Healthy aging in complex environments : exploring the benefits of systems thinking for health promotion practice

J. Naaldenberg

    Research output: Thesisinternal PhD, WU


    Many different stakeholders and contextual factors influence the success or failure of health promotion activities. Conventional approaches and evaluation designs underlying health
    promotion interventions, often explicitly take contextual variables out of consideration by
    controlling them. In doing so, relevant information about why a project was successful or
    failed to reach success remains invisible and ‘black boxed’. Next to this, in health promotion
    practice, control over contextual variables often is not possible.
    Given the complexity of health promotion practice, research approaches often do not fit the realities of practice. As a result, health promotion activities are not always experienced as meaningful by all stakeholders involved. This thesis aims to appreciate the complex environment in which health promotion takes place by applying a systems
    thinking perspective to healthy aging in order to contribute to more robust strategies and
    interventions to support the aging population.
    Systems thinking aims to include a diversity of viewpoints on an issue. Therefore, to be
    able to answer the research questions, multiple methods were required. A combination of
    literature review, semi-structured and open interviews, interactive workshops, case study
    and survey research was used. Different sources for data collection included the aging
    population, local and national stakeholders, and AGORA project members.
    Part I of this thesis concludes that a systems thinking approach strengthens health promotion by 1) including diverse stakeholder perspectives, 2) explicitly addressing contextual factors, and 3) co-creating solutions with all involved.
    Following this conclusion, Part II addressed the application of systems thinking at the local level by investigating different stakeholders perspectives on healthy aging. Results show how there is a discrepancy between the way aging individuals experience healthy aging as an integral part of everyday life and the way services and interventions are presented with a focus on isolated health themes. Local healthy aging strategies can benefit by taking into account an assets based approach that better matches aging persons’ perspectives. Next to this, collaboration between local stakeholders can be facilitated when shared issues are made visible and contextual preconditions are taken into account. Since the operationalization of systems thinking in health promotion can benefit from learning experiences with application in practice, findings from Part II were discussed in interactive presentations and workshop formats within participating municipalities. This resulted in the co-creation of a model to facilitate collaboration and the co-creation
    of an intervention through application of this model. The salutogenic concept Sense of
    Coherence was identified as a promising concept to operationalize systems approaches
    in health promotion practice. It was therefore expected that quantitative measurement of
    SOC could provide useful information for both the development and evaluation of health
    promotion. The OLQ-13 scale to measure Sense of Coherence was therefore investigated for its psychometric properties. Results indicate difficulties with the use of this scale in aging
    populations. Deleting two items from the original 13 items, improved the functioning of OLQ.
    The importance of the fact that health issues and possible intervention strategies are perceived differently by involved actors was argued within this thesis. Research is one amongst many stakeholders and a systems thinking approach implies linking all kinds of
    actors in order to enable co-creation of projects. Consequently, the definition of health
    risks, health determinants, and possible intervention effects have to be verified in both
    scientific research and everyday practice.
    Strategies to improve health are context sensitive, and consequently, certain strategies may not work in some settings whereas they function perfectly well in others. Measurement of successes of interventions should therefore use multi-method evaluations combining
    the use of quantitative and qualitative approaches to gain insight in the ‘black box’ of why
    an intervention failed or was successful. If not, alternatives are overlooked and at the same
    time successes may go unnoticed.

    Original languageEnglish
    QualificationDoctor of Philosophy
    Awarding Institution
    • Wageningen University
    • Koelen, Maria, Promotor
    • Leeuwis, Cees, Promotor
    • Vaandrager, Lenneke, Co-promotor
    Award date14 Jun 2011
    Place of PublicationS.l.
    Print ISBNs9789085859123
    Publication statusPublished - 2011


    • aging
    • well-being
    • health promotion
    • methodology
    • efficiency


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