed by the assigned working groups for only four actions (Table 3). Group A (n = 5) worked on an implementation plan for action 5 and group B (n = 6) worked on actions 10 and 17. The group expanded the scope of action 17 to include increasing accessibility to healthy/sustainable food for low-income families by expanding the municipality’s governmental financial support system so the beneficiaries can spend this budget in stores selling healthy/sustainable food. Group C (n = 7) worked on an implementation plan for action 9 (Table 3). A local policy advisor became the representative for groups A and B, and a lifestyle coach became the representative for group C.
Follow-up on implementation of actions
The group representatives accepted the invitation for the telephone interview. During the first telephone interview, the group representative for groups A and B indicated that there had been occasional communication within the group. However, this participant was mostly establishing new collaborations within the municipality to work on actions 5, 10 and 17 (Table 3).
During the second telephone interview, the representative for groups A and B explained that contact with the group members terminated, but the representative successfully established new connections with colleagues from other departments of the municipality to implement the actions. The representative mentioned that the intrinsic motivation and enthusiasm of colleagues facilitated this progress. However, the representative mentioned the need for continuous follow-up to ensure progress as well as the importance of budget and timing. While this project had secured funding through a public health policy, this was reaching its end [34]. Now the efforts were directed at incorporating actions 5 and 17 in a new policy for long-term funding [41].
Timing played a role too: action 5 could be included in a rewritten event policy; although, action 10 faced challenges as existing contracts for advertisements in bus stops could not be modified (Table 3). Finally, the representative for groups A and B argued that the lack of jurisdictional instruments hindered the implementation of certain policies, such as a policy to restrict the amount of publicity for unhealthy and unsustainable food (action 10). Despite this, the representative was exploring alternative options.
During the first telephone interview, the representative for group 3 indicated that three participants already quit the group due to lack of time, and three other participants were not responding to emails. The representative declared that due to lack of time, response and motivation from the group, the efforts to implement action 9 were insufficient. No telephone interview was conducted at 12 months.
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