Using Group Model Building to Identify the Drivers and Levers of the Double Burden of Malnutrition in Cape Town, South Africa
1
Institute for Medical Information Processing, Biometry and Epidemiology; Chair of Public Health and Health Services Research; Faculty of Medicine, LMU Munich, Munich, Germany
2
Pettenkofer School of Public Health, LMU Munich, Munich, Germany
3
School of Public Health, University of the Western Cape, Cape Town, South Africa
4
Non-Communicable Disease Research Unit, South African Medical Research Council, Belville, South Africa
5
Chair of Public Health Nutrition, University of Bayreuth, Bayreuth, Germany
6
Chronic Diseases Initiative for Africa, University of Cape Town, Cape Town, South Africa
7
Department of Public Health, Universiteit Brussel, Brussels, Belgium
Popul. Med. 2026;8(Supplement Supplement 1):A2936
ABSTRACT
BACKGROUND:
The double burden of malnutrition (DBM), consisting of under- and overnutrition, is a substantial health problem in South Africa. Addressing the DBM requires understanding the common drivers and interactions of undernutrition and overweight which is suited to a complex systems approach. This study applied participatory group model building with multisectoral stakeholders in Cape Town to develop a causal loop diagram (CLD) of the drivers and levers of the DBM across the micro- (individual, household) and meso- (community, local policy) level.
METHODS:
Semi-structured interviews were conducted with 35 stakeholders at micro-level (community health workers and coordinators) and meso-level (civil society representatives, researchers, and city and provincial government employees). Analysis was conducted using grounded theory and a complex systems approach to assemble preliminary variables on the drivers of the DBM for group model building. One workshop was conducted for each level to develop a CLD depicting drivers of the DBM and identify leverage points for action.
RESULTS:
The CLD illustrates 63 variables within eight themes: food environment domains, social vulnerability and equity awareness, access to resources, governance principles, relationships, barriers to food security, commercial determinants of health, and policy development. At micro-level, stakeholders proposed levers of greater nutrition literacy training for community health workers, support for food gardens, and advocacy on food safety at informal shops and alcohol policy. At meso-level, recommended leverage points included mobilizing civil society, supporting evidence uptake in agenda setting, increasing transparency of the corporate sector, developing structures to enable a healthier food environment, and regulating food marketing.
CONCLUSIONS:
Group model building helped stakeholders develop a shared understanding of the drivers of the DBM as a complex system. The findings of the CLD emphasize that double-duty actions are needed across levels, including strengthening food security within communities and bolstering supportive governance structures to improve healthy food consumption.
The double burden of malnutrition (DBM), consisting of under- and overnutrition, is a substantial health problem in South Africa. Addressing the DBM requires understanding the common drivers and interactions of undernutrition and overweight which is suited to a complex systems approach. This study applied participatory group model building with multisectoral stakeholders in Cape Town to develop a causal loop diagram (CLD) of the drivers and levers of the DBM across the micro- (individual, household) and meso- (community, local policy) level.
METHODS:
Semi-structured interviews were conducted with 35 stakeholders at micro-level (community health workers and coordinators) and meso-level (civil society representatives, researchers, and city and provincial government employees). Analysis was conducted using grounded theory and a complex systems approach to assemble preliminary variables on the drivers of the DBM for group model building. One workshop was conducted for each level to develop a CLD depicting drivers of the DBM and identify leverage points for action.
RESULTS:
The CLD illustrates 63 variables within eight themes: food environment domains, social vulnerability and equity awareness, access to resources, governance principles, relationships, barriers to food security, commercial determinants of health, and policy development. At micro-level, stakeholders proposed levers of greater nutrition literacy training for community health workers, support for food gardens, and advocacy on food safety at informal shops and alcohol policy. At meso-level, recommended leverage points included mobilizing civil society, supporting evidence uptake in agenda setting, increasing transparency of the corporate sector, developing structures to enable a healthier food environment, and regulating food marketing.
CONCLUSIONS:
Group model building helped stakeholders develop a shared understanding of the drivers of the DBM as a complex system. The findings of the CLD emphasize that double-duty actions are needed across levels, including strengthening food security within communities and bolstering supportive governance structures to improve healthy food consumption.
| eISSN: | 2654-1459 |
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