Understanding persistent patterns and exploring action strategies for a healthier and more sustainable hospital food environment: findings from a Dutch group model building study using systems archetypes

Background Hospitals can be key stakeholders in attaining public and planetary health through healthy and sustainable food environments. However, many hospital food environments remain unhealthy and unsustainable despite efforts to change them, reflecting persistent patterns within a complex system. This study uses a systems approach to understand what sustains these patterns and to explore action strategies for long-term change towards a healthier and more sustainable hospital food environment for staff and visitors. Methods This study used a systems approach, where two Group Model Building workshops were conducted with 39 key stakeholders at a major Dutch academic hospital. First, participants discussed factors and causal relationships sustaining the current hospital food environment for staff and visitors. Based on these insights, researchers constructed a Causal Loop Diagram and applied systems archetypes to identify persistent patterns. Potential leverage points were identified based on the systems archetype literature and used to guide the development of stakeholder-informed action strategies. Results The food environment was characterized by three interconnected persistent patterns. First, commercial pressures and an uneven playing field for food providers were found to maintain the dominance of unhealthy food products over healthier alternatives, reflected in availability, promotion and pricing (systems archetype: Success to the Successful ). Second, the hospital’s reliance on short-term solutions limited implementation of structural changes (systems archetype: Shifting the Burden ). Third, food providers’ reluctance to invest in healthier and plant-based alternatives reinforced high prices, limited availability, and suboptimal taste, thereby sustaining low consumer demand (systems archetype: Limits to Success ). In collaboration with stakeholders, seventeen action strategies were identified as a starting point to disrupt these patterns and support a transition towards a healthy and sustainable hospital food environment. Conclusions This study shows how an unhealthy and unsustainable hospital food environment, and the difficulties in changing it, may be explained by an uneven playing field, reliance on short-term solutions over structural change, and limited demand for healthy and plant-based alternatives. Effectively changing the system requires a targeted approach that considers all three underlying patterns and their interactions.