Health (f)or Profit? Systemic challenges for the promotion of healthy dietary behaviours in the Dutch food-retail system

Unhealthy dietary behaviours are a major threat to public health, in which the modern food-retail environment (e.g., supermarkets) have a substantial role. In recent years, there has been a growing realization that these environments are themselves the products of underlying systemic factors and dynamics, which obstruct attempts to address these environments. In this thesis we set out to explore this issue, with the objective “to acquire insight into the factors in food-retail systems which underlie the persistence of drivers of unhealthy dietary behaviours in retail food environments, and to explore how a transformation of these systems can be realized, in order to contribute to healthier dietary behaviours.” We explored this problem through a transition theory lens, in which we combined Multi-Level and Constellation Perspectives. Our research activities focussed on the Dutch context, in which we examined the SUPREME NUDGE project, which aimed to develop and trial health promotion interventions in collaboration with a Dutch supermarket chain, as a case study. Five separate studies were performed: 1) A systematic literature review method, which explored implementation barriers and facilitators and underlying systemic factors for health interventions in food-retail settings. 2) A system analysis, which combined historical literature, with semi-structured interviews on the Dutch food-retail system, to explore the dynamics and factors which promote unhealthy food-retail environments. 3) A co-creative design process in which supermarket actors took part in the development of a multi-component intervention to promote healthier diets in supermarkets. 4) A reflexive monitoring study, in which the implementation of the previously developed intervention was monitored, and used to reflect upon, and seek underlying causes of and solutions for, observed implementation issues. 5) A roadmapping study, in which representatives of relevant stakeholders for the Dutch food-retail system collaborated to decides what steps would need to be taken to realise healthier supermarket environments. These studies provided several insights: 1) Barriers for health promotion in food-retail environments are systemically embedded through a complex interplay in which landscape factors interact with strong valuations of commercial success to shape beliefs on how to achieve such success among food-retail organisations. These values and beliefs in turn lead to the establishment of various tools, metrics, processes, and systems to regulate, monitor, and evaluate whether commercial success is being achieved, resulting in various situation in which health promotion activities receive the necessary attention and resources in practice. 2) When implementing health interventions, supermarket stakeholders weigh barriers and costs against facilitators and beneficial outcomes to assess priority, which is generally given to what is perceived to provide ‘better’ commercial outcomes. This is compounded by limitations in staff, time and space at the store level. The most feasible interventions seemed to be those which were highly integrated in routine processes, systems, and practices, or required little resources. 3) The major bottleneck in realising healthier food-retail environment is the lack of systemic incentives to make practical changes. Furthermore, it seems that cultivating societal pressure is vital to motivating the relevant stakeholders to instigate such incentives, which poses a challenge in itself.